What are the clinical presentation and treatment options for vasospastic angina?

Vasospastic Angina: Clinical Presentation and Treatment

Vasospastic angina typically presents as chest pain occurring at rest, associated with transient ST-segment elevation that resolves spontaneously or rapidly with nitrates, and is characterized by preserved exercise capacity. 1

Clinical Presentation

Key Characteristics

• Chest pain predominantly occurs at rest rather than with exertion
• Episodes typically happen in early morning hours (circadian variation)
• Pain resolves within minutes, either spontaneously or with nitrates
• Preserved exercise capacity between episodes

ECG Findings

• Transient ST-segment elevation during episodes is the classic finding
• Some patients may show ST-depression or no ST-segment changes
• ST-elevation corresponds to the distribution of the involved artery

Risk Factors and Triggers

• Smoking is the most prominent risk factor
• Common triggers include:
  • Emotional stress
  • Hyperventilation
  • Exercise
  • Cold exposure
  • Cocaine and methamphetamine use 2
  • Electrolyte disturbances

Diagnostic Approach

Initial Evaluation

• 24-hour ECG monitoring to document ST-segment shifts associated with symptoms
• Continuous 12-lead ECG monitoring during episodes of chest pain

Definitive Diagnosis

• Coronary angiography is recommended in patients with episodic chest pain accompanied by transient ST-elevation to rule out severe obstructive coronary artery disease 2
• Provocative testing during invasive coronary angiography may be considered when clinical criteria and noninvasive testing fail to establish the diagnosis 2
  • Using agents such as acetylcholine, ergonovine, or methylergonovine
  • Should be avoided in patients with significant left main disease, advanced 3-vessel disease, high-grade obstructive lesions, significant valvular stenosis, significant LV dysfunction, or advanced heart failure

Treatment Approach

First-Line Therapy

• Calcium channel blockers (CCBs) are the cornerstone of treatment for vasospastic angina, either alone or in combination with long-acting nitrates 2, 1
• High-dose calcium channel blockers can prevent spasm in approximately 90% of patients 1
• Amlodipine has been shown to decrease attacks by approximately 4/week compared with a placebo decrease of approximately 1/week (p<0.01) 3

Additional Pharmacologic Options

• Long-acting nitrates are effective when combined with CCBs for persistent symptoms 2, 1
• In patients with refractory vasospastic angina who don't respond to typical medications, additional options may include:
  • Alpha1-adrenergic receptor antagonists 4
  • Intracoronary nicardipine and nitroglycerin for acute management 5

Risk Factor Modification

• Smoking cessation is essential as smoking exacerbates coronary vasospasm 2
• Statin therapy is recommended 2
• Additional atherosclerosis risk factor modification is beneficial 2
• Avoidance of vasospastic triggers

Prognosis and Complications

• Most episodes resolve without complications
• Potential complications include:
  • Arrhythmias
  • Syncope
  • Myocardial infarction
  • Sudden death 2, 1
• Annual mortality rate is approximately 0.5% in patients with non-obstructive lesions 1
• Prognosis is least favorable when vasospastic angina occurs with obstructive coronary artery disease 2
• Higher risk of adverse events is seen in patients with multivessel disease 1

Treatment Pitfalls and Considerations

• Beta-blockers should be avoided in acute stages of cocaine-induced vasospasm as they may result in unopposed alpha stimulation with worsening coronary spasm 2
• Provocative testing carries small but serious risks including sustained spasm, serious arrhythmias, and rarely death 2
• Patients with vasospastic angina superimposed on stenotic lesions have significantly worse outcomes 1
• Vasospastic angina can be involved in many clinical scenarios beyond typical angina, including sudden cardiac death, acute coronary syndrome, arrhythmia, or syncope 6