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Variant Angina

(Prinzmetal Angina)

By

Ranya N. Sweis

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


Arif Jivan

, MD, PhD, Northwestern University Feinberg School of Medicine

Last full review/revision Jul 2020| Content last modified Jul 2020
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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.

Many patients with variant 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

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

  • Provocative testing with ergonovine or acetylcholine during angiography

Diagnosis of variant angina 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 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

  • Calcium channel blockers

  • Sublingual nitroglycerin

Average survival at 5 years is 89 to 97%, but mortality risk is greater for patients with both variant angina and atherosclerotic coronary artery obstruction. Risk increases with increasing 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 proven clinically.

Oral drugs most commonly used are calcium channel blockers:

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

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

  • Amlodipine 5 to 10 mg once a day (dose must be reduced in elderly patients and in patients with hepatic dysfunction)

Although all these drugs relieve symptoms, they do not appear to alter prognosis.

Drugs Mentioned In This Article

Drug Name Select Trade
NITRO-DUR
NORVASC
No US brand name
CALAN
CARDIZEM, CARTIA XT, DILACOR XR
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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
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