Prinzmetal's angina pectoris

Prinzmetal's angina pectoris (variant AP, vasospastic AP, angina pectoris inversa) is a specific type of angina pectoris.
 * Occurs as a result of 'spasm of epicardial coronary vessels (spasm can affect two or more coronary vessels at the same time).
 * On EKG we observe transient ST segment elevation'.

It was first described in 1959 by the American cardiologist Myron Prinzmetal.

Etiopathogenesis


Vasoconstrictive stimulus (histamine, serotonin, ergonovine, acetylcholine, noradrenaline, blood pH) + local hyperreactivity of coronary arteries to vasoconstrictive stimulus → epicardial spasm coronary arteries.

Most coronary spasms are clinically manifested as angina pectoris and resolve spontaneously. However, longer-lasting spasms can result in myocardial infarction, arrhythmia or sudden cardiac death.

Clinical symptoms
A typical symptom is angina. Their occurrence is often significantly higher depending on the weather and season; they are more common in autumn and winter in dry weather. Prinzmetal's AP can also cause a variety of arrhythmias' (from AV block to ventricular fibrillation).

Diagnosis

 * Prinzmetal's AP is not tied to physical activity. Angina occurs most often at night (median is 4 am).
 * During an episode of angina, we observe ST elevation (or ST depression, inversion or pseudonormalization of the T wave) on the ECG. Holter monitoring can be used to capture ST elevation.
 * Provocation tests: provocation with acetylcholine, methacholine, methylergonovine; provocation by exercise, cold, hyperventilation (hyperventilation echocardiography – the patient is allowed to hyperventilate during the echocardiography, which can initiate a coronary spasm, which is subsequently manifested by a disturbance in the kinetics of the ischemic region of the myocardium).

In the case of a negative coronary angiographic examination, ST elevation capture during the attack is sufficient for the diagnosis of Prinzmetal's AP.

Treatment
Pharmacological therapy is similar to classical AP. Antiplatelet therapy is controversial.
 * Healthy lifestyle + elimination of provoking factors' (smoking, alcohol, cocaine, emotional stress, hyperventilation, hypomagnesemia, severe cold).
 * Pharmacotherapy (calcium channel blockers, nitrates, α-blockers).
 * Intracoronary stenting.
 * Sympathectomy (in resistant patients).

Related Articles

 * Angina pectoris
 * Sudden Cardiac Death
 * Heart-attack
 * Cardiotonics