Prinzmetal's angina

Last edited 09/2022 and last reviewed 09/2022

This is angina caused by focal spasm of angiographically normal coronary arteries. In about 75% of patients there is also atherosclerotic coronary artery obstruction. In cases where there is atherosclerotic obstruction the vasospasm occurs near the stenotic lesion.

The chest pain may:

• occur at rest or wake the patient from sleep
• be accompanied by dyspnoea and/or palpitations
• be triggered by exertion; there is variability in the workload required to precipitate pain

Vasospastic angina may result in recurrent episodes of angina (including nocturnal angina), which can progress on to major adverse cardiac events (6)

The presumptive diagnosis of vasospastic (or variant angina) is made when the patient has angina in association with transient ST-segment elevation, both of which resolve spontaneously or with nitroglycerin (1)

• can be clinically diagnosed during a spontaneous episode by documenting nitrate-responsive rest angina with associated transient ischaemic ECG changes but more often requires provocative coronary spasm testing with acetylcholine during coronary angiography (6)
• coronary arteriography is recommended in all patients with Prinzmetal's angina (1)
  • when coronary arteriogram is normal or shows only nonobstructive plaques and if transient ST-segment elevation can be demonstrated in association with discomfort, the diagnosis of Prinzmetal's angina can be made and no further tests are necessary

The management of variant angina resembles that for other forms of angina. Nifedipine and nitrates are particularly effective (2). Coronary stenting can be useful for refractory spasm, CABG can be used for important coronary atherosclerosis (2).

• in patients with acute coronary syndromes in course of variant angina, adequate early stent implantation may prevent acute myocardial infarction (3)

Once treated the prognosis is excellent and severe complications such as arrhythmias, myocardial infarction or sudden death are rare (2).

Notes:

• rarely, VA can develop as a manifestation of a generalized vasospastic disorder associated with attacks of migraine and Raynaud's phenomenon (4)
• patients with variant angina are at the highest risk of cardiac death or acute myocardial infarction during the early phase of the follow-up period, when disease activity is high (1)
  • during the first year of observation the patient must be followed very closely
  • in the great majority of patients there is a tendency for symptoms to decrease; although in some patients may have periods of remission and exacerbation of disease activity. Therefore, it has been recommended that careful follow-up and medical therapy should not be discontinued in patients with Prinzmetal's angina (1)
• DVLA guidance for Prinzmetal's angina (variant angina) is as for angina per se (5)

Reference:

1. Seniuk W et al. Journal of Internal Medicine 2002;252 (4): 368-376.
2. Dendale P et al. Acta Cardiol 1999; 54 (2): 71-6.
3. Sosnowski C et al. Coronary artery stent placement as a treatment of acute coronary syndrome in course of variant angina.International Journal of Cardiology, available online 6 April 2005.
4. Gersh BJ, Braunwald E, Rutherford JD. Prinzmetal's variant angina. In: Braunwald E (ed.). Braunwald Heart Disease. WB Saunders Company, Philadelphia, 1997; 1340-3.
5. Driving and Vehicle Licensing Agency. Report from Ischaemic Heart Disease Workshop – 6-7 July 2005
6. Beltrame JF. Management of vasospastic angina. Heart Published Online First: 02 September 2022. doi: 10.1136/heartjnl-2022-321268