Coronary artery vasospasm

Background

  • Typically affects patients <50 yo
  • Associated with transient ST deviation in local distribution
  • Often occurs in early morning [1]
  • Mechanism is likely vagal withdrawal
  • Tobacco use a major risk factor[2]
  • May be associated with migraines [3]
  • Vfib, tachycardia, and complete AV block may be associated with ischemic episodes

Clinical Features

  • Chest discomfort/tightness/pressure
  • Gradual onset/resolution
  • No respirophasic component to pain
  • Poorly localized; radiation of pain is common
  • Associated with nausea, diaphroesis, and palpations
  • Attacks may be precipitated by hyperventilation
  • Often no exertional component to chest pain
    • Exertion results in variable symptoms, including increase, decreased, or no change in chest pain
    • Makes exertional symptoms unreliable

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Evaluation

  • ECG and troponin
    • May demonstrate ST elevation during spasm, but troponin often negative
  • CXR
  • Holter monitor
  • Stress testing typically done to evaluate for fixed CAD
    • 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

  • Sublingual nitroglycerin
  • Counsel on smoking cessation
  • For chronic management
    • Diltiazem 240-360mg/day
    • Isosorbide mononitrate considered 2nd line due to adverse effect profile
  • Avoid nonselective β-blockers as they may exacerbate vasospasm [6]
  • ASA used with caution and at low dose in patients without history of CAD [7]

Disposition

  • Consider admission for serial cardiac enzymes and provocative testing
  • Sometimes spasm occurs around an already existing plaque

See Also

External Links

References

  1. 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.
  2. 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.
  3. Rosamond W. Are migraine and coronary heart disease associated? An epidemiologic review. Headache. 2004;44 Suppl 1:S5-12.
  4. Stern SS. Coronary artery spasm: a 2009 update.. Circulation (New York, N.Y.). 2009-05;119:2531-2534.
  5. 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.
  6. Robertson RM, Wood AJ, Vaughn WK, Robertson D. Exacerbation of vasotonic angina pectoris by propranolol. Circulation. 1982;65(2):281-5.
  7. 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.