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Current Concepts in Coronary Artery Spasm

Coronary artery spasm is an abnormality of coronary vascular smooth muscle contraction that is associated with significant morbidity and mortality. The underlying pathophysiological process has remained unclear since Myron Prinzmetal described it in 1959... CAS can manifest clinically as a wide spectrum of coronary syndromes, which can make diagnosis challenging. It is suspected in the presence of severe chest pain at rest, with concurrent electrocardiogram (ECG) changes showing transient ST-segment elevation. Although chest pain remains the most common symptom of CAS, it is worth noting that many attacks of CAS can be asymptomatic or silent

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 Unraveling The Mysteries of Prinzmetal Angina: What Is It And How Do We Diagnose It?

It is clear that the phenomenon of Prinzmetal angina is a complicated, multifaceted product of forces that are not only anatomical, but also genetic, chemical, physiological and behavioral in nature. While endothelial nitric oxide bioactivity appears to play a critical role in this process, there are undoubtedly several other factors involved. Over time, our knowledge of the pathophysiology driving Prinzmetal angina will continue to expand, as will our diagnostic and therapeutic repertoire for this fascinating clinical entity.

 Variant Angina: Why do you Ignore Spasm of Coronary Arteries?

As described in introduction, I cannot understand why many cardiologists have no concern to coronary vasospasm. However, variant angina, even in the absence of coronary narrowing on angiography, can cause acute myocardial infarction and fatal arrhythmias. Cardiologists must study more on this serious disease and establish better method of treatment of patients with vasospasm.

Articles of Interest

Coronary artery spasm: What is it and what are the treatment options?

An under-diagnosed condition called coronary artery spasm, also known as Variant angina or Prinzmetal angina, causes chest pain for many people.

Management of Coronary Artery Spasm

The most typical and well-defined clinical condition caused by coronary artery spasm (CAS) is Prinzmetal or variant angina. Variant angina is characterised by recurrent angina attacks that usually last 5–10 min, but sometimes only 30–60 s, and occur at rest, frequently at night, and usually in the absence of apparent triggering factors. However, exercise may trigger CAS in approximately 25% of patients. The ECG recorded during angina attacks typically shows ST-segment elevation, indicating transmural myocardial ischaemia, although ST-segment depression may occur in some patients/episodes, possibly because of subocclusive spasm and/or the presence of collateral flow.

The Silent Threat: Prinzmetal Angina Presenting As Polymorphic Ventricular Tachycardia

Prinzmetal angina remains an elusive diagnosis due to its intermittent presentation. Clinicians should maintain a high index of suspicion in patients with recurrent unexplained arrhythmias, as timely recognition and appropriate management can be life-saving.

Understanding Prinzmetal Angina

Sometimes, however, a cardiac catheterization with “provocative testing” is necessary to make the diagnosis. Because Prinzmetal angina is caused by coronary artery spasm rather than by a fixed blockage in the artery, the catheterization usually shows “normal” coronary arteries.

Unraveling The Mysteries of Prinzmetal’s Angina: What Is It And How Do We Diagnose It?

It is important to note that, although ST elevation would be diagnostic, it is frequently not observed in cases of coronary artery spasm. Rather, the diagnosis of coronary artery spasm should be suspected based on the timing of chest pain and the presence of syncope, arrhythmia or cardiac arrest.

Variant Angina

In 1959 Prinzmetal et al described 32 cases of angina occurring at rest, reporting that the clinical characteristics of these patients differed to those with Heberden’s classical angina of effort since: The angina did not occur with exertion and exercise - stress tests were typically negative. During pain, ST segment elevation rather than depression occurred. The angina episodes often recurred at the same time, frequently awaking the patient from sleep. The episodes may be associated with arrhythmias or progress on to myocardial infarction. Considering these differences, Prinzmetal coined the term "variant angina" and speculated that the condition was due to an "increased coronary tonus" or vasospasm.

Why Having a Chronic Condition Makes You Rethink Your Daily Routine

My heart issues also affect my sleep. As I lay awake in bed with severe angina pain, I wonder if I should wake my husband to get him to call an ambulance and face the inevitable. The explaining Prinzmetal’s angina to doctors who stand over you and say, “This is fascinating. I have only read about these cases.” The poking and prodding with needles of someone trying to cannulate me. You see, my veins don’t respond like everyone else’s. They close up, disappear, rupture, spasm; they will seemingly do anything to prevent cannulation.

Resources

5 Things You Should Know About Coronary Spasm

Chest pain is a common symptom of coronary artery disease. However, people without fixed, severe coronary blockages also can have chest pain due to a rare condition called coronary spasm. While the number of people with coronary spasm is very small, the disorder is often misdiagnosed or not diagnosed at all.

Prinzmetal.org

The American Prinzmetal's Angina Association, Inc. has been formed to foster awareness about this little known but devastating heart disease.

StatPearls

The cause of Prinzmetal Angina is a diffuse or segmental spasm in the coronary arteries which generate a decrease in blood supply to the myocardium generating chest pain. The coronary arteries may spasm as a result of exposure to cold weather, exercise, or a substance that promotes vasoconstriction such as alpha-agonists (pseudoephedrine and oxymetazoline). The use of recreation drugs such as cocaine has also been associated with the development of vasospastic angina, especially when associated the use of cigarettes.

Patient

There is no specific cure. Managing lifestyle factors is important in prevention. Smoking, alcohol, and high levels of anxiety have a significant role in coronary spasm.