Can Coronary Stents Cause Prinzmetal Angina?
No, coronary stents do not cause Prinzmetal angina—the condition is caused by coronary artery vasospasm, which is a functional disorder of vascular tone, not a structural problem created by stents. However, stents have been used experimentally to treat refractory vasospastic angina, though this remains controversial and is not standard practice 1.
Understanding the Pathophysiology
- Prinzmetal angina results from temporary increases in coronary vascular tone (vasospasm) causing marked but transient reductions in luminal diameter 2.
- The vasospasm is usually focal at a single site and can occur in either normal or diseased vessels 2.
- Endothelial dysfunction is considered primarily responsible for the condition, not mechanical obstruction 2.
The Relationship Between Stents and Vasospasm
- Stents are placed to treat fixed obstructive lesions, while Prinzmetal angina is a dynamic vasospastic disorder—these are fundamentally different pathophysiologic processes 3, 2.
- Approximately 58% of Prinzmetal angina patients have underlying obstructive coronary disease that may require stenting, but the stent addresses the fixed stenosis, not the vasospasm 4.
- In rare cases reported in the literature, stenting has been attempted for refractory vasospastic angina unresponsive to triple drug therapy, but this is not standard care and requires long-term follow-up data 1.
Critical Diagnostic Distinction
- Stenoses that appear fixed on angiography in Prinzmetal angina patients should be suspected to be spasm even if unresponsive to nitroglycerin, especially when the rest of the vessel is normal 3.
- Additional pharmacologic manipulation and even recatheterization may be necessary to prove the dynamic nature of the lesion and avoid unnecessary stenting 3.
Standard Treatment Approach
- The American Heart Association recommends calcium channel blockers and nitrates as first-line therapies for variant angina, not mechanical intervention 5.
- Calcium channel blockers prevent spasm in approximately 90% of patients 4.
- Beta-blockers are contraindicated as they cause unopposed alpha-adrenergic vasoconstriction, precipitating coronary spasm 4, 2.
Common Clinical Pitfall
- The critical error is mistaking vasospasm for fixed stenosis and placing unnecessary stents 3.
- When patients with stents for obstructive disease develop Prinzmetal angina symptoms, this represents coexisting vasospastic disease superimposed on their fixed coronary disease, which carries a worse prognosis and requires aggressive medical therapy with vasodilators 5.