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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Chest pain at rest, which does not occur with exercise or emotional stress

  • Transient ST-segment elevation on ECG

  • Resolution of pain and ECG changes spontaneously or after nitroglycerin administration

  • Focal or diffuse coronary arterial spasm may be demonstrated on coronary angiography

GENERAL CONSIDERATIONS

  • Much more common in Japan, Korea, and Italy than in the United States

  • On coronary angiography, sites of vasospasm usually have at least minimal atherosclerosis as detected by intravascular ultrasound

  • Precise mechanism is not clear, although the following is known:

    • – An imbalance of endothelium-derived vasoconstrictor versus dilators

  • Cigarette smoking is an important risk factor

  • Patients with this disorder are younger than patients with angina secondary to classic atherosclerosis

  • Myocardial infarction (MI) and sudden cardiac death may occur

  • Rare cases may develop this disorder after coronary artery bypass graft (CABG) surgery

  • It may occur in association with aspirin-induced asthma

  • Alcohol withdrawal may provoke an attack

  • Chemotherapy may provoke variant angina (5-fluorouracil and cyclophosphamide)

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Severe chest pain unlike angina

  • Syncope

  • Clustering of chest pain between midnight and 8:00 AM

  • Normal exercise capacity and rarely, if ever, chest pain on exertion

PHYSICAL EXAM FINDINGS

  • Usually normal between episodes

    • – Previous MI may change clinical examination

  • During chest pain, an S4 may be heard

DIFFERENTIAL DIAGNOSIS

  • Unstable chronic ischemic heart disease

  • MI

  • Pericarditis

  • Other conditions mimicked on ECG, such as early repolarization

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC, metabolic panel

  • Cardiac biomarkers during acute episodes

ELECTROCARDIOGRAPHY

  • ECG shows transient ST elevation suggestive of acute MI during pain

  • Ambulatory ECG monitoring may reveal asymptomatic ST elevation

IMAGING STUDIES

  • Echocardiography may demonstrate left ventricular wall motion abnormalities during pain

DIAGNOSTIC PROCEDURES

  • Coronary angiogram

  • Fixed stenosis of a proximal vessel may be seen in the majority of patients

  • Diagnostic of the condition are:

    • – Normal coronary angiogram in the absence of ischemia

    • – Focal or diffuse coronary spasm during ischemia

  • Right coronary artery spasm is more common than left

  • Spasm at different sites or sequential involvement of different sites may be noted

  • Acetylcholine provocation test may be helpful

  • Ergonovine provocation may be helpful

TREATMENT

CARDIOLOGY REFERRAL

  • All patients should be referred to a cardiologist

HOSPITALIZATION CRITERIA

  • Hospitalization during acute episodes

MEDICATIONS

  • Sublingual nitroglycerin for acute attacks

  • Long-acting nitrates

  • Calcium channel blockers

  • Percutaneous or surgical revascularization is rarely successful

  • Aspirin increases severity of ischemic episodes

THERAPEUTIC PROCEDURES

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