Rapid Review·Cardiovascular
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Coronary Artery Disease
T1Must knowVasospastic Angina
Focus on
Young smoker, chest pain at rest in the small hours, transient ST elevation that vanishes with the pain, normal troponin, clean coronaries. Calcium-channel blockers treat and prevent it; beta blockers make it worse.
Key takeaways
What it is
Prinzmetal (variant) angina
transient spasm of a coronary artery with normal coronaries.Cause
hyperreactivity of coronary smooth muscle from endothelial dysfunction and autonomic imbalance.Causes and risk factors
Smoking is the strongest risk factor
and the only classic atherosclerotic risk factor that applies.Drug triggers
stimulants (cocaine, amphetamines), alcohol and triptans provoke it.Other vasospastic disorders
it is associated with Raynaud phenomenon and migraine.Typical patient
young.Clinical features
Episodic chest pain that resolves quickly on its own
not brought on by exertion.- It often occurs at rest, typically at night or early in the morning.
Triggers
stress, hyperventilation, and exposure to cold.Diagnosis
Electrocardiogram (ECG) during pain
ST elevation in the territory of the spastic artery; it is normal between attacks.Troponin is usually normal
it is not an ST-elevation myocardial infarction (STEMI).Coronary angiography shows no coronary artery disease
acetylcholine testing during the angiogram can confirm the diagnosis.Management
Abortive
sublingual nitroglycerin.Preventive, first line
a calcium-channel blocker (verapamil, diltiazem or nifedipine).- It works for both attacks and prophylaxis.
Smoking cessation.
Avoid beta blockers
they block smooth-muscle relaxation.| Feature | Vasospastic angina | Stable angina |
|---|---|---|
| Patient | Young smoker; migraine, Raynaud | Older, multiple atherosclerotic risk factors |
| Timing | Rest, night to early morning | Exertion, emotion |
| ECG during pain | ST elevation | Normal or non-specific between attacks |
| Angiography | Normal coronaries | Fixed stenosis |
| First-line prevention | Calcium-channel blocker | Beta blocker |
| Beta blockers | Avoid | First line |
A 32-year-old smoker with migraines wakes at 4 a.m. with chest pain; the ECG shows inferior ST elevation that is gone 20 minutes later, and troponin is normal. What is the diagnosis and the first-line preventive drug?
Vasospastic (Prinzmetal) angina: rest pain in the early morning, transient ST elevation, normal troponin, and a young smoker with another vasospastic disorder. Prevent attacks with a calcium-channel blocker (verapamil, diltiazem or nifedipine), stop smoking, and avoid beta blockers.
How it's tested
A 32-year-old woman who smokes has recurrent 4 a.m. chest pain; the ECG shows inferior ST elevation that is gone 20 minutes later, and troponin is normal: vasospastic angina; start a calcium-channel blocker and stop smoking.
Same patient given metoprolol at discharge returns with more frequent attacks: beta blockade worsened the spasm; switch to diltiazem.
A young man with cocaine use, chest pain and ST elevation: benzodiazepines, nitroglycerin and a calcium-channel blocker; avoid beta blockers.
What confirms the diagnosis when the resting angiogram is clean: intracoronary acetylcholine or ergonovine provocation.
Go deeper
Guidelines: 2023 AHA/ACC Chronic Coronary Disease Guideline
Related Step 2 pages: Stable Angina, Acute Coronary Syndrome, Approach to Chest Pain
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