Treatment for Vasospastic Angina
Calcium channel blockers alone or in combination with long-acting nitrates are the first-line therapy for vasospastic angina to control symptoms and prevent potentially fatal complications. 1
First-Line Therapy
Calcium Channel Blockers
- High-dose calcium channel blockers are most effective in preventing coronary spasm, with a success rate of approximately 90% 1
- Amlodipine has been specifically demonstrated to block coronary artery constriction and restore blood flow in response to various vasoconstrictive stimuli 2
- Typical dosing:
- Amlodipine: 5-10 mg once daily
- Diltiazem: 120-360 mg daily in divided doses
- Verapamil: 240-480 mg daily in divided doses
Nitrates
- Add long-acting nitrates if symptoms persist despite calcium channel blocker therapy 1
- Typical dosages:
- Isosorbide mononitrate: 20 mg twice daily
- Isosorbide dinitrate: 5-80 mg 2-3 times daily 1
- Short-acting sublingual nitroglycerin should be used for acute symptom relief 3
Additional Therapeutic Options
Statins
- HMG-CoA reductase inhibitors (statins) are useful in patients with vasospastic angina 1
- Statins improve endothelial function and may help stabilize coronary plaques
Risk Factor Modification
- Smoking cessation is critical as smoking is the most prominent risk factor 1
- Address other atherosclerosis risk factors:
- Correct electrolyte disturbances (potassium, magnesium)
- Avoid cocaine use
- Avoid cold exposure
- Manage insulin resistance 3
Special Considerations
Treatment Duration
- Consider tapering and discontinuing treatment 6-12 months after angina has disappeared 1
- Spontaneous remission occurs in about half of patients after medical treatment for at least 1 year
Coexisting Obstructive CAD
- Patients with obstructive CAD and vasospasm have a less favorable prognosis compared to those with normal coronary arteries 3, 1
- These patients should follow standard guideline recommendations for secondary prevention
Medications to Avoid
- Beta-blockers should be avoided as they can precipitate spasm 1
- Absolute contraindication: combining nitrates with phosphodiesterase inhibitors 1
Management of Refractory Vasospastic Angina
For patients who don't respond to conventional therapy:
- Maximize calcium channel blocker doses
- Try a different class of calcium channel blocker
- Consider alpha1-adrenergic receptor antagonists 4
- Nicorandil (where available) may be beneficial 4, 5
- Rho-kinase inhibitors have shown promise in research settings 4
- In cases with inflammatory etiology, some patients have achieved remission with glucocorticoid and immunoglobulin treatments 6
Prognosis
- Death and myocardial infarction are not frequent in patients without angiographically significant obstructive disease, but do occur 3
- Coronary death rate in patients with non-obstructive lesions is reported as 0.5% per annum 3
- Patients with spasm superimposed on stenotic lesions have significantly worse outcomes 3
Vasospastic angina requires prompt diagnosis and aggressive treatment with calcium channel blockers as the cornerstone therapy, with nitrates added for persistent symptoms. Risk factor modification, particularly smoking cessation, is essential for long-term management and improved outcomes.