Variant Angina

Question 1

Definition?

Answer 1

Pain or discomfort in chest, shoulders, neck or jaw caused by insufficient blood supply to myocardium-due to vasospasm of coronary arteries at rest.

Question 2

RF?

Answer 2

• Many or may not have AS
• Smoking
• Ethnicity
• High cholesterol and BP
• Alcohol withdrawal/drugs, stress
• Cold
• meds

Question 3

Ddx?

Answer 3

• MI
• Mixed angina
• Tako-tsubo cardiomyopathy-rest angina with ST elevation
• Non-cardiac causes of chest pain

Question 4

Epidemiology?

Answer 4

Age: Elderly
Sex: Male
Ethnicity: Japanese, Caucasian

Question 5

Aetiology?

Answer 5

Coronary artery vasospasm

Question 6

CP?

Answer 6

• ST elevation-transmural ischaemia
• Chest discomfort-during rest and at night
• Relieved by short-acting nitrates
• Arrhythmias
• Heart burn
• Nausea and vomiting
• Dizziness and palpitations

Question 7

Pathophysiology?

Answer 7

• Coronary artery vasospasm-reduced blood flow enough to cause ischaemia of all layers of heart wall-transmural
• Doesn’t correlate to exercise
• VC like TXA2 can also be released abnormally
Reversible

Question 8

Investigations-first line?

Answer 8

First line: CVS and resp exam, ECG-ST elevation

Question 9

Investigations- second line?

Answer 9

Exercise ECG, Coronary angiography-no obstruction but vasospasm seen

Question 10

Investigations-third line?

Answer 10

Provocative spasm testing-using methacholine, adrenaline-chest pain, ECG changes or coronary VC

Question 11

Management first line?

Answer 11

Lifestyle-smoking and CVD risk factors

Question 12

Management second line?

Answer 12

GTN and CCB

Question 13

Management-third line?

Answer 13

nicorandil (KCA), and the rho kinase inhibitor, fasudil

Question 14

Prognosis?

Answer 14

• Linked to significant morbidity-60-95% risk of 5yr death
• Caucasians have a worse prognosis
Determinants include CCB, severity of CAD and multivessel spasm

Question 15

Complications?

Answer 15

• Unstable angina
• ACS
• Syncope
• HF
• Arrhythmia
• Chest pain