eMedicine Specialties > Cardiology > Coronary Artery Disease
Coronary Artery Vasospasm: Treatment & Medication
Updated: Jul 14, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Patients with angina pectoris at rest are routinely admitted to a hospital for observation, evaluation, and initiation of medical therapy. This should include a 12-lead electrocardiograph (which should be repeated with each episode of chest pain), telemetry monitoring for the initial 24-48 hours, and serial cardiac enzyme assays.
Thallium scintigraphy and coronary angiography may be required for diagnostic, prognostic, and therapeutic reasons. Ambulatory electrocardiography and Holter monitoring may increase the sensitivity of the aforementioned in-hospital evaluation if the diagnosis of variant angina remains elusive.
Medical therapy initially should include intravenous or sublingual nitroglycerin and an oral calcium channel antagonist. Long-acting oral nitrates are appropriate for the prevention of recurrent episodes and may be used in combination with the calcium channel antagonist for long-term prophylaxis.
Surgical Care
Percutaneous coronary revascularization and coronary artery bypass surgery may be helpful in patients with a mixed presentation, including both rest and limiting exertional angina with suitable proximal coronary artery stenoses.
Medication
Nitrates and calcium channel blockers (CCBs) are the mainstays of medical therapy for variant angina. Nitroglycerin effectively treats episodes of angina and myocardial ischemia within minutes of administration, and the long-acting nitrate preparations reduce the frequency of recurrent events.
Nifedipine, amlodipine, verapamil, and diltiazem effectively prevent coronary vasospasm and variant angina, and they should be administered in preference to beta-blockers.
Beta-blockers can be beneficial in patients with fixed coronary artery stenoses and exertional angina pectoris and are sometimes necessary in combination with the aforementioned drugs to achieve control of symptoms, especially in patients with significant fixed stenoses. However, nonselective beta-blockers may be detrimental in some patients because blockade of the beta-receptors, which mediate vasodilation, allows unopposed alpha-receptor–mediated coronary vasoconstriction to occur, thus possibly causing an actual worsening of symptoms.
Spontaneous remission following an early period of acute activity is not infrequent; therefore, it is reasonable to carefully reduce the dose of medications after an initial 3-month symptom-free period.
Because atherosclerosis is common in patients with variant angina, the dietary and medical treatment of dyslipidemia is appropriate.
Nitrates
Affect direct endothelium-independent vasodilatation of the large coronary arteries. In addition, a reduction of preload occurs due to dilatation of venous capacitance vessels, resulting in a decrease in myocardial oxygen consumption. Nitrates act as an exogenous source of nitric oxide, which causes vascular smooth muscle relaxation and may have a modest effect on platelet aggregation and thrombosis.
Nitroglycerin (Nitrolingual, Nitrostat, Minitran, Nitro-Bid, Nitro-Dur)
Causes relaxation of vascular smooth muscle by stimulating intracellular cyclic GMP. The result is a decrease in blood pressure. Dosage forms include SL, TD, and IV preparations. The distinction between short-acting preparations for treatment of acute attacks and long-acting preparations for prevention of recurrent episodes is important.
Adult
SL: 0.2-0.6 mg prn chest pain
Spray: Single spray (0.4 mg), which is equivalent to a single 1/150 SL dose; dose may be repeated prn as hemodynamics permit; not to exceed 1.2 mg
Injection: Continuous 5-20 mcg/min IV infusion
Patch: 0.1-0.8 mg/h TD 12-14 h/d
Pediatric
Not established
Aspirin may increase nitrate serum concentrations; marked symptomatic orthostatic hypotension may occur with coadministration of CCBs (dose adjustment of either agent may be necessary)
Documented hypersensitivity, severe anemia, shock, postural hypotension, head trauma, closed-angle glaucoma, cerebral hemorrhage
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in coronary artery disease, hypertrophic cardiomyopathy, low systolic blood pressure, volume depletion, shock; monitor for tolerance
Isosorbide dinitrate (Isordil, Sorbitrate)
Relaxes vascular smooth muscle by stimulating intracellular cyclic GMP. Decreases preload and afterload, causing decreased myocardial oxygen demand. For the treatment and prevention (SR preparations) of variant angina. The onset of action is approximately 3.5 min and antianginal effect lasts about 2 h.
Adult
2.5-10 mg SL prn chest pain; 5-40 mg/d PO SR with at least an 18-h interval between doses to prevent tolerance; do not use for acute attacks
Pediatric
Not established
Coadministration with alcohol or sildenafil (Viagra) may cause severe hypotension and cardiovascular collapse; aspirin may increase serum concentrations of isosorbide and actions; coadministration with CCBs may increase symptomatic orthostatic hypotension (adjust dose of either agent); may decrease effects of heparin
Documented hypersensitivity, severe anemia, closed-angle glaucoma, postural hypotension, head trauma, cerebral hemorrhage
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tolerance to vascular and antianginal effects of nitrates may develop; minimize tolerance by using smallest effective dose, pulse therapy (intermittent dosing), or alternating with other coronary vasodilators (take last daily dose of short-acting agent no later than 7:00 PM); caution when administering to patients with glaucoma, volume depletion, hypotension, shock, hypertrophic cardiomyopathy
Isosorbide mononitrate (ISMO, Imdur, Monoket)
For the prevention of variant angina. The onset of action of oral isosorbide mononitrate is not sufficient for use as an acute antianginal agent. The half-life is approximately 5 h.
Adult
5-20 mg/d PO upon awakening and 7 h later
Pediatric
Not established
Hypotension may be potentiated by other vasodilators
Documented hypersensitivity, severe anemia, closed-angle glaucoma, postural hypotension, head trauma, cerebral hemorrhage
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tolerance to vascular and antianginal effects of nitrates may develop; minimize tolerance by using smallest effective dose, pulse therapy (intermittent dosing) or by alternating with other coronary vasodilators (take last daily dose of short-acting agent no later than 7:00 PM); caution in glaucoma, volume depletion, hypotension, shock, hypertrophic cardiomyopathy
Calcium channel blockers
Relax coronary smooth muscle and produce coronary vasodilation, which in turn improves myocardial oxygen delivery. Dihydropyridines exhibit greater vascular selectivity over nondihydropyridines (verapamil and diltiazem), which also inhibit the impulse conduction within the sinoatrial and atrioventricular nodes.
Nifedipine (Adalat, Adalat CC, Procardia, Procardia XL)
Prototypical dihydropyridine indicated for treatment of acute attacks and prevention of recurrent attacks. SL administration generally is safe, despite theoretical concerns.
Adult
30-90 mg/d IR cap PO divided tid; not to exceed 180 mg/d or 30-90 mg/d SR tab PO qd
Pediatric
Not established
Caution with coadministration of any agent that can lower blood pressure, including beta-blockers (may lead to heart failure or paradoxical angina) and opioids; H2 blockers (cimetidine) may increase toxicity; monitor oral anticoagulants and quinidine
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause lower extremity edema; allergic hepatitis has occurred but is rare; caution in aortic stenosis, severe obstructive coronary artery disease, heart failure
Amlodipine (Norvasc)
Generally regarded as a dihydropyridine, although experimental evidence suggests that it also may bind to the nondihydropyridine binding sites. Has a substantially longer half-life than nifedipine and is administered qd. Appropriate for the prophylaxis of variant angina.
Adult
2.5-10 mg/d PO
Pediatric
Not established
Caution with coadministration of any agent that can lower blood pressure, including beta-blockers and opioids; coadministration with cyclosporine may increase cyclosporine levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hepatic dysfunction, elderly persons; caution when administering with vasodilators, particularly in aortic stenosis, severe obstructive coronary artery disease, and heart failure
Verapamil (Calan, Calan SR, Covera HS, Isoptin, Verelan)
During depolarization, inhibits calcium ion from entering slow channels or voltage-sensitive areas of the vascular smooth muscle and myocardium.
Nondihydropyridine appropriate for the prophylaxis of variant angina.
Recommended for rate control in atrial fibrillation/flutter.
Adult
240-480 mg/d PO divided tid/qid; 5-10 mg IV bolus over 2 min
Pediatric
Not established
May increase carbamazepine, digoxin, cyclosporine, theophylline, rifampin, inhalation anesthetics, and neuromuscular blocking agents levels; coadministration with amiodarone can cause bradycardia and a decrease in cardiac output; when administered concurrently with beta-blockers may increase cardiac depression; cimetidine may increase verapamil levels; flecainide, quinidine may have additive inotropic effects; coadministration with lithium may cause neurotoxicity and psychotic symptoms; phenobarbital may decrease effects
Documented hypersensitivity; severe CHF, sick sinus syndrome or second- or third-degree AV block (unless paced), atrial flutter/fibrillation, cardiogenic shock, hypotension (<90 mm Hg systolic)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hepatocellular injury may occur; transient elevations of transaminases with and without concomitant elevations in alkaline phosphatase and bilirubin have occurred (elevations have been transient and may disappear with continued verapamil treatment), periodically monitor liver function; caution in heart failure, atrioventricular conduction delay, neuromuscular transmission disorders, hypertrophic cardiomyopathy
Diltiazem (Cardizem, Cardizem CD, Dilacor, Dilacor XR, Tiazac)
During depolarization inhibits calcium ions from entering the slow channels and voltage-sensitive areas of vascular smooth muscle and myocardium. Nondihydropyridine appropriate for prophylaxis of variant angina.
Adult
IR: 90-360 mg/d PO divided tid/qid
SR: 120 mg/d; titrate slowly over 7-14 d up to 480 mg/d prn
IV: 5-20 mg IV bolus (0.25 mg/kg), followed by a second dose of 0.35 mg/kg if response is inadequate or 5-15 mg/h IV infusion; recommended IV doses for rate control in patients with atrial fibrillation/flutter; no specific recommendations for IV use in variant angina exist
Pediatric
Not established
May increase carbamazepine, digoxin, cyclosporine, and theophylline levels; when administered with amiodarone, may cause bradycardia and a decrease in cardiac output; when administered with beta-blockers may increase cardiac depression; cimetidine may increase diltiazem levels
Documented hypersensitivity, severe CHF, sick sinus syndrome, second- or third-degree AV block unless paced, severe left ventricular dysfunction, cardiogenic shock, hypotension (<90 mm Hg systolic)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in heart failure, atrioventricular conduction delay, hypertrophic cardiomyopathy, impaired renal or hepatic function; may increase LFT levels, and hepatic injury may occur
More on Coronary Artery Vasospasm |
| Overview: Coronary Artery Vasospasm |
| Differential Diagnoses & Workup: Coronary Artery Vasospasm |
 Treatment & Medication: Coronary Artery Vasospasm |
| Follow-up: Coronary Artery Vasospasm |
| References |
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Further Reading
Keywords
coronary artery vasospasm, vasospastic angina, variant angina, Prinzmetal angina, Prinzmetal's angina, focal coronary artery vasospasm, acute myocardial infarction, myocardial ischemia, coronary vasoconstriction, dynamic coronary obstruction, myocardial infarction, MI, dyslipidemia, platelet aggregation, atherosclerotic coronary artery disease, stable angina pectoris, unstable angina pectoris, focal coronary artery vasospasm, normal vasodilator function abnormality, subclinical atherosclerosis, clinical atherosclerosis
