Question Title: ANGINA!

Forum: The Heart Forum
Topic: Angina

Dear keithgroo,

Thank you for your question. Coronary artery spasm (also called variant or Prinzmetal's angina) was originally described in 1959 by Prinzmetal and colleagues. This uncommon syndrome is found in approximately 2% to 3% of patients presenting with chest pain at large referral centers. The syndrome consists of chest pain at rest. ST changes during the pain and normal or near normal appearing coronary arteries found on angiogram. The spasm is usually confined to one vessel but may occur in several vessels at once. The spasm may be provoked in the cath lab with an injection of ergotamine. Although the angiogram appears normal there is actually some underlying coronary artery disease at the site of spasm. Heart attacks have been reported with coronary artery spasm and sudden death due to coronary spasm cannot be ruled out.

Multiple etiologies have been proposed for coronary artery spasm and these are outlined below:

1. The basal release of nitric oxide appears deficient in arteries where spasm occurs leading to the suggestion that basal nitric oxide synthetase may be a culprit.

2. Low levels of intracellular magnesium and therapeutic response to intravenous magnesium have led to the suggestion that it may be involved.

3. Low plasma levels of vitamin E in patients with active variant angina and improvement in symptoms when vitamin E is used supplementary to calcium channel blockers has been observed.

4. Hyperinsulinemia and insulin resistance are thought to be risk factors.

5. There is an increase of symptoms during sleep and in the early morning hours suggesting certain blood factors that vary with the day.

6. Hyperventilation, cigarette smoking cocaine use and withdrawal and alcohol withdrawal are known to precipitate coronary spasm.

Treatment for coronary artery spasm is with calcium channel blockers (nifedipine, diltiazem, verapamil, etc) and nitrates (nitroglycerine). Potential side effects of calcium channel blockers are constipation, swelling in the legs and in some persons severe swelling in the mouth and throat. Nitroglycerin may cause headaches and could reduce blood pressure to the point that nausea and vomiting occurs.

Also important to treatment is risk factor modification such as cholesterol reduction, weight loss, quiting smoking and increasing exercise.

When symptoms are not responding to calcium channel blockers and nitrates the addition of vitamin E (300 mg a day) significantly reduced recurrent symptoms. Experimental evidence has shown benefit with cyproheptadine (a nonselective serotonergic antagonist) and this may be available in the future. Hope this information helps.

I hope you find this information useful. Information provided in the heart forum is for general purposes only. Only your physician can provide specific diagnoses and therapies. Please feel free to write back with additional questions.

If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter. The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.

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