Medicine, via pristina

Login

Medicine, via pristina

Login

Welcome to
HMD Articles

Vasospastic (Prinzmetal) Angina

Cardiology > Stable Angina (Angina Pectoris).

Stable Angina (Angina Pectoris)

Classification
Pathophysiology
Epidemiology

What causes it
Risk factors

History (Symptoms)
Physical Exam findings / signs

Empty

Background 

Vasospastic angina, also known as Prinzmetal or Variant angina, is a clinical condition characterized by transient myocardial ischemia due to coronary artery vasospasm. Unlike stable angina, it occurs at rest and is often not triggered by exertion. Symptoms typically occur in cyclical patterns, often during the night or early morning hours. 

Classification/Types 

    • Pure vasospastic angina: No evidence of obstructive coronary artery disease (CAD) 

    • Mixed angina: Vasospasm superimposed on fixed coronary stenosis 

Epidemiology 

    • More common in women under 50 years 
    • Higher prevalence in East Asian populations 
    • Increased incidence in smokers 
    • Often associated with other vasospastic disorders (e.g., Raynaud’s phenomenon) 

Etiology

I) Causes 

Vasospasmic angina is caused by: 

    • Hyperreactivity of vascular smooth muscle 
    • Endothelial dysfunction 
    • Autonomic nervous system imbalance 
    • Low-grade inflammation or oxidative stress 

II) Risk Factors 

    • Smoking (most significant) 
    • Cocaine or stimulant use 
    • Emotional stress or hyperventilation 
    • Cold exposure 
    • Medications (e.g., triptans, ergot alkaloids) 
    • Alcohol withdrawal 

Clinical Presentation

   I) History (Symptoms) 

    • Chest pain at rest, often occurring in early morning hours 
    • Pain may be severe, squeezing or pressure-like, sometimes radiating to jaw, neck, or arms 
    • Relieved rapidly by nitrates 
    • Episodes may be cyclical or clustered 

II) Physical Exam (Signs) 

    • Often normal between episodes 

Vital Signs During Episode: 

    • May show transient hypertension, tachycardia, or bradycardia 

Physical Exam: 

    • Cardiac: May detect transient S4 or S3, especially during ischemia 
    • Pulmonary: Generally clear unless coexisting condition 
    • Neurological: Rule out cocaine intoxication if suspected 
    • Skin: Look for pallor, diaphoresis 

Differential Diagnosis

    • Acute coronary syndrome (ACS) 
    • Pericarditis 
    • Aortic dissection 
    • Esophageal spasm  
    • GERD 
    • Panic attacks or anxiety disorders 
    • Cocaine-induced chest pain 

Diagnostic Tests

   Initial Tests 

    • 12-lead ECG during chest pain: May show transient ST-segment elevations 
    • Cardiac Enzymes (CK-MB, Troponins): Usually normal unless prolonged vasospasm causes myocardial injury 

   Imaging and Labs  

    • Resting ECG: Often normal when asymptomatic 
    • Holter monitoring: May capture spontaneous episodes 
    • Exercise stress testing: Typically normal 
    • Coronary angiography: Gold standard; may include provocative testing (ergonovine or acetylcholine) to induce spasm under controlled conditions 

   Basic Labs 

    • CBC, CMP, lipid panel 
    • Toxicology screen (if substance abuse suspected) 
    • Magnesium levels (hypomagnesemia can precipitate spasm) 

Treatment

A. Acute Management During Episode 

      • Sublingual nitroglycerin: Rapid symptom relief 
      • Oxygen therapy if SpO₂ <90% 
      • Cardiac monitoring during prolonged episodes 

B. Long-Term Management 

           Pharmacologic Therapy

      • Calcium channel blockers (first-line medication): Amlodipine, Diltiazem, Verapamil 
      • Long-acting nitrates: Isosorbide mononitrate, Isosorbide dinitrate 
      • Magnesium supplements if low 

          Medications to Avoid

      • Non-selective beta-blockers: May worsen vasospasm (eg, Propranolol, Nadolol) 
      • Sumatriptan and ergot derivatives 
      • Lifestyle Modifications
      • Smoking cessation (critical) 
      • Avoidance of triggers (e.g., cold, stress, certain meds) 

 Consults

      • Cardiologist for diagnostic confirmation and long-term management 
      • Addiction medicine or social work referral if substance abuse is a factor 

 Patient Education 

      • Educate on avoiding known triggers 
      • Stress importance of medication adherence 
      • Smoking cessation programs 
      • Annual influenza and COVID-19 vaccination 
 

Follow-Up

      • Routine follow-up to assess symptom control and medication tolerance 
      • Holter monitor or event monitor if symptoms recur 
      • Cardiology follow-up for provocative testing or angiography if not done initially 

Recommended

Play Video

Stay on top of medicine. Get connected. Crush the boards.

HMD is a beacon of medical education, committed to forging a global network of physicians, medical students, and allied healthcare professionals.

Contact Us

Additional Services

Planning phase $150
An country demesne message it. Bachelor domestic extended doubtful.
Execution phase $600
Morning prudent removal an letters extended doubtful seamles.
Post construction phase $355
Tolerably behaviour may admitting daughters offending her ask own.
Design-build $255
Boisterous he on understood attachment as entreaties ye devonshire.
Building services $350
Way now instrument had eat diminution melancholy expression.
Building management systems $700
An country demesne message it. Bachelor domestic extended doubtful.
Energy allocation $525
Morning prudent removal an letters extended doubtful seamles.
Boosting project $130
Tolerably behaviour may admitting daughters offending her ask own.
Water system $455
Boisterous he on understood attachment as entreaties ye devonshire.
Building connectivity $250
Way now instrument had eat diminution melancholy expression.
Shopping Basket