Prinzmetal’s variant angina

Overview

A rare disorder where the heart artery spasms which affects the blood flow to the heart and causes pain. The condition can occur with or without physical activity.

Symptoms

* Located under the chest bone * Described as squeezing, constricting, tightness, pressure, or crushing, which is usually severe and may radiate to the neck, jaw, shoulder, or arm * Often occurs at rest * May occur at the same time each day, usually between 12:00 midnight and 8:00 AM * Lasts from 5 to 30 minutes * Relieved by nitroglycerin * Can cause fainting or loss of consciousness

Causes

It is not known exactly what causes coronary spasms. They may be due to problems with the thin lining of the blood vessels called the endothelium. Usually the artery lining produces a chemical (nitric oxide) that widens the blood vessel allowing blood to flow through with ease. If the artery lining is damaged or isn’t working properly, the blood vessels may narrow more easily, which may cause a coronary spasm. This idea is supported by research done in women. Levels of the artery-widening chemical are higher when estrogen levels are also high at certain stages of the menstrual cycle. Studies have shown that during these times when estrogen levels are high, women have fewer chest pain attacks. In addition, smokers tend to have lower levels of nitric oxide in their blood vessels than nonsmokers, and smoking is a major risk factor for coronary spasm.

Diagnosis

Prinzmetal’s angina is often diagnosed with an ECG (electrocardiogram or EKG) during an episode of chest pain. The ECG may show a particular pattern called ST-segment elevation—a bump on a graph of the heart’s electrical activity that shows up in a telltale place. The pattern will disappear when the chest pain resolves. If you do not have heart disease (meaning an X-ray of your heart shows no major blockages in the arteries of your heart) or have only mild heart disease, and this pattern appears during ECG testing, you will probably be diagnosed with a Prinzmetal’s angina. If you have heart disease, this particular ECG pattern is may indicate that you are having a heart attack. The gold standard for confirming a diagnosis of Prinzmetal’s angina is the coronary angiogram, a test that produces an X-ray of the heart’s arteries on a monitor. The physician will give you medication to see if it induces a spasm (the spasm will be visible on the monitor). If a focal spasm (a spasm at just one spot, rather than all over) occurs and you have ST-segment elevation on an ECG, you have Prinzmetal’s angina.

Prognosis

With medication, the prognosis is very good for people with Prinzmetal’s angina, and their chest pain can be treated successfully. One study found that 97% of patients survived 5 years after being diagnosed with Prinzmetal’s angina, and 83% survived without having a heart attack.8 Another study of 202 patients (18% female) who were diagnosed with variant angina between 1991 and 2002 found that 80% survived without a heart attack, and that most negative events happened within a month of when the patient first started having symptoms

Treatment

Prinzmetal’s angina is treated with medications, specifically nitroglycerin (NTG), long-acting nitrates, and calcium channel blockers — all of which widen or open the blood vessels and improve blood and oxygen flow to the heart muscle. Calcium channel blockers are generally prescribed first. If you continue to experience episodes of chest pain, then a different class of calcium channel blocker or a long-acting nitrate may be given. For people who do not respond well to either of these drugs, alpha blockers can be prescribed. Alpha blockers lower blood pressure and reduce blood vessel narrowing by blocking the action of stress hormones. Nitroglycerin is used when you are experiencing a spasm to stop it, thereby alleviating pain; it is not used as a preventive medication. Nitroglycerin is usually given as a spray that you use in your mouth or a tablet that you place under your tongue. Risk factor modification is also important because most people with Prinzmetal’s angina also have heart disease and are therefore at risk for a heart attack. It is especially important to stop smoking because smoking increases the likelihood of coronary artery spasms.5 By lowering your risk factors, you will reduce your chances of developing atherosclerosis. In addition, people diagnosed with Prinzmetal’s angina should avoid exposure to cold and high stress situations since these can trigger spasms.