What is the recommended acute and preventive management for a middle‑aged smoker with chest pain at rest and transient ST‑segment elevation due to Prinzmetal (variant) angina?

Management of Prinzmetal (Variant) Angina

For acute episodes, administer sublingual or intravenous nitroglycerin immediately, which is exquisitely effective at relieving coronary vasospasm; for long-term prevention, initiate high-dose calcium channel blockers (verapamil 240-480 mg/day, diltiazem 180-360 mg/day, or amlodipine 5-10 mg/day) combined with long-acting nitrates, and mandate immediate smoking cessation. 1, 2, 3

Acute Management

Nitroglycerin is the cornerstone of acute treatment:

• Sublingual or intravenous nitroglycerin rapidly reverses coronary vasospasm and should be administered at the first sign of chest pain 1
• Symptoms and ST-segment elevation typically resolve promptly after nitroglycerin administration 1
• If performing provocative testing during angiography, intracoronary nitroglycerin can immediately relieve refractory spasm 1, 4

Preventive Medical Therapy

Calcium channel blockers are first-line preventive therapy:

• Start with moderate to high doses: verapamil 240-480 mg/day, diltiazem 180-360 mg/day, or nifedipine 60-120 mg/day 1
• Amlodipine 5-10 mg once daily is FDA-approved specifically for vasospastic angina (Prinzmetal's or variant angina) and may be used as monotherapy or combined with other antianginal agents 3
• Calcium channel blockers prevent spasm in approximately 90% of patients, with diltiazem showing a 90% reduction in pain episodes in clinical trials 5, 6

Nitrates provide additional vasodilation:

• Long-acting nitrates should be combined with calcium channel blockers for patients with very active disease 1
• The combination of calcium channel blockers and nitrates represents first-line therapy according to ACC/AHA guidelines 2, 5

Critical medication considerations:

• Beta-blockers are contraindicated because they cause unopposed alpha-adrenergic vasoconstriction, which can precipitate or worsen coronary spasm 1, 2, 5, 4
• Large doses of aspirin are contraindicated in pure vasospastic angina 5, 4
• For patients not responding completely to calcium channel blockers and nitrates, alpha-receptor blockers have been reported to be beneficial 2

Smoking Cessation

Smoking cessation is mandatory and non-negotiable:

• Smoking is strongly associated with Prinzmetal angina, and patients are predominantly smokers despite having fewer other traditional coronary risk factors 1, 2
• Discontinuation of smoking is essential for disease control 1, 2

Diagnostic Confirmation

Coronary angiography is necessary to guide treatment:

• Angiography determines whether vasospasm is superimposed on obstructive coronary disease (present in 58% of cases) or occurs in normal vessels 1, 5
• Patients with vasospasm superimposed on fixed obstructive coronary artery disease have a worse prognosis and require more aggressive therapy 1, 2, 5
• Spasm often develops spontaneously during angiography, aiding diagnosis 1

Long-Term Management Considerations

Maintain therapy despite symptom-free intervals:

• Variant angina goes through waxing and waning phases, with periods of numerous daily episodes followed by long asymptomatic periods 1, 2
• Long-term therapy is necessary despite symptom-free intervals 2
• Continue calcium channel blockers and nitrates without interruption, particularly during perioperative periods 5

Monitor for complications:

• During active phases, patients are at risk for myocardial infarction, sudden cardiac death, high-degree AV block, and life-threatening ventricular arrhythmias 1, 7
• Lethal cardiac events are more frequent in patients with complex ventricular tachyarrhythmias or AV block associated with transient myocardial ischemia 1

Common Pitfalls to Avoid

Do not use exercise stress testing for diagnosis:

• Exercise testing is unreliable in Prinzmetal angina, showing unpredictable results (one-third ST elevation, one-third ST depression, one-third no change) 1, 8, 5
• Since this is a supply (vasospastic) abnormality rather than demand-induced ischemia, exercise testing has no diagnostic value 4

Do not assume normal resting ECG excludes disease:

• The resting ECG when asymptomatic may be entirely normal 8, 5
• Diagnosis requires documentation of transient ST-segment elevation during chest pain episodes 1, 8

Avoid precipitating factors:

• Attacks often occur in early morning hours and can be precipitated by emotional stress, cold exposure, or hyperventilation 5