Prinzmetal's angina

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2],Amandeep Singh M.D.[3] Roukoz A. Karam, M.D.[4] Synonyms and Keywords: Variant angina; angina inversa; vasospastic angina

Overview

Vasospastic angina was previously referred to as Prinzmetal or variant angina. Vasospastic angina is a syndrome typically consisting of angina (cardiac chest pain) at rest that occurs in periodic cycles. Vasospastic angina is caused by vasospasm, a narrowing of the coronary arteries caused by contraction of the smooth muscle tissue in the vessel walls rather than fixed narrowings of the coronary arteries due to atherosclerosis (buildup of fatty plaque and hardening of the arteries).

Historical Perspective

Printzmetal's angina was first described as a variant form in 1959 by the American cardiologist Dr. Myron Prinzmetal.[1]

It was first documented by coronary arteriography in 1973.[2]

Classification

Classification by Location

Coronary artery spasm can be classified according to the location of vasoconstriction:

Focal coronary spasm

Focal coronary spasm is limited to a localized segment of the coronary artery.

Multifocal coronary spasm

Multifocal coronary spasm involves several localized segments of the same coronary artery.

Multivessel coronary spasm

Multivessel coronary spasm involves several coronary arteries.[3][4]

Classification by Clinical Syndrome

Coronary artery vasospasm can be classified into either spontaneous or iatrogenic.

Spontaneous

Iatrogenic

Pathophysiology

  • The exact pathogenesis of coronary vasospasm is not well understood, but some causes and contributing factors are known.
  • A significant group of patients with variant angina have underlying obstructive coronary artery disease.[7]

Epidemiology and Demographics

  • Incidence or prevalence of Prinzmetal angina is still unknown.
  • Young patients with fewer cardiovascular risk factors (with the exception of smoking) are at a higher risk for coronary vasospasm, as are noncalcified lesions and eccentric plaques.
  • Some studies show that the Japanese population has an increased risk of developing vasospastic angina when compared with Caucasian populations.
  • The average age of presentation of vasospastic angina is around the fifth decade of life.[8]

Risk Factors

  • Smoking[9]
  • Genetic factors and insulin resistance
    • There is some evidence that genetic factors and insulin resistance are associated with vasospastic angina
  • Patients with vasospastic angina are often younger and exhibit fewer classic cardiovascular risk factors (except smoking).
  • Vasospastic angina may be associated with other vasospastic disorders, such as Raynaud's phenomenon and migraine headache or its treatment [54-56].
  • A history of drug abuse such as cocaine may be present.
  • Hyperventilation can precipitate attacks of vasospastic angina [57].

Differential diagnosis

Vasopastic angina must be differentiated from other diseases that cause chest pain, view chest pain differential diagnosis for more.

Natural History, Complications and Prognosis

  • There are no findings characteristic for vasospastic angina. However, during an episode, tachycardia, hypertension, diaphoresis, and a gallop rhythm may be present.
  • Bradycardia and hypotension can be observed if the sinus nodal, atrioventricular nodal, and right ventricular arteries are involved during proximal right coronary artery vasospasm.
  • If left untreated, 25% of patients with prinzmetal angina may progress to develop myocardial infarction and life threatening arrhythmias.[10][11]
  • Two-thirds of patients have concurrent atherosclerosis of a major coronary artery. This is often mild or not in proportion to the degree of symptoms.
  • Coronary vasospasm can lead to life-threatening arrhythmias, depending on the vessel that is involved.
  • Once detected, aggressive management of coronary vasospasm is necessary, as vasospasm can provoke fatal arrhythmias or myocardial infarction.[12]
  • Patients who have coronary artery disease in addition to coronary vasospasm have an overall worse prognosis.[13]
  • The prognosis of vasospastic angina depends on the extent of underlying coronary artery disease (CAD).

History and Symptoms

While the symptoms of chronic stable angina occur with exertion, the symptoms of Prinzmetal's angina typically occur at rest. The symptoms may occur reproducibly at certain times of the day or night. In the classic description, the symptoms often come on at night.

Characteristic pain features for vasospastic angina include:

  • Discomfort better describes the spasms than pain. Other common ways to describe the episodes: squeezing, tightness, pressure, constriction, strangling, burning, heart burn, fullness in the chest, a band-like sensation, knot in the center of the chest, lump in the throat, ache, and heavy weight on chest.
  • Each episode is typically gradual in onset and offset.
  • There is no change in the quality of pain with respiration or position.
  • The patient may have some difficulty in describing the location of the pain, although the substernal location is common. Radiation to the neck, throat, lower jaw, teeth, upper extremity, or shoulder is common.
  • During each episode, symptoms of nausea, sweating, dizziness, dyspnea, and palpitations may be present.

Diagnosis

  • Physicians should suspect vasospasm if ST segment elevation is detected in patients experiencing angina, and if the ECG completely returns to baseline upon resolution of symptoms.
    • These changes are usually transient (less than 15 minutes) and may occur in multiple leads of a 12-lead ECG.
  • Patients who develop cardiac chest pain are generally treated empirically as an "acute coronary syndrome" patient, and are generally evaluated with serial testing of cardiac enzymes such as creatine kinase isoenzymes or troponin I or T. These may in some cases be abnormal or positive, as coronary spasm can lead to myocardial necrosis in severe cases.
  • The gold standard test is coronary angiography including the administration of provocative agents, such as acetylcholine or ergonovine, via the intracoronary route. The definitive diagnosis of coronary vasospasm is made angiographically by demonstration of reduction of luminal diameter in a discrete segment of the vessel, which is proven to be reversible. Reversibility may be demonstrated by previous or subsequent enlargement of luminal diameter, often after the administration of intracoronary vasodilators.
  • It should be noted that two-thirds of patients with Prinzmetal's angina have concurrent atherosclerosis of a major coronary artery, but the extent of the atherosclerosis is generally mild, and the symptoms are out of proportion to the extent of disease. Depending on the local protocol, provocative testing may utilize either ergonovine, methylergonovine or acetylcholine. Exaggerated spasm is diagnostic of Prinzmetal's angina. Care should be taken to have nitrates and calcium channel agents readily available to reverse the spasm.

Electrocardiogram

Prinzmetal's angina is associated with transmural injury and ST segment elevation rather than ST segment depression.

The most important ECG change during a focal proximal coronary spasm is in around 50% of cases the appearance of peaked and symmetrical T wave that is followed, if the spasm persist, by progressive ST-segment elevation that last for a few minutes, and later progressively resolve.[14]

The most frequent ECG changes associated with ST-segment elevation are:

  • Increased height of the R wave
  • Coincident S-wave diminution
  • Upsloping TQ in many cases
  • Alternans of the elevated ST-segment
  • Negative T wave deepness
    • In 20% of cases.

Treatment

Prinzmetal angina typically responds to nitrates and calcium channel blockers. Patients with multivessel spasm, refractory spasm, spasm that results in sudden death may benefit from dual calcium channel blocker therapy.

  • Calcium channel blockers:
    • Generally, well tolerated and can aid with hypertension control.[15]
    • A combination of dihyropyridine and non-dihydropyridine calcium channel blockers should be used in patients with refractory coronary vasospasm, particularly if it has resulted in ventricular arrhythmia.
    • Multiple calcium channel blockers may be required in patients with refractory or multi-vessel spasm.
    • A patient who has suffered ventricular tachycardia or ventricular fibrillation due to spontaneous vasospasm (not due to acute infarction) should also likely undergo ICD placement.
  • Long-acting nitrates:
  • Statins:
  • Hormone replacement therapy:
    • This remains controversial, particularly due to the risk of concern of increased cardiac events.
  • Smoking cessation:
  • Percutaneous coronary intervention:
    • While resolution occurs following PTCA/stenting in some cases, spasm can propagate to a new location, proximal or distal to the stented site.[19]
    • PCI is not commonly indicated for patients with focal spasm and minimal obstructive disease. However, it may be helpful if significant obstructive coronary disease is present and thought to be a potential trigger for focal spasm.
  • ICD placement:
  • Surgical autonomic denervation/plexectomy:
    • Can be useful in cases that are refractory to medical therapy or percutaneous intervention. It's reserved only for the most refractory cases.

Making a Selection

  • Treatment of chronic vasospasm should be performed in this order (step-wise fashion): medical therapy, percutaneous intervention, and then, surgery.

Medical Therapy

Percutaneous Intervention (PCI)

  • If vasospasm has a clearly definable area that is associated with coronary artery disease and refractory to medical therapy, stenting may be an effective strategy. However, stenting may simply propagate the spasm to a proximal or distal location in the vessel.
  • Following any PCI, adjunctive medical therapy must be continued.
  • Resolution of symptoms, ECG changes, and angiographic vasospasm is usually apparent within one minute post-procedure.
  • Refractory spasm occurring during PCI is likely secondary to dissection, which requires stenting unless the artery is small and the patient is clinically stable.
  • The role of revascularization in the setting of multivessel vasospasm is uncertain.

Surgery

  • In the rare circumstance that a patient is refractory to pharmacologic and percutaneous therapy, surgical denervation and plexectomy have been effective.

2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) [20]

Recommendations for Prizmental's angina

Class I
"1.CCBs alone or in combination with long-acting nitrates are useful to treat and reduce the frequency of vasospastic angina.(Level of Evidence: B)"
"2.Treatment with HMG-CoA reductase inhibitor, cessation of tobacco use, and additional atherosclerosis risk factor modification and are useful in patients with vasospastic angina. (Level of Evidence: B)"
"3.Coronary angiography (invasive or noninvasive) is recommended in patients with episodic chest pain accompanied by transient ST-elevation to rule out severe obstructive CAD. (Level of Evidence: C)"
Class IIb
"1. Provocative testing during invasive coronary angiography†† may be considered in patients with suspected vasospastic angina when clinical criteria and noninvasive testing fail to establish the diagnosis (Level of Evidence: B)"

ESC Guidelines for Diagnostic Tests in Suspected Vasospastic Angina (DO NOT EDIT)[21]

Class I
"1. ECG during angina if possible. (Level of Evidence: B)"
"2. Coronary arteriography in patients with characteristic episodic chest pain and ST-segment changes that resolve with nitrates and/or calcium channel blockers to determine the extent of underlying coronary disease. (Level of Evidence: B)"
Class IIa
"1. Intracoronary provocative testing to identify coronary spasm in patients with normal findings or nonobstructive lesions on coronary arteriography and the clinical picture of coronary spasm. (Level of Evidence: B)"
"2. Ambulatory ST Segment Monitoring to identify ST-deviation. (Level of Evidence: C)"

ESC Guidelines for Pharmacological Therapy of Vasospastic Angina (DO NOT EDIT)[21]

Class I
"1. Treatment with calcium channel blocker and if necessary nitrates in patients whose coronary arteriogram is normal or shows only non-obstructive lesions. (Level of Evidence: B)"

References

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  9. Takaoka K, Yoshimura M, Ogawa H, Kugiyama K, Nakayama M, Shimasaki Y; et al. (2000). "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. 72 (2): 121–6. doi:10.1016/s0167-5273(99)00172-2. PMID 10646952.
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  12. Kishida H, Tada Y, Tetsuoh Y, Yamazaki Y, Saito T, Fukuma N; et al. (1991). "A new strategy for the reduction of acute myocardial infarction in variant angina". Am Heart J. 122 (6): 1554–61. doi:10.1016/0002-8703(91)90271-i. PMID 1835559.
  13. Bory M, Pierron F, Panagides D, Bonnet JL, Yvorra S, Desfossez L (1996). "Coronary artery spasm in patients with normal or near normal coronary arteries. Long-term follow-up of 277 patients". Eur Heart J. 17 (7): 1015–21. doi:10.1093/oxfordjournals.eurheartj.a014996. PMID 8809518.
  14. de Luna AB, Cygankiewicz I, Baranchuk A, Fiol M, Birnbaum Y, Nikus K; et al. (2014). "Prinzmetal angina: ECG changes and clinical considerations: a consensus paper". Ann Noninvasive Electrocardiol. 19 (5): 442–53. doi:10.1111/anec.12194. PMID 25262663.
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  17. Yasue H, Mizuno Y, Harada E, Itoh T, Nakagawa H, Nakayama M; et al. (2008). "Effects of a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, fluvastatin, on coronary spasm after withdrawal of calcium-channel blockers". J Am Coll Cardiol. 51 (18): 1742–8. doi:10.1016/j.jacc.2007.12.049. PMID 18452779.
  18. Miwa K, Fujita M, Miyagi Y (1994). "Beneficial effects of smoking cessation on the short-term prognosis for variant angina--validation of the smoking status by urinary cotinine measurements". Int J Cardiol. 44 (2): 151–6. doi:10.1016/0167-5273(94)90019-1. PMID 8045660.
  19. Corcos T, David PR, Bourassa MG, Val PG, Robert J, Mata LA; et al. (1985). "Percutaneous transluminal coronary angioplasty for the treatment of variant angina". J Am Coll Cardiol. 5 (5): 1046–54. doi:10.1016/s0735-1097(85)80004-8. PMID 3157733.
  20. Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD et al.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. September 2014 (ahead of print)
  21. 21.0 21.1 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.

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