Coronary Artery Vasospasm Clinical Presentation

Updated: Nov 14, 2018
  • Author: Stanley S Wang, JD, MD, MPH; Chief Editor: Eric H Yang, MD  more...
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Presentation

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. [31] 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. [4] In severe cases, associated arrhythmias may be present, ranging from heart block to ventricular tachycardia. [32]

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, [15] 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. [14] Spasm is found more often in patients with symptoms that occur at rest (55.5%) than in those with exertional angina (27.7%). [16]

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. [33]

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).