What should be avoided in patients with non-ischemic vasoconstriction?

Avoiding Triggers in Non-Ischemic Vasoconstriction

In patients with non-ischemic vasoconstriction, beta-blockers should be avoided as they can potentiate coronary spasm through unopposed alpha-adrenergic stimulation. 1, 2

Key Medications to Avoid

• Beta-blockers: Should be avoided in patients with non-ischemic vasoconstriction, particularly in those with signs of acute intoxication (such as with cocaine) due to risk of potentiating coronary spasm 1, 2, 3

• Immediate-release nifedipine: Contraindicated in the absence of beta-blocker therapy as it can cause reflex tachycardia and worsen vasoconstriction 1, 4

• Phosphodiesterase inhibitors: Should not be administered within 24 hours of sildenafil or vardenafil, or within 48 hours of tadalafil if nitrates are being used for vasospasm management 1

• Nonsteroidal anti-inflammatory drugs (NSAIDs): Should be discontinued during management of vasospastic conditions due to increased risk of major adverse cardiac events 1

• Vasoactive substances: Should be avoided as they can trigger or worsen non-ischemic vasoconstriction syndromes 5, 6

Recommended Alternatives

• Calcium channel blockers: First-line therapy for non-ischemic vasoconstriction, especially vasospastic angina, either alone or in combination with nitrates 1

• Nitrates: Recommended for management of coronary vasospasm, particularly in combination with calcium channel blockers 1

• Benzodiazepines: Reasonable for management of hypertension and tachycardia in patients with cocaine-induced vasoconstriction 2, 3

• HMG-CoA reductase inhibitors (statins): Recommended for patients with vasospastic angina along with risk factor modification 1

Special Considerations

• Cocaine and methamphetamine users: In patients with recent cocaine or methamphetamine use, avoid beta-blockers due to risk of unopposed alpha-stimulation leading to worsened coronary vasospasm 1, 2, 3

• Diagnostic testing: For suspected vasospastic angina with episodic chest pain and transient ST-elevation, coronary angiography (invasive or non-invasive) is recommended to detect severe coronary artery disease 1

• Provocative testing: Should be avoided in patients with significant left main disease, advanced 3-vessel disease, high-grade obstructive lesions, significant valvular stenosis, or significant LV dysfunction 1

• Pharmacologic triggers: More than half of reversible cerebral vasoconstriction syndrome cases occur after exposure to vasoactive substances, which should be identified and discontinued 5, 6

Management Approach

1. Identify and remove triggers: Discontinue any vasoactive substances, cocaine, methamphetamines, or other potential triggers 5, 6

2. First-line pharmacotherapy: Initiate calcium channel blockers alone or in combination with nitrates for vasospastic conditions 1

3. Risk factor modification: Recommend cessation of tobacco use and modification of atherosclerosis risk factors 1

4. Monitor for complications: In reversible cerebral vasoconstriction syndrome, monitor for potential complications including ischemic stroke, subarachnoid hemorrhage, or intracerebral hemorrhage 5, 6

By avoiding these triggers and medications while implementing appropriate management strategies, the risk of exacerbating non-ischemic vasoconstriction can be minimized, leading to improved outcomes for patients with these conditions.