Overview
Definition
A syndrome of episodic angina typically occurring at rest (often between midnight and early morning), associated with transient ST-segment elevation.
Epidemiology
Relatively uncommon compared to atherosclerotic angina. Often seen in younger patients who smoke.
Etiology & Risk Factors
- Coronary artery vasospasm (hyperreactivity of vascular smooth muscle)
- Triggers: Cocaine use, smoking, triptans (migraine meds), cold exposure, emotional stress
Clinical Symptoms
- Chest pain that occurs at rest (often waking the patient from sleep)
- Typically resolves spontaneously or with rapidly acting nitrates
Clinical Approach
Diagnosis
- ECG during an attack shows transient ST-segment elevation that resolves when the pain resolves
- Coronary angiography with provocative testing (Ergonovine or Acetylcholine) induces focal spasm
Management
- Calcium Channel Blockers (Diltiazem, Amlodipine) are first-line (prevent vasospasm)
- Nitrates (for acute attacks)
- Smoking cessation
- AVOID Non-selective Beta-blockers (can worsen spasm due to unopposed alpha-receptor vasoconstriction)
Complications
- Myocardial infarction (if spasm is prolonged)
- Life-threatening arrhythmias (VT/VF) during the ischemic episode