Coronary artery vasospasm: Difference between revisions
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==Background== | ==Background== | ||
*Typically affects patients <50 yo | *Typically affects patients <50 yo | ||
*A/w transient ST deviation; typically local distribution | *A/w transient ST deviation; typically local distribution | ||
*Typically | *Typically occurs in early morning <ref> Prinzmetal M, Kennamer R, Merliss R, Wada T, Bor N. Angina pectoris. I. A variant form of angina pectoris; preliminary report. Am J Med. 1959;27:375-88.</ref> | ||
*Mechanism is likely vagal withdrawal | *Mechanism is likely vagal withdrawal | ||
*Tobacco use a major risk factor<ref> Takaoka K. Comparison of the risk factors for coronary artery spasm with those for organic stenosis in a Japanese population: role of cigarette smoking. Int J Cardiol. 2000;72:121–126.</ref> | *Tobacco use a major risk factor<ref> Takaoka K. Comparison of the risk factors for coronary artery spasm with those for organic stenosis in a Japanese population: role of cigarette smoking. Int J Cardiol. 2000;72:121–126.</ref> | ||
*May be a/w migraines <ref> Rosamond W. Are migraine and coronary heart disease associated? An epidemiologic review. Headache. 2004;44 Suppl 1:S5-12. </ref> | *May be a/w migraines <ref> Rosamond W. Are migraine and coronary heart disease associated? An epidemiologic review. Headache. 2004;44 Suppl 1:S5-12. </ref> | ||
*Vfib, tachycardia, and complete AV block may be a/w ischemic episodes | *Vfib, tachycardia, and complete AV block may be a/w ischemic episodes | ||
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*Chest discomfort/tightness/pressure | *Chest discomfort/tightness/pressure | ||
*Gradual onset/resolution | *Gradual onset/resolution | ||
*Often no exertional component to CP | |||
*No respirophasic component to pain | *No respirophasic component to pain | ||
*Poorly localized; radiation of pain is common | *Poorly localized; radiation of pain is common | ||
*a/w nausea, diaphroesis, and palpations | *a/w nausea, diaphroesis, and palpations | ||
*Attacks may be precipitated by hyperventilation | *Attacks may be precipitated by hyperventilation | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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*Holter monitor | *Holter monitor | ||
*Stress testing typically done to evaluate for fixed CAD, though prinzmetal angina often yields negative results | *Stress testing typically done to evaluate for fixed CAD, though prinzmetal angina often yields negative results | ||
**Often yields negative results <ref>Stern SS. Coronary artery spasm: a 2009 update.. Circulation (New York, N.Y.). 2009-05;119:2531-2534.</ref> | |||
*Coronary angiography considered in following patients:<ref> Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.</ref> | *Coronary angiography considered in following patients:<ref> Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.</ref> | ||
**ECG with STE | **ECG with STE | ||
Revision as of 12:59, 20 September 2015
Background
- Typically affects patients <50 yo
- A/w transient ST deviation; typically local distribution
- Typically occurs in early morning [1]
- Mechanism is likely vagal withdrawal
- Tobacco use a major risk factor[2]
- May be a/w migraines [3]
- Vfib, tachycardia, and complete AV block may be a/w ischemic episodes
Clinical Features
- Chest discomfort/tightness/pressure
- Gradual onset/resolution
- Often no exertional component to CP
- No respirophasic component to pain
- Poorly localized; radiation of pain is common
- a/w nausea, diaphroesis, and palpations
- Attacks may be precipitated by hyperventilation
Differential Diagnosis
- Acute pericarditis
- Anxiety disorder
- Aortic dissection
- Cocaine toxicity
- Esophageal spasm
- MI
- Unstable angina
- Cardiac X syndrome
Diagnosis
- EKG
- CXR
- Holter monitor
- Stress testing typically done to evaluate for fixed CAD, though prinzmetal angina often yields negative results
- Often yields negative results [4]
- Coronary angiography considered in following patients:[5]
- ECG with STE
- History strongly indicative and stress testing/ambulatory monitoring are normal
Management
- SLN
- Counsel on smoking cessation
- For chronic management
- Diltiazem 240-360 mg/day
- Isosorbide mononitrate considered 2nd line due to adverse effect profile
- Avoid nonselective beta blockers as they may exacerbate vasospasm [6]
- ASA used with caution and at low dose in pts without h/o CAD [7]
Disposition
See Also
External Links
References
- ↑ Prinzmetal M, Kennamer R, Merliss R, Wada T, Bor N. Angina pectoris. I. A variant form of angina pectoris; preliminary report. Am J Med. 1959;27:375-88.
- ↑ Takaoka K. Comparison of the risk factors for coronary artery spasm with those for organic stenosis in a Japanese population: role of cigarette smoking. Int J Cardiol. 2000;72:121–126.
- ↑ Rosamond W. Are migraine and coronary heart disease associated? An epidemiologic review. Headache. 2004;44 Suppl 1:S5-12.
- ↑ Stern SS. Coronary artery spasm: a 2009 update.. Circulation (New York, N.Y.). 2009-05;119:2531-2534.
- ↑ Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.
- ↑ Robertson RM, Wood AJ, Vaughn WK, Robertson D. Exacerbation of vasotonic angina pectoris by propranolol. Circulation. 1982;65(2):281-5.
- ↑ Miwa K, Kambara H, Kawai C. Effect of aspirin in large doses on attacks of variant angina. Am Heart J. 1983;105(2):351-5.