Prinzmetal angina

A 20 year old female presents with recurrent episodes of central chest pain that are non exertional, sudden in onset, and last 5 to 15 minutes. The pain is substernal, severe, and radiates to the left arm, jaw, and neck, and is associated with nausea and diaphoresis. She has a history of Raynaud disease. Vital signs are normal. Electrocardiography shows transient ST segment elevation during an ergonovine provocation test. Coronary angiography demonstrates coronary vasospasm without significant atherosclerosis. Diagnosis?

Diagnosis is Prinzmetal angina (variant angina).

1. Definition

Prinzmetal angina is a form of vasospastic angina caused by transient coronary artery vasospasm, leading to myocardial ischemia in the absence of significant atherosclerotic obstruction.

2. Etiology

1. Coronary artery vasospasm due to:
• Endothelial dysfunction
• Hyperreactivity of vascular smooth muscle
2. Associated conditions:
• Raynaud disease
• Other vasospastic disorders
3. Triggers include:
• Smoking
• Cocaine
• Cold exposure
• Emotional stress
• Ergonovine or acetylcholine

3. Pathophysiology

1. Transient vasospasm of coronary arteries
2. Leads to reduced myocardial blood flow
3. Causes transmural ischemia resulting in transient ST segment elevation

4. Clinical Features

4.1 Core Features

1. Chest pain at rest, often severe
2. Episodes typically occur at night or early morning
3. Not related to exertion
4. Rapid relief with nitrates

4.2 Associated Features

1. Diaphoresis, nausea
2. Association with vasospastic disorders such as Raynaud disease

5. Diagnosis

5.1 Electrocardiography

1. Transient ST segment elevation during episodes
2. ECG normal between episodes

5.2 Cardiac Biomarkers

1. Usually normal
2. May be mildly elevated if ischemia is prolonged

5.3 Coronary Angiography

1. Normal or near normal coronary arteries
2. Demonstrates reversible vasospasm

5.4 Provocation Testing

1. Ergonovine or acetylcholine induces vasospasm
2. Used when diagnosis is uncertain

6. Management

1. Calcium channel blockers are first line therapy
• Diltiazem, verapamil, amlodipine
2. Nitrates for acute relief and prevention
3. Avoid triggers such as:
• Smoking
• Cocaine
• Cold exposure
4. Avoid beta blockers, especially nonselective agents, as they may worsen vasospasm

7. Complications

1. Arrhythmias
2. Myocardial infarction
3. Sudden cardiac death

8. Key Clinical Insight

Rest angina + transient ST elevation + normal coronary arteries + vasospastic history = Prinzmetal angina

9. Exam Level Pearls

1. Occurs at rest, not with exertion
2. ST elevation resolves completely between episodes
3. Smoking is the strongest modifiable risk factor
4. Calcium channel blockers are first line treatment
5. Beta blockers can worsen vasospasm
6. Associated with Raynaud disease and other vasospastic conditions
7. May cause transient arrhythmias or AV block during episodes