Definition
• Distinct syndrome of ischemic CP classically occurring at rest & associated transient STE as a result of coronary artery spasm
• Although VA results from focal coronary spasm, the exact etiology is unknown
History
• Usually younger pts (35–50 y/o), smokers, F>M; often occurs in the AM, precipitated by hyperventilation or cold, but not exertion
• No known cardiac hx & may have had a negative coronary angiogram
• Associations: EtOH use, family h/o migraine, Raynaud’s syndrome, pericarditis, & primary MV prolapse
• Sxs include substernal pressure that radiates to jaw & arm, usually in morning hours awakening from sleep; pain is typically responsive to NTG
Evaluation
• EKG reveals transient STE in a distribution of a sp coronary artery & reciprocal STΔs; these episodes may induce a variety of conduction disturbances or arrhythmias
• Stress testing may induce no STΔs, STDs, or STEs; STEs may be seen during recovery phase of stress testing
• Angiography → nonobstructive CAD; intracoronary acetylcholine injection (90% sens)
• Provocative testing w/ ergonovine or hyperventilation (not performed in ED)
Treatment
• High-dose CCB (nifedipine, verapamil, diltiazem), nitrates (SL prn); d/c smoking
Disposition
• Admit, given risk of MI & arrhythmia during acute episodes