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Monday, February 16, 2009

Acute Coronary Syndrome: Coronary Vasospasm

Acute Coronary Syndrome: Coronary Vasospasm


Ø Spontaneous episodes of chest pain due to coronary artery vasospasm in absence of increase in myocardial oxygen demand in either normal or diseased coronary vessels

Ø Also known as Prinzmetal angina or variant angina

Ø Most common in younger patients and men

Ø Occurs in patients without other cardiac risk factors

Ø Risk factors:

o Smoking

o Hyperinsulinemia

o Insulin resistance

Ø Associated with minimal coronary artery disease:

o Usually has normal coronary angiogram


  • Abnormal vasodilator function in coronary arteries
  • Focal coronary artery vasospasm
  • Often adjacent to or at the site of fixed stenoses
  • Unopposed alpha sympathetic stimulation
  • Sympathetic stimulation by endogenous hormones may cause vasoconstriction
  • Hypersensitivity of coronary arteries due to mediators of vasoconstriction
  • May or may not be associated with a fixed coronary lesion


Signs and Symptoms

  • Chest pain:
    • Retrosternal
    • Radiates to neck, jaw, left shoulder, or arm
    • Occurs at rest
  • Palpitations
  • Presyncope or syncope
  • Associated with migraine headaches and Raynaud disease in a minority of patients
  • May occur during cold weather or stress
  • May be prolonged in duration compared to typical angina
  • May be elicited by hyperventilation
  • May be relieved by exercise
  • Circadian pattern, most commonly in early morning



  • Transient ST-segment elevation is characteristic
  • May be followed by ST depression or T-wave inversion
  • May have associated arrhythmia during coronary spasm
  • Heart block with right coronary artery spasm
  • Ventricular tachycardia with LAD spasm


  • CK-MB and troponin I or T
  • Toxicologic screen:
    • Helpful if cocaine is suspected as etiology of chest pain


  • Chest radiograph:
    • May be helpful to rule out other etiologies such as pneumonia, pneumothorax, or aortic dissection
  • Thallium scintigraphy may be useful to localize area of spasm

Diagnostic Procedures/Surgery

  • Exercise stress testing:
    • Helpful only if there are underlying fixed stenoses
  • Coronary angiography:
    • Mild atherosclerosis is often the norm
    • Provocative test with ergonovine, acetylcholine, or hyperventilation will induce coronary spasm

Differential Diagnosis

  • Angina pectoris
  • Anxiety and panic disorders
  • Aortic dissection
  • Esophageal rupture
  • Esophageal spasm
  • Esophagitis
  • Gastroesophageal reflux
  • Mitral valve prolapse
  • Musculoskeletal chest pain
  • Myocardial infarction
  • Peptic ulcer disease
  • Pericarditis
  • Pneumothorax
  • Pulmonary embolism


Pre Hospital

Treat as any other acute coronary syndrome

Initial Stabilization

  • IV access
  • Oxygen
  • Cardiac monitoring
  • Vital signs and oxygen saturation

ED Treatment

  • All patients with chest pain in which cardiac ischemia is a consideration should receive an aspirin upon arrival to the ED:
    • Possibility of actually increasing severity of episodes in Prinzmetal angina due to inhibiting biosynthesis of naturally-occurring coronary vasodilator prostacyclin
  • Nitroglycerin should then be administered and is appropriate to help relieve both ischemic and vasospastic chest pain.
  • A trial of calcium-channel blockers is indicated if clinical history is consistent with coronary vasospasm
  • Heparin and beta-blockers are not helpful:
    • Beta-blockers may actually be detrimental due to unopposed alpha-mediated vasoconstriction.

Medication (Drugs)

  • Aspirin: 325 mg PO
  • Diltiazem: 30-60 mg PO
  • Nitroglycerin, either:
    • 0.4 mg sublingual
    • 10-20 mcg/min IV, titrating to effect
    • 1-2 inches of nitropaste
  • Verapamil: 40-80 mg PO



Admission Criteria

  • New-onset chest pain
  • Rest chest pain (by definition most patients with coronary vasospasm)
  • Accelerated chest symptoms

Discharge Criteria

Stable (chronic chest pain)


1. Braunwald E. Unstable angina: an etiologic approach to management [editorial]. Circulation. 1998;98:2219-2222.
2. Crea F, Kaski JC, Maseri A. Key references on coronary artery spasm. Circulation. 1994;89:2442-2446.
3. Gersh BJ, Braunwald E, Bonow RO. Chronic coronary artery disease. In: Braunwald E, ed. Heart disease: a textbook of cardiovascular disease. 6th ed. Philadelphia: WB Saunders, 2001;1324-1328.
4. Mayer S, Hillis LD. Prinzmetal's variant angina. Clin Cardiol. 1998;21:243-246.
5. Orford JL. Coronary artery vasospasm. Med J. 2001;2:111.
6. Prinzmetal M, Kennamer R, Merliss R. A variant form of angina pectoris. Am J Med. 1959;27:375-388.


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