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Synonym: variant angina, Prinzmetal's angina
See separate related articles Stable Angina and Acute Coronary Syndrome.
First described by Prinzmetal et al in 1959, coronary artery vasospasm may be associated with acute myocardial infarction, serious ventricular arrhythmias and sudden death. Most patients also have underlying coronary artery disease, but some have normal arteries.
- Coronary artery spasm affects approximately 4 out of 100,000 people. Few UK patients with angina have coronary artery spasm - possibly because of the widespread use of calcium-channel blockers for other indications.
- The prevalence of coronary spasm is higher in Japan and Korea. Series in Japan have identified spasm in 40% of patients with angina pain undergoing angiography.
Age, smoking, high-sensitivity C-reactive protein (hs-CRP), and remnant lipoproteins are a significant risk factor for coronary spasm.
- This variant of angina occurs at rest, usually lasting for between 5 and 30 minutes. Most episodes occur between midnight and early morning.
- The pain is often severe and may be associated with palpitations or syncope secondary to arrhythmia.
- A few patients have a general abnormality of vasomotor tone. They may also present with symptoms of migraine headache and Raynaud's phenomenon.
- Finding other evidence of diffuse atherosclerotic disease does not differentiate patients with variant angina from those with unstable angina. Physical examination does not reliably differentiate between variant angina and occlusive coronary artery disease.
See also separate articles Chest Pain and Cardiac-type Chest Pain Presenting in Primary Care.
- Distinguishing Prinzmetal's angina from an acute coronary syndrome is very difficult and so patients usually require hospital assessment and admission.
- Many patients with coronary artery spasm also have obstructive coronary artery disease.
- The absence of risk factors for atherosclerotic coronary artery disease suggests coronary artery spasm. Cigarette smoking is a risk factor for both coronary artery disease and spasm.
- FBC, renal function, electrolytes, fasting blood glucose and lipid levels.
- Cardiac enzymes and troponins to assess for acute coronary syndrome.
- ECG: transient ST-segment elevation during attacks is characteristic.
- Ambulatory ECG monitoring may be required because episodes of coronary artery vasospasm are often brief and ECG findings are often normal between attacks.
- Coronary angiography is the gold standard for the diagnosis of variant angina. Several provocative tests for coronary spasm are used; intracoronary acetylcholine and ergonovine are most common.
- If coronary revascularisation is not being considered or invasive coronary angiography is not clinically appropriate or acceptable to the person, offer non-invasive functional imaging. Options for non-invasive functional testing include:
- Myocardial perfusion scintigraphy (MPS) using single photon emission computed tomography (SPECT).
- Stress echocardiography.
- First-pass contrast-enhanced magnetic resonance (MR) perfusion.
- MR imaging for stress-induced wall motion abnormalities.
Managing lifestyle factors is important in prevention. Smoking, alcohol, and high levels of anxiety have a significant role in coronary spasm.
Specific measures include:
- Patients with angina at rest should be admitted to a hospital for observation, evaluation and initial management.
- Co-existing coronary artery disease is common and so management includes assessment and modification of all cardiovascular risk factors.
- Nitrates and calcium-channel blockers are the mainstay of medical therapy:
- Glyceryl trinitrate effectively treats episodes of angina and myocardial ischaemia and long-acting nitrate preparations reduce the frequency of recurrent events.
- Calcium-channel blockers are very effective in preventing coronary vasospasm and variant angina.
- Selective beta-blockers may be required in combination with nitrates and calcium-channel blockers to achieve symptom control, especially in patients with significant coronary artery disease.
- Implantable cardioverter defibrillator devices have been used in patients who survive ventricular tachycardia or fibrillation due to coronary artery spasm. This treatment is controversial.
- Coronary artery stenting may be required for refractory spasm.
- Coronary revascularisation may be required for associated fixed stenosis due to coronary artery disease.
- Myocardial infarction:
- Incidence is as high as 30% in some series.
- The incidence and prognosis of myocardial infarction in patients with variant angina appear to be associated with the extent and severity of any underlying atherosclerotic coronary stenoses.
- Syncope and presyncope may be associated with variant angina and are usually due to any associated significant arrhythmias.
- There is an increased incidence of ventricular tachycardia, ventricular fibrillation and complete atrioventricular block during episodes of coronary vasospasm.
- The risk of sudden death is increased in patients with multivessel spasm and serious arrhythmia during anginal attacks but in not those with fixed coronary stenosis.
- The overall prognosis is good if the patients take calcium-channel blockers and avoid smoking.
- Multivessel spasms have a greater risk of fatal arrhythmias.
Further reading & references
- Koschyk D, Munzel T, Brockhoff C, et al; Clinical picture. Prinzmetal angina. Lancet. 2000 Oct 21;356(9239):1434.
- Chen HS, Pinto DS; Images in clinical medicine. Prinzmetal's angina. N Engl J Med. 2003 Jul 3;349(1):e1.
- Prinzmetal M, Kenhammer R, Merliss R, et al; Angina pectoris. I. A variant form of angina pectoris; preliminary report. Am J Med. 1959 Sep;27:375-88.
- Yasue H, Nakagawa H, Itoh T, et al; Coronary artery spasm--clinical features, diagnosis, pathogenesis, and treatment. J Cardiol. 2008 Feb;51(1):2-17. Epub 2008 Feb 1.
- Wang SS, Coronary Artery Vasospasm, Medscape, Jan 2011
- Chest pain of recent onset, NICE Clinical Guideline (March 2010)
- Kusama Y, Kodani E, Nakagomi A, et al; Variant angina and coronary artery spasm: the clinical spectrum, pathophysiology, J Nihon Med Sch. 2011;78(1):4-12.
- Van Spall HG, Overgaard CB, Abramson BL; Coronary vasospasm: a case report and review of the literature. Can J Cardiol. 2005 Sep;21(11):953-7.
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Dr Hayley Willacy
Dr Hayley Willacy
Prof Cathy Jackson