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Prinzmetal's Angina, also known as vasospastic or alternative angina, is one of the rarer types of ischemic heart disease. The predominant symptom is angina chest pain caused by spasm of the coronary artery.

Prinzmetala's Angina , classified as one of the stable coronary syndromes, is a relatively rare disease. The background of symptoms related to the vasoconstruction of the arteries affects an average of 2 out of 100 patients with angina. Unlike classic angina, it occurs in the younger patient population.

Angina Prinzmetala: reasons

Coronary pain in Prinzmetal's angina is caused by myocardial ischemia, which is the result of spontaneous contraction of the coronary arteries. This is a different mechanism than in typical cases of coronary artery disease, where the reduction of blood flow to the heart is caused by atherosclerotic plaques restricting the lumen of the vessels.

It should be remembered, however, that spasm occurs in both normal arteries and those affected by atherosclerotic changes. The exact causes and mechanisms of arterial contraction are unknown, although there are several hypotheses explaining this phenomenon.

Most of them are based on the dysfunction of the innermost layer of the vessel wall, i.e. endothelium. It is assumed that the spasm may be the result of a defect in the endothelial enzyme responsible for the production of nitric oxide - one of the key mediators inducing vasodilation.

Angina Prinzmetala: risk factors

Factors that may induce contraction of the coronary arteries may be:

  • smoking - the strongest factor
  • cocaine, amphetamines, and marijuana use
  • emotional stress
  • intense effort
  • hyperventilation
  • low temperature

Alternative angina is more likely in patients with other conditions associated with impaired vascular contractility, such as migraine or Raynaud's disease.

Angina Prinzmetala: symptoms

The main symptom is chest pain. Usually it is crushing or pressing, it is localized retrosternally and can radiate to the neck, mandible,upper abdomen or left arm. Pain is usually sensitive to the effects of nitroglycerin. It clears up within minutes of giving it.

Unlike classic angina pain, it can be more often not provoked by exercise. It often occurs at rest - at night or in the early morning hours. Patients experiencing such ailments very often go to the invasive cardiology laboratories and hospital emergency departments as a matter of urgency, with suspected acute coronary syndrome - heart attack or unstable angina.

Remember not to underestimate the chest pain with the above-described characteristics, because its sudden onset at rest is more often the result of a heart attack.

Angina Prinzmetala: diagnostic tests and diagnosis

The ECG test, i.e. electrocardiography, plays an important role in the diagnosis of vasospastic angina. In the asymptomatic period, significant deviations are usually not recorded. During the onset of pain, ST-segment elevations or depressions may appear, which are an expression of heart ischemia. However, such a picture is typical of acute coronary syndromes - it is necessary to differentiate these conditions. In order to capture changes in the ECG during a vasospastic episode, a prolonged study of the so-called Holter ECG.

A study with the greatest diagnostic value and constituting the so-called The "gold standard" is a provocative coronary angiography. Coronary angiography is an angiographic examination used in the diagnosis of ischemic heart disease. With the help of special catheters inserted through the arteries (usually radial or femoral), a contrast agent is administered into the coronary arteries of the heart, thanks to which, under the control of x-rays, their patency can be visualized.

The provocation test consists of the administration of ergovine or acetylcholine to the coronary arteries. The role of these substances is to cause the vessel to contract. Stenosis>70% of the lumen of the artery confirms the diagnosis. The contraction stops immediately after the administration of nitroglycerin.

Angina Prinzmetala: treatment

Treatment of Prinzmetal's angina has been successful if we wish to begin by avoiding the provoking factors.
The main element is pharmacotherapy with preparations with vasodilating properties. The first-line drugs are the calcium channel antagonists diltiazem, verapamil or nifedipine, used in high doses.

A second line of treatment can be long-acting nitrates (usually in combination with calcium blockers).

Note! Very often used beta-blockers can induce spasmcoronary arteries and are contraindicated in this disease.

When sudden chest pain occurs, short-acting nitrates (usually a sublingual nitroglycerin spray) are an emergency treatment, and the pain is usually resolved within 1-5 minutes when administered.

Angioplasty of the coronary arteries with the use of stents is not a routine procedure in this case. Some benefits may be obtained by stenting contracting arteries in which there is a coexisting flow restricting plaque.

Angina Prinzmetala: prognosis

Prinzmetal's angina symptoms frequently recur, especially in the first years of the disease - on average, half of the patients experience a relapse within 3 years from the onset of symptoms. The prognosis for long-term survival in patients with vasospastic angina is relatively good. The five-year survival rate fluctuates around 90%. With the coexistence of typical atherosclerotic coronary artery disease, the risk of fatal cardiovascular events is greater.

Source:

  1. Alternative causes of myocardial ischemia in women: An update on spontaneous coronary artery dissection, vasospastic angina and coronary microvascular dysfunction, Vascular Medicine (London, England). 22 (2): 146-160 Bina Ahmed, Mark A Creager

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Cardiology