prinzmetal angina?

[JIM-Weidner]

  Had a triple bypass 5 years ago and a stent placed in RCA
  on Dec 7th, 98.   Since then, have had sporadic, occasional
  "stabs" of pain in upper left quadrant. These occur while at
  rest (as passenger in car, watching TV, typeing at computer,
  rarely while being active (e.g., carried two armloads of logs
  from outside to fireplace -- 50 ft.)
  Cardiologist says probably not related to heart. Nurse friend
  suggested "prinzmetal syndrome"  or a variant of angina. Now,
  I am concerned enough to have had an echocardiagram and a thalium
  stress test (physical limitation on hips prohibits treadmill type
  of stress test).  This was 5 days ago; I got the results via call
  from cariologist's secretary (haven't been able to talk to the dr
  himself yet), who said that the test results showed all was OK and
  there were no problems.
  Nevertheless, I have just returned from a drive with a friend during
  which time I experienced several episodes of chest pain. My first
  inclination was to take the Nitro, but not knowing exactly what is
  going on, and believing the test results, I was hesitant to do so.
  Questions: Could all this be simply anxiety and/or stress as a follwoup
  to the recent angioplasty/stent (I tend by nature to be an organizer and
  worrier), or is this "prinzmetal angina" a reality and something to be
  concerned about (by the way, the nurse that suggested this is a psych
  nurse and family, not a cardiac nurse)?  How reliable are the thalium
  stress tests (during which I felt NO discomfort or chest pain whatsoever)
  and the echocardiograms?
  Can you help me?  At least let me know what's going on -- even if it's
  bad news!
  JIM
  

[Cleveland Clinic, MD]

Dear JIM,
Yes Prinzmetal's angina does exist (and I have listed some information below) though I doubt that is what you have.  Worry can certainly heighten what would otherwise be considered normal aches and pains.  However there are many causes of this type of pain and the best course of action is to follow-up with your cardiologist.  Good luck.
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.
Information provided here is for general educational purposes only. Only your doctor can provide specific diagnoses and treatments. If you would like to be seen at the Cleveland Clinic, please Call 1 - 800 - CCF - CARE for an appointment at Desk F15 with a cardiologist.