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Vasospastic angina

Duane S Pinto, MD, MPH
Filippo Crea, MD
Section Editor
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Deputy Editor
Gordon M Saperia, MD, FACC


Vasospastic angina, which was previously referred to as Prinzmetal or variant angina, is a clinical entity characterized by episodes of rest angina that promptly respond to short-acting nitrates and are attributable to coronary artery vasospasm. Prinzmetal, et al [1] initially described a clinical syndrome that manifested as rest angina associated with ST-segment elevation that promptly responded to sublingual nitrates. Since this differed to the classical angina described by Heberden (effort angina associated with ST depression) [2], he referred to it as “variant angina.” With the advent of coronary angiography, subsequent studies confirmed Prinzmetal’s original suspicion that variant angina was attributable to coronary artery spasm but also demonstrated that episodes could be associated with ST-segment depression. Consequently, the term "vasospastic angina" evolved. This topic will discuss all aspects of vasospastic angina; other forms of (cardiac) angina are discussed in separate topic reviews. (See "Stable ischemic heart disease: Overview of care" and "Classification of unstable angina and non-ST elevation myocardial infarction", section on 'Classification of unstable angina' and "Cardiac syndrome X: Angina pectoris with normal coronary arteries".)


Within the literature, there have been a variety of definitions for vasospastic angina, leading to confusion. Consequently, the Coronary Vasomotion Disorders International Study group (COVADIS) has published diagnostic criteria for vasospastic angina (table 1) [3]. There are three core elements establishing the diagnosis of vasospastic angina, including nitrate-responsive angina, transient ischemic electrocardiographic (ECG) changes, and angiographic evidence of coronary artery spasm. In patients with a documented spontaneous episode, the diagnosis can be made on the basis of nitrate-responsive angina with associated transient ECG changes. Occasionally, a spontaneous episode may occur during diagnostic angiography so that all three elements may be documented. However, typical spontaneous episodes are not documented. As such, provocative testing is undertaken to make the diagnosis. During provocation testing, the diagnosis of vasospastic angina is confirmed if the provocative stimulus induced chest pain, transient ECG changes, and a >90 percent constrictor response.


Vasospastic angina is caused by focal or diffuse spasm (of the smooth muscle layer of the arterial wall) of a major coronary artery [4,5], resulting in a high-grade obstruction. Transient myocardial ischemia causes angina in many patients; myocardial infarction may develop in some [1,6]. Vascular smooth muscle hyper-reactivity is thought to be central to the pathogenesis of vasospastic angina [1,4,5].

Spasm may occur in the absence of any preceding increase in myocardial oxygen demand (eg, exercise) and in normal or diseased vessels. It is usually focal in its anatomic distribution, although spasm in more than one site and diffuse spasm have been described [7]. Spasm can occur in angiographically normal coronary vessels but more commonly at the site of atherosclerotic plaques of variable severity.

Vascular smooth muscle hyper-reactivity — Animal and clinical studies have implicated coronary vascular smooth muscle hyper-reactivity as a key factor in the pathogenesis of coronary artery spasm. Important observations include:


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Literature review current through: Sep 2016. | This topic last updated: Sep 12, 2016.
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