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Variant Angina

(Prinzmetal Angina)

By James Wayne Warnica, MD, FRCPC , Professor Emeritus of Cardiac Sciences and Medicine, The University of Calgary

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Variant angina is angina pectoris secondary to epicardial coronary artery spasm. Symptoms include angina at rest and rarely with exertion. Diagnosis is by ECG and provocative testing with ergonovine or acetylcholine. Treatment is with calcium channel blockers and sublingual nitroglycerin.

Most patients with variant angina have significant fixed proximal obstruction of at least one major coronary artery. Spasm usually occurs within 1 cm of the obstruction (often accompanied by ventricular arrhythmia).

Symptoms and Signs

Symptoms are anginal discomfort occurring mainly during rest, often at night, and only rarely and inconsistently during exertion (unless significant coronary artery obstruction is also present). Attacks tend to occur regularly at certain times of day.


  • Provocative testing with ergonovine or acetylcholine during angiography

Diagnosis is suspected if ST-segment elevation occurs during the attack. Between anginal attacks, the ECG may be normal or show a stable abnormal pattern. Confirmation is by provocative testing with ergonovine or acetylcholine, which may precipitate coronary artery spasm. Coronary artery spasm is identified by significant ST-segment elevation or by observation of a reversible spasm during cardiac catheterization. Testing is done most commonly in a cardiac catheterization laboratory and occasionally in a coronary care unit.


  • Calcium channel blockers

  • Sublingual nitroglycerin

Average survival at 5 yr is 89 to 97%, but mortality risk is greater for patients with both variant angina and atherosclerotic coronary artery obstruction. Usually, sublingual nitroglycerin promptly relieves variant angina. Calcium channel blockers may effectively prevent symptoms. Theoretically, beta-blockers may exacerbate spasm by allowing unopposed alpha-adrenergic vasoconstriction, but this effect has not been proved clinically.

Oral drugs most commonly used are calcium channel blockers:

  • Sustained-release diltiazem 120 to 540 mg once/day

  • Sustained-release verapamil 120 to 480 mg once/day (dose must be reduced in patients with renal or hepatic dysfunction)

  • Amlodipine 15 to 20 mg once/day (dose must be reduced in elderly patients and in patients with hepatic dysfunction)

In refractory cases, amiodarone may be useful. Although these drugs relieve symptoms, they do not appear to alter prognosis.