We need you! Join our contributor community and become a WikEM editor through our open and transparent promotion process.
Coronary artery vasospasm
From WikEM
Contents
Background
- Typically affects patients <50 yo
- Associated with transient ST deviation in local distribution
- Often occurs in early morning [1]
- Mechanism is likely vagal withdrawal
- Tobacco use a major risk factor[2]
- May be associated with migraines [3]
- Vfib, tachycardia, and complete AV block may be associated with ischemic episodes
Clinical Features
- Chest discomfort/tightness/pressure
- Gradual onset/resolution
- Often no exertional component to chest pain
- No respirophasic component to pain
- Poorly localized; radiation of pain is common
- Associated with nausea, diaphroesis, and palpations
- Attacks may be precipitated by hyperventilation
Differential Diagnosis
Chest pain
Critical
- Acute Coronary Syndromes
- Aortic Dissection
- Cardiac Tamponade
- Pulmonary Embolism
- Tension Pneumothorax
- Boerhhaave's Syndrome
- Coronary Artery Dissection
Emergent
- Pericarditis
- Myocarditis
- Pneumothorax
- Mediastinitis
- Cholecystitis
- Pancreatitis
- Cocaine-associated chest pain
Nonemergent
- Stable angina
- Asthma exacerbation
- Valvular Heart Disease
- Aortic Stenosis
- Mitral valve prolapse
- Hypertrophic cardiomyopathy
- Pneumonia
- Pleuritis
- Tumor
- Pneumomediastinum
- Esophageal Spasm
- Gastroesophageal Reflux Disease (GERD)
- Peptic Ulcer Disease
- Biliary Colic
- Muscle sprain
- Rib Fracture
- Arthritis
- Chostochondirits
- Spinal Root Compression
- Thoracic outlet syndrome
- Herpes Zoster / Postherpetic Neuralgia
- Psychologic / Somatic Chest Pain
- Hyperventilation
- Panic attack
Evaluation
- ECG and troponin
- May demonstrate ST elevation during spasm, but troponin often negative
- CXR
- Holter monitor
- Stress testing typically done to evaluate for fixed CAD
- Often yields negative results [4]
- Coronary angiography considered in following patients:[5]
- ECG with STE
- History strongly indicative and stress testing/ambulatory monitoring are normal
Management
- Sublingual nitroglycerin
- Counsel on smoking cessation
- For chronic management
- Diltiazem 240-360mg/day
- Isosorbide mononitrate considered 2nd line due to adverse effect profile
- Avoid nonselective beta blockers as they may exacerbate vasospasm [6]
- ASA used with caution and at low dose in patients without history of CAD [7]
Disposition
- Consider admission for serial cardiac enzymes and provocative testing
- Sometimes spasm occurs around an already existing plaque
See Also
External Links
References
- ↑ Prinzmetal M, Kennamer R, Merliss R, Wada T, Bor N. Angina pectoris. I. A variant form of angina pectoris; preliminary report. Am J Med. 1959;27:375-88.
- ↑ Takaoka K. Comparison of the risk factors for coronary artery spasm with those for organic stenosis in a Japanese population: role of cigarette smoking. Int J Cardiol. 2000;72:121–126.
- ↑ Rosamond W. Are migraine and coronary heart disease associated? An epidemiologic review. Headache. 2004;44 Suppl 1:S5-12.
- ↑ Stern SS. Coronary artery spasm: a 2009 update.. Circulation (New York, N.Y.). 2009-05;119:2531-2534.
- ↑ Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.
- ↑ Robertson RM, Wood AJ, Vaughn WK, Robertson D. Exacerbation of vasotonic angina pectoris by propranolol. Circulation. 1982;65(2):281-5.
- ↑ Miwa K, Kambara H, Kawai C. Effect of aspirin in large doses on attacks of variant angina. Am Heart J. 1983;105(2):351-5.
