From the Guidelines
The treatment of Variant angina (Prinzmetal's angina) should focus primarily on calcium channel blockers and nitrates to prevent coronary artery spasm, with long-acting calcium channel blockers like verapamil (up to 480 mg/day) and nitrates being the main elements of drug therapy. The goal of treatment is to alleviate the signs and symptoms of coronary spasm and prevent attacks of resting angina. According to the European Society of Cardiology guidelines 1, calcium channel blockers are more effective in alleviating the signs and symptoms of coronary spasm, and treatment should be aimed at using high doses. Some key points to consider in the treatment of Variant angina include:
- Removal of precipitating factors such as cessation of smoking is essential 1
- Nitrates are highly effective in abolishing acute vasospasm, but are not as successful in preventing attacks of resting angina 1
- Calcium channel blockers achieve a complete resolution of symptoms in only 38% of patients, but a combination therapy with long acting nitrates and high doses of calcium antagonists will result in an improvement of symptoms 1
- The role of a-blockers is controversial, but occasional therapeutic benefit has been reported 1
- Nicorandil, a potassium channel activator, may also be useful in occasional patients with refractory vasospastic angina 1
- Spontaneous remission of spasmodicity occurs in about half of western people following medical treatment for at least 1 year, and it is acceptable to taper and discontinue treatment 6 –12 months after angina has disappeared 1. In contrast to the American College of Cardiology/American Heart Association guidelines 1, the European Society of Cardiology guidelines 1 provide more specific recommendations for the treatment of Variant angina, and are more recent. Therefore, the most effective treatment for Variant angina is a combination of calcium channel blockers and nitrates, with the goal of alleviating symptoms and preventing coronary artery spasm.
From the FDA Drug Label
Amlodipine has been demonstrated to block constriction and restore blood flow in coronary arteries and arterioles in response to calcium, potassium epinephrine, serotonin, and thromboxane A2 analog in experimental animal models and in human coronary vessels in vitro This inhibition of coronary spasm is responsible for the effectiveness of amlodipine in vasospastic (Prinzmetal's or variant) angina. Amlodipine besylate tablets is indicated for the treatment of confirmed or suspected vasospastic angina. Amlodipine besylate tablets may be used as monotherapy or in combination with other antianginal agents
The treatment for Variant angina (Prinzmetal's angina) is Amlodipine, which can be used as monotherapy or in combination with other antianginal agents 2 2.
- Key points:
- Amlodipine blocks constriction and restores blood flow in coronary arteries
- Amlodipine is effective in vasospastic (Prinzmetal's or variant) angina
- Amlodipine can be used alone or with other antianginal agents
From the Research
Treatment Options for Variant Angina (Prinzmetal's Angina)
The treatment for Variant angina (Prinzmetal's angina) includes:
- Nitrates: Nitroglycerin and isosorbide dinitrate can effectively relieve coronary-artery vasospasm (CAS) 3, 4, 5
- Calcium-channel blocking agents: These are considered the drugs of first choice for Prinzmetal's angina, and include nifedipine, verapamil, and diltiazem 3, 6, 7, 5
- Adrenergic-blocking agents: However, studies on treating PVA with adrenergic-blocking agents have been equivocal, with some studies reporting improvement and some reporting worsening 3
Pharmacologic Treatment
The mainstay of pharmacologic treatment of coronary artery spasm is:
- Calcium channel blocking agents: Together with nitrates to cover the periods in which spasm is most likely to occur 5
- Nitrates: Sublingual administration of short-acting nitrates, such as nitroglycerin or isosorbide dinitrate, can promptly respond to attacks of variant angina 5
Treatment Approach
Treatment of PVA should begin with:
- Oral nitrates: As the initial treatment approach 3
- Calcium-channel blocking agents: Indicated in patients who have failed to respond or are intolerant to maximum doses of nitrates 3
Contraindications
Certain medications are contraindicated in PVA, including: