Prinzmetal angina

Vignette says a 20 year old female presents to the cardiology clinic for evaluation of chest pain; She is experiencing increased episodes of central chest pain which is non exertional, self-limiting in nature that typically lasts for brief period (5-15 minutes); The pain is sudden in onset, substernal, tight, and crushing in nature, severe in intensity with radiation to the left arm, jaw and neck associated with nausea, vomiting and diaphoresis; She was diagnosed with Raynaud disease 1 year back but is not under any medications; She doesn't smoke cigarettes but drinks alcohol occasionally; Vital signs are normal; ECG shows ST-segment elevation in leads II, III and aVF during ergonovine test; Coronary catheterization shows coronary vasospasm with no atherosclerotic occlusions; Diagnosis?

Diagnosis is Prinzmetal angina (i.e. variant angina).

Prinzmetal angina occurs due to transient coronary artery vasospasm, leading to reduced blood flow and ischemia in the heart muscle and is characterized by chest pain at rest that is responsive to nitrates with ECG showing transient ST-segment elevation present during chest pain. 

It is characterized by the triad of:- 

1. Chest pain at rest, typically self-limiting and responsive to nitrates. 

2. ECG showing transient ST-segment elevation during chest pain.

3. Coronary catheterization showing coronary vasospasm with no or minimal atherosclerotic occlusions.

Diagnosis:-

1. ECG shows ST-segment elevation during pain episodes.

2. Cardiac biomarkers (e.g. CK-MB, Troponins) are negative.

3. Coronary angiography shows provocative coronary vasospasm (i.e. ergonovine, acetylcholine) with no or minimal atherosclerotic occlusions.

Management:- 

1. Stop the offending agents (e.g. smoking, cocaine, marijuana, triptans).

2. Medical therapy includes nitrates, and CCB's (e.g. verapamil, diltiazem, amlodipine). 

Beta blockers (i.e. nonselective) are contraindicated as they worsen vasospasm.