Vasospastic Angina

• Angina caused by transient coronary spasms (usually due to spasms occurring close to areas of coronary stenosis)

• Not affected by exertion (may also occur at rest)

• Typically occurs early in the morning [36]

• Highest prevalence in the Japanese population (especially young women)

• Average age of onset: 50 years

• Cigarette smoking; use of stimulants (e.g., cocaine, amphetamines), alcohol, or triptans

• Stress, hyperventilation, exposure to cold

• Associated with other vasospastic disorders (e.g., Raynaud phenomenon, migraine headaches) [38]

• Common atherosclerotic risk factors (except smoking) do not apply to vasospastic angina.

The goal of diagnostic testing is to detect transient ischemic changes and/or coronary artery spasm during anginal episodes, as well as concomitant coronary artery stenosis. Specialist consultation is advised. [11]

• Initial testing [11][40]

  • Resting ECG

  • Consider Holter monitor

  • Exercise stress test

• Cardiac biomarkers

  • Measure serial troponin I and/or troponin T levels during periods of acute chest pain (i.e., at arrival and 1–6 hours later) if acute coronary syndrome is suspected (see also “Complications”).

  • Serial troponin levels are unlikely to be elevated in patients with transient ischemic changes.

• General recommendations

  • Smoking cessation

  • Avoid beta-blockers (particularly nonselective beta blockers) , and other agents that induce vasoconstriction

  • Atherosclerotic risk factor modification, as appropriate (see “Prevention”) [36]

• Pharmacotherapy: The goal is to prevent spasms and arrhythmias, and to improve symptoms during acute attacks. [11][40]

  • First-line therapy: calcium channel blockers, e.g., verapamil, diltiazem, or nifedipine [11]

  • Alternatively:

    • Long-acting nitrates: e.g., isosorbide dinitrate

    • Combination therapy for symptom control: nitrates with up to two CCBs from different classes [11]

Prognosis

• 5-year survival rate is > 90% (with treatment). [45]

• The persistence of symptoms is common.