CMPP -- Ischemic Heart Disease 4: Prinzmetal's Variant Angina

Prinzmetal's Variant Angina

episodes of angina pectoris typically triggered at night (between midnight and the early morning) the tis associated with ST segment elevation

between midnight and the early morning

Prinzmetal's Variant Angina usually occurs...

tissue is not infracting

Prinzmetal's Variant Angina looks like a STEMI, but...

Coronary Vasospasm

hyperactivity of coronary artery vascular smooth muscle

focal spasm of a major coronary artery, myocardial ischemia and even infarction if prolonged

Coronary vasospasm can lead to...

imbalance between vagal and sympathetic tone

coronary vasospasm is caused by a possible...

atherosclerotic

in coronary arteries that vasospasm, _________ are present, but not critical

right coronary artery

coronary vasospasm more commonly occurs in the...

Smoking

what is the major risk factor for Prinzmetal's variant angina/coronary vasospasm?

changes in autonomic activity, drugs (ephedrine-based (cold drugs), cocaine, marijuana, amphetamines), food borne botulism, magnesium deficiency, hyperventilation (blow off too much CO2, can cause vasoconstriction)

triggers for Prinzmetal's Variant Angina

pts are younger, fewer cardiovascular risk factors, can be associated with other vasospastic disease (Migraines, Raynaud's), exercise does NOT precipitate angina, patients can have a history of cocaine abuse

how can we tell the difference between Prinzmetal's Variant Angina and STEMI?

no :)

are there any specific physical exam signs for Prinzmetal's Variant Angina?

normal

in between episodes, EKGs for a patient with Prinzmetal's Variant Angina are...

ST segment elevation present in multiple leads

in active spasm phase, what would a EKG for a pt with Prinzmetal's Variant Angina look like?

negative (because no infarction is taking place)

what are the troponin results in one with Prinzmetal's Variant Angina

STRESS TEST

if you have a patient with a strong Prinzmetal's Variant Angina history and a normal EKG, how can you diagnose the issue?

ambulatory EKG monitoring, long term monitoring for events (can find that many episodes are asymptomatic)

if the pt with the strong PVA history/normal EKG had a negative stress test, what should you do?

Holter monitoring

an ECG device is worn during a 24-hour period to detect cardiac arrhythmias

go to the CATH LAB! (can have underlying coronary disease, vasospasm induced secondary to catecholamine release from exercise)

if the pt with the strong PVA history/normal EKG had a positive stress test, what should you do?

a pt with a strong history of PVA and abnormal EKG, a patient with astride history even with a normal stresss/holter (still need to rule out high grade obstruction)

who gets catheterized?

Nitroglycerin or CCBs

what medicine should we give a PVA patient if the problem is coronary artery spasm?

PRN nitroglycerine, long acting calcium channel blockers, long acting nitrates (if CCB alone is ineffective) CCB combined with beta blockers (cardiac selective)

chronic tx for PVA

long acting nitrates (isosorbide)

if CCB alone is ineffective, what could you add to the regimen?

Verapamil (VERELAN)

CCB of choice for PVA

non-selective BBs (propalolol, can exacerbate vasospasm); Sumatriptan (normally used to treat migraines, associated with vasospasm)

medicines to avoid in PVA

MI (patients usually with co-existing CAD risk factors), life threatening arrythmias

complications of PVA