Coronary Artery Vasospasm Clinical Presentation
- Author: Stanley S Wang, MD, JD, MPH; Chief Editor: Eric H Yang, MD more...
History and Physical Examination
Patients with coronary artery vasospasm typically describe anginal symptoms, including retrosternal pain or pressure with radiation to the neck, jaw, left shoulder, or arm. This may be particularly true if there is significant coexistent atherosclerosis. Notably, symptoms associated with vasospastic angina often occur at rest and may exhibit a circadian pattern, with most episodes occurring in the early hours of the morning. In severe cases, associated arrhythmias may be present, ranging from heart block to ventricular tachycardia.
Distinguishing unstable angina pectoris related to coronary atherosclerosis from variant angina may be difficult and require special investigations for diagnosis, including coronary angiography. In some patients, the distinction may be an arbitrary one because it is likely that vasospasm is both a cause and a consequence of plaque rupture and thrombosis in patients with unstable angina pectoris.
In addition, many patients with variant angina have obstructive coronary artery disease (CAD). Indeed, in as many as 60% of cases, coronary artery vasospasm occurs at a site with preexisting coronary atherosclerosis, which suggests that underlying arterial dysfunction may be a predisposing factor for spasm.
Although spasm is more likely to occur in the presence of atherosclerotic lesions, the absence of traditional risk factors for atherosclerotic CAD may make vasospastic angina more likely; the exception is cigarette smoking, which is a common risk factor for both clinical syndromes. Spasm is found more often in patients with symptoms that occur at rest (55.5%) than in those with exertional angina (27.7%).
A minority of patients with variant angina may have a more systemic abnormality of vasomotor tone; this may include symptoms of migraine headache and Raynaud phenomenon.
No features on physical examination are specific for vasospastic angina. Signs may be absent between symptomatic episodes. During periods of angina, physical findings relating to ischemia and ventricular dysfunction may be present, including rales, jugular venous distention, peripheral edema, extra heart sounds, ectopy or other arrhythmia (eg, tachycardia or bradycardia), and murmurs (such as occur with ischemic mitral regurgitation).
Prinzmetal M, Kennamer R, Merliss R. A variant form of angina pectoris. Am J Med. 1959. 27:375-388.
Maseri A, Severi S, Nes MD, et al. "Variant" angina: one aspect of a continuous spectrum of vasospastic myocardial ischemia. Pathogenetic mechanisms, estimated incidence and clinical and coronary arteriographic findings in 138 patients. Am J Cardiol. 1978 Dec. 42(6):1019-35. [Medline].
Yasue H, Omote S, Takizawa A, Nagao M, Miwa K, Tanaka S. Circadian variation of exercise capacity in patients with Prinzmetal's variant angina: role of exercise-induced coronary arterial spasm. Circulation. 1979 May. 59(5):938-48. [Medline].
Yasue H, Nakagawa H, Itoh T, Harada E, Mizuno Y. Coronary artery spasm--clinical features, diagnosis, pathogenesis, and treatment. J Cardiol. 2008 Feb. 51(1):2-17. [Medline].
Ajani AE, Yan BP. The mystery of coronary artery spasm. Heart Lung Circ. 2007 Feb. 16(1):10-5. [Medline].
Yasue H, Touyama M, Kato H, Tanaka S, Akiyama F. Prinzmetal's variant form of angina as a manifestation of alpha-adrenergic receptor-mediated coronary artery spasm: documentation by coronary arteriography. Am Heart J. 1976 Feb. 91(2):148-55. [Medline].
Yasue H, Horio Y, Nakamura N, et al. Induction of coronary artery spasm by acetylcholine in patients with variant angina: possible role of the parasympathetic nervous system in the pathogenesis of coronary artery spasm. Circulation. 1986 Nov. 74(5):955-63. [Medline].
Kaneda H, Taguchi J, Kuwada Y, et al. Coronary artery spasm and the polymorphisms of the endothelial nitric oxide synthase gene. Circ J. 2006 Apr. 70(4):409-13. [Medline].
Nishijima T, Nakayama M, Yoshimura M, et al. The endothelial nitric oxide synthase gene -786T/C polymorphism is a predictive factor for reattacks of coronary spasm. Pharmacogenet Genomics. 2007 Aug. 17(8):581-7. [Medline].
Egashira K, Katsuda Y, Mohri M, et al. Basal release of endothelium-derived nitric oxide at site of spasm in patients with variant angina. J Am Coll Cardiol. 1996 May. 27(6):1444-9. [Medline].
Nakano T, Osanai T, Tomita H, Sekimata M, Homma Y, Okumura K. Enhanced activity of variant phospholipase C-delta1 protein (R257H) detected in patients with coronary artery spasm. Circulation. 2002 Apr 30. 105(17):2024-9. [Medline].
Stern S, Bayes de Luna A. Coronary artery spasm: a 2009 update. Circulation. 2009 May 12. 119(18):2531-4. [Medline].
Adlam D, Azeem T, Ali T, Gershlick A. Is there a role for provocation testing to diagnose coronary artery spasm?. Int J Cardiol. 2005 Jun 22. 102(1):1-7. [Medline].
Harding MB, Leithe ME, Mark DB, et al. Ergonovine maleate testing during cardiac catheterization: a 10-year perspective in 3,447 patients without significant coronary artery disease or Prinzmetal's variant angina. J Am Coll Cardiol. 1992 Jul. 20(1):107-11. [Medline].
Bertrand ME, LaBlanche JM, et al. Frequency of provoked coronary arterial spasm in 1089 consecutive patients undergoing coronary arteriography. Circulation. 1982 Jun. 65(7):1299-306. [Medline].
Sueda S, Kohno H, Fukuda H, et al. Frequency of provoked coronary spasms in patients undergoing coronary arteriography using a spasm provocation test via intracoronary administration of ergonovine. Angiology. 2004 Jul-Aug. 55(4):403-11. [Medline].
Sueda S, Kohno H, Oshita A, et al. Coronary abnormal response has increased in Japanese patients: Analysis of 17 years' spasm provocation tests in 2093 cases. J Cardiol. 2010 May. 55(3):354-361. [Medline].
Bory M, Pierron F, Panagides D, Bonnet JL, Yvorra S, Desfossez L. Coronary artery spasm in patients with normal or near normal coronary arteries. Long-term follow-up of 277 patients. Eur Heart J. 1996 Jul. 17(7):1015-21. [Medline].
Mayer S, Hillis LD. Prinzmetal's variant angina. Clin Cardiol. 1998 Apr. 21(4):243-6. [Medline].
Selzer A, Langston M, Ruggeroli C, Cohn K. Clinical syndrome of variant angina with normal coronary arteriogram. N Engl J Med. 1976 Dec 9. 295(24):1343-7. [Medline].
Rha SW, Park JY, Ryu SK, et al. TCT-437 The impact of gender difference on angiographic characteristics during intracoronary acetylcholine provocation test in Korean patients. J Am Coll Cardiol. 2012 Oct 23. 60(17 Supp B):B124.
Pristipino C, Beltrame JF, Finocchiaro ML, et al. Major racial differences in coronary constrictor response between japanese and caucasians with recent myocardial infarction. Circulation. 2000 Mar 14. 101(10):1102-8. [Medline].
Bott-Silverman C, Heupler FA Jr. Natural history of pure coronary artery spasm in patients treated medically. J Am Coll Cardiol. 1983 Aug. 2(2):200-5. [Medline].
Mishra PK. Variations in presentation and various options in management of variant angina. Eur J Cardiothorac Surg. 2006 May. 29(5):748-59. [Medline].
Yasue H, Takizawa A, Nagao M, et al. Long-term prognosis for patients with variant angina and influential factors. Circulation. 1988 Jul. 78(1):1-9. [Medline].
Onaka H, Hirota Y, Shimada S, et al. Prognostic significance of the pattern of multivessel spasm in patients with variant angina. Jpn Circ J. 1999 Jul. 63(7):509-13. [Medline].
Ong P, Athanasiadis A, Borgulya G, Voehringer M, Sechtem U. 3-year follow-up of patients with coronary artery spasm as cause of acute coronary syndrome: the CASPAR (coronary artery spasm in patients with acute coronary syndrome) study follow-up. J Am Coll Cardiol. 2011 Jan 11. 57(2):147-52. [Medline].
Takagi Y, Takahashi J, Yasuda S, et al. Prognostic stratification of patients with vasospastic angina: a comprehensive clinical risk score developed by the Japanese Coronary Spasm Association. J Am Coll Cardiol. 2013 Sep 24. 62(13):1144-53. [Medline].
Kobayashi N, Hata N, Shimura T, et al. Characteristics of patients with cardiac arrest caused by coronary vasospasm. Circ J. 2013. 77(3):673-8. [Medline].
Hendriks ML, Allaart CP, Bronzwaer JG, Res JJ, de Cock CC. Recurrent ventricular fibrillation caused by coronary artery spasm leading to implantable cardioverter defibrillator implantation. Europace. 2008 Dec. 10(12):1456-7. [Medline].
Figueras J, Cortadellas J, Gil CP, Domingo E, Soler JS. Comparison of clinical and angiographic features and longterm follow-up events between patients with variant angina and patients with ST elevation myocardial infarction. Int J Cardiol. 2006 Aug 10. 111(2):256-62. [Medline].
Previtali M, Klersy C, Salerno JA, et al. Ventricular tachyarrhythmias in Prinzmetal's variant angina: clinical significance and relation to the degree and time course of S-T segment elevation. Am J Cardiol. 1983 Jul. 52(1):19-25. [Medline].
Rosamond W. Are migraine and coronary heart disease associated? An epidemiologic review. Headache. 2004 May. 44 Suppl 1:S5-12. [Medline].
Hirano Y, Uehara H, Nakamura H, et al. Diagnosis of vasospastic angina: comparison of hyperventilation and cold-pressor stress echocardiography, hyperventilation and cold-pressor stress coronary angiography, and coronary angiography with intracoronary injection of acetylcholine. Int J Cardiol. 2007 Apr 4. 116(3):331-7. [Medline].
Miwa K, Kambara H, Kawai C, Murakami T. Two electrocardiographic patterns with or without transient T-wave inversion during recovery periods of variant anginal attacks. Jpn Circ J. 1983 Dec. 47(12):1415-22. [Medline].
Im SI, Rha SW, Choi BG, et al. TCT-436 Association of myocardial bridge and acetylcholine dose response in patients with vasospastic angina. J Am Coll Cardiol. 2012 Oct. 60(17 Supp B):B124.
Sueda S, Kohno H, Fukuda H, et al. Clinical impact of selective spasm provocation tests: comparisons between acetylcholine and ergonovine in 1508 examinations. Coron Artery Dis. 2004 Dec. 15(8):491-7. [Medline].
Im SI, Choi BG, Choi SY, et al. TCT-433 Impact of beta-blocker on angiographic and clinical parameters during intracoronary acetylcholine provocation test. J Am Coll Cardiol. 2012. 60(17 Supp B):B123.
Jang HJ, Kim TH, Kwon SW, et al. Left ventricular end diastolic pressure for detection of intracoronary ergonovine-induced myocardial ischemia. Herz. 2015 Nov 6. [Medline].
Piao ZH, Jeong MH, Li Y, et al, for the Other Korea Acute Myocardial Infarction Registry (KAMIR) Investigators. Benefit of statin therapy in patients with coronary spasm-induced acute myocardial infarction. J Cardiol. 2015 Nov 13. [Medline].
Taylor SH. Usefulness of amlodipine for angina pectoris. Am J Cardiol. 1994 Jan 27. 73(3):28A-33A. [Medline].
Krishnan U, Win W, Fisher M. First report of the successful use of bosentan in refractory vasospastic angina. Cardiology. 2010. 116(1):26-8. [Medline].
Khitri A, Jayasuriya S, Habibzadeh MR, Movahed MR. Coronary stenting in patients with medically resistant vasospasm. Rev Cardiovasc Med. 2010 Fall. 11(4):264-70. [Medline].
Bertrand ME, Lablanche JM, Rousseau MF, Warembourg HH Jr, Stankowtak C, Soots G. Surgical treatment of variant angina: use of plexectomy with aortocoronary bypass. Circulation. 1980 May. 61(5):877-82. [Medline].