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Vasospastic Angina

(Prinzmetal Angina; Variant Angina)


Ranya N. Sweis

, MD, MS, Northwestern University Feinberg School of Medicine;

Arif Jivan

, MD, PhD, Northwestern University Feinberg School of Medicine

Reviewed/Revised Feb 2024

Vasospastic angina is angina pectoris Angina Pectoris Angina pectoris is a clinical syndrome of precordial discomfort or pressure due to transient myocardial ischemia without infarction. It is typically precipitated by exertion or psychologic stress... read more secondary to epicardial coronary artery spasm. Symptoms include angina at rest and rarely with exertion. Diagnosis is by electrocardiography (ECG) and provocative testing with ergonovine or acetylcholine. Treatment is with calcium channel blockers and sublingual nitroglycerin.

Many patients with vasospastic angina also have significant fixed obstruction of at least one major coronary artery. Patients with mild or no fixed obstructions have better long-term outcomes than patients with associated severe fixed obstructions.

Symptoms and Signs of Vasospastic Angina

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.

Diagnosis of Vasospastic Angina

  • Provocative testing with ergonovine or acetylcholine during angiography

Diagnosis of vasospastic angina is suspected if ST-segment elevation occurs during an 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 finding significant ST-segment elevation on ECG or by observation of a reversible spasm during cardiac catheterization. Testing is done most commonly in a cardiac catheterization laboratory.

Treatment of Vasospastic Angina

  • Calcium channel blockers

  • Sublingual nitroglycerin

Usually, sublingual nitroglycerin promptly relieves vasospastic angina. Calcium channel blockers may effectively prevent symptoms. Theoretically, beta-blockers (other than labetalol and carvedilol) may exacerbate spasm by allowing unopposed alpha-adrenergic vasoconstriction, but this effect has not been proven clinically.

Oral medications most commonly used are calcium channel blockers:

  • Sustained-release diltiazem

  • Sustained-release verapamil

  • Amlodipine

Although all these medications relieve symptoms, they do not appear to alter prognosis. Average survival at 5 years is approximately 95% (if obstruction is absent or present in only one vessel), but mortality risk is greater for patients with both vasospastic angina and atherosclerotic coronary artery obstruction (1, 2 Treatment references Vasospastic angina is angina pectoris secondary to epicardial coronary artery spasm. Symptoms include angina at rest and rarely with exertion. Diagnosis is by electrocardiography (ECG) and provocative... read more ). Risk increases with increasing obstruction.

Treatment references

Drugs Mentioned In This Article

Drug Name Select Trade
Deponit, GONITRO , Minitran, Nitrek, Nitro Bid, Nitrodisc, Nitro-Dur, Nitrogard , Nitrol, Nitrolingual, NitroMist , Nitronal, Nitroquick, Nitrostat, Nitrotab, Nitro-Time, RECTIV, Transdermal-NTG, Tridil
Normodyne, Trandate
Coreg, Coreg CR
Cardizem, Cardizem CD, Cardizem LA, Cardizem SR, Cartia XT , Dilacor XR, Dilt-CD , Diltia XT, Diltzac, Matzim LA, Taztia XT, TIADYLT ER, Tiamate, Tiazac
Calan, Calan SR, Covera-HS, Isoptin, Isoptin SR, Verelan, Verelan PM
Katerzia, Norliqva, Norvasc
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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