Vasospastic Angina: Clinical Presentation and Treatment
Vasospastic angina typically presents as chest pain occurring at rest (especially in early morning hours), associated with transient ST-segment elevation that resolves spontaneously or rapidly with nitrates, and is characterized by preserved exercise capacity. 1
Clinical Presentation
Key Symptoms
- Chest pain/discomfort that:
- Occurs predominantly at rest rather than with exertion 1
- Typically happens in early morning hours (circadian pattern) 1
- Resolves within minutes, either spontaneously or with nitrates 1
- May be described as starting at low intensity, slowly intensifying, remaining at maximum for up to 15 minutes, then slowly decreasing 1
Electrocardiographic Features
- Transient ST-segment elevation during episodes (classic finding) 1
- Some patients may show ST-depression or no ST-segment changes 1
- Quick resolution of ECG changes when pain subsides 1
- Difficult to capture on standard 12-lead ECG due to transient nature 1
- 24-hour ECG monitoring may help document ST-segment shifts associated with symptoms 1
Risk Factors and Triggers
- Smoking (most prominent risk factor) 1
- Emotional stress, hyperventilation, exercise, cold exposure 1
- Other potential triggers: electrolyte disturbances (potassium, magnesium), cocaine use, autoimmune diseases, insulin resistance 1
Clinical Spectrum
- Can occur in patients with:
- Normal coronary arteries
- Non-obstructive coronary disease
- Obstructive coronary disease (associated with worst prognosis) 1
- May present as stable angina, acute coronary syndrome, arrhythmia, or syncope 2
Diagnostic Approach
Initial Evaluation
- Continuous 12-lead ECG monitoring during episodes of chest pain 1
- Coronary angiography to rule out obstructive coronary disease 1
Definitive Diagnosis
- Provocative testing during coronary angiography using:
- Acetylcholine
- Ergonovine
- Methylergonovine 1
Caution with Provocative Testing
- Avoid in patients with:
- Significant left main disease
- Advanced 3-vessel disease
- High-grade obstructive lesions
- Significant valvular stenosis
- Significant LV dysfunction
- Advanced heart failure 1
Treatment
First-Line Therapy
- Calcium channel blockers (CCBs) are the cornerstone of treatment, either alone or in combination with long-acting nitrates 1, 3
Additional Pharmacotherapy
- Long-acting nitrates when symptoms persist despite CCB therapy 3
- Isosorbide mononitrate 20 mg twice daily
- Isosorbide dinitrate 5-80 mg 2-3 times daily
- Statins (HMG-CoA reductase inhibitors) 1, 3
- Consider alpha1-adrenergic receptor antagonists, rho-kinase inhibitors, or nicorandil in refractory cases 2, 5
Lifestyle Modifications
- Smoking cessation (critical) 1, 3
- Avoidance of known triggers 3
- Management of other atherosclerosis risk factors 1, 3
Treatment Duration
- Consider tapering and discontinuing treatment 6-12 months after angina has disappeared 3
- Spontaneous remission occurs in about half of patients after medical treatment for at least 1 year 3
Special Considerations
Prognosis
- Generally favorable in patients without significant obstructive coronary disease 1
- Annual mortality rate of approximately 0.5% in patients with non-obstructive lesions 1
- Significantly worse outcomes in patients with spasm superimposed on stenotic lesions 1, 3
Potential Complications
- Arrhythmias, syncope, myocardial infarction, and sudden death can occur 1
- Higher risk of adverse events in patients with multivessel disease 1
Medications to Avoid
- Beta-blockers should be avoided as they can precipitate spasm 3
- Phosphodiesterase inhibitors are contraindicated when using nitrates 3
Refractory Cases
- In patients with persistent symptoms despite optimal therapy, consider:
By understanding the unique presentation of vasospastic angina and implementing appropriate diagnostic and treatment strategies, clinicians can effectively manage this condition and reduce the risk of potentially fatal complications.