A 37-year-old woman comes to the clinic due to occasional episodes of nocturnal substernal chest pain that wake her during sleep. The pain is occasionally associated with sweating, palpitations, and nausea but no dyspnea. The pain episodes resolve spontaneously after 10-15 minutes. She leads a sedentary lifestyle but states that she can climb 2 flights of stairs without any discomfort. The patient has no history of hypertension or diabetes. She smokes half a pack of cigarettes daily. She does not use alcohol or illicit drugs. Blood pressure is 134/70 mm Hg, pulse is 75/min and regular, and respirations are 14/min. There is no jugular venous distension. The thyroid is normal. There is no carotid bruit. Heart sounds are normal without murmurs. Lungs are clear. Extremities have no edema. Extended ambulatory ECG monitoring shows transient ST-segment elevation in leads I, aVL, and V4-V6 during her episodes of pain. She is referred for coronary angiogram, which shows no significant coronary obstruction. Which of the following is the best treatment for this patient?

Question

A 37-year-old woman comes to the clinic due to occasional episodes of nocturnal substernal chest pain that wake her during sleep.  The pain is occasionally associated with sweating, palpitations, and nausea but no dyspnea.  The pain episodes resolve spontaneously after 10-15 minutes.  She leads a sedentary lifestyle but states that she can climb 2 flights of stairs without any discomfort.  The patient has no history of hypertension or diabetes.  She smokes half a pack of cigarettes daily.  She does not use alcohol or illicit drugs.  Blood pressure is 134/70 mm Hg, pulse is 75/min and regular, and respirations are 14/min.  There is no jugular venous distension.  The thyroid is normal.  There is no carotid bruit.  Heart sounds are normal without murmurs.  Lungs are clear.  Extremities have no edema.  Extended ambulatory ECG monitoring shows transient ST-segment elevation in leads I, aVL, and V4-V6 during her episodes of pain.  She is referred for coronary angiogram, which shows no significant coronary obstruction.  Which of the following is the best treatment for this patient?

Quizplus · Accepted Answer

11ec25c8_d240_2a1e_bc81_c1641da3be95_MD0003_00 This patient most likely has vasospastic angina (formerly known as variant or Prinzmetal angina). Hyperreactivity of intimal smooth muscle in the coronary arterial wall leads to intermittent coronary artery vasospasm; an imbalance in autonomic stimulation likely plays a role. Patients with vasospastic angina typically have recurrent episodes of chest discomfort that resolve spontaneously within 15 minutes. The episodes commonly occur during sleep and may be accompanied by diaphoresis, nausea, palpitations, and dyspnea. Patients are typically young (age <50) and lack most risk factors for coronary artery disease (CAD) (eg, hypertension, diabetes); however, smoking is a strong risk factor. The diagnosis is typically made by ambulatory ECG demonstrating contiguous ST elevation during an episode of chest discomfort. Coronary angiography is usually performed to rule out atherosclerotic CAD. Preferred treatment is smoking cessation and initiation of a calcium channel blocker to dilate coronary arteries and help prevent anginal episodes. Diltiazem, a weak systemic arterial dilator but potent coronary arterial dilator, is commonly used; the dihydropyridines (eg, amlodipine, felodipine) are also effective. Sublingual nitroglycerin is used to limit myocardial ischemia once an episode occurs. (Choice A) Aspirin and statins (eg, rosuvastatin) are standard therapy in patients with atherosclerotic CAD. Aspirin should be avoided in patients with vasospastic angina as it can inhibit prostacyclin production and worsen coronary vasospasm. (Choice B) Cilostazol is a phosphodiesterase III inhibitor that causes arterial vasodilation and inhibits platelet aggregation. It is often used in patients with intermittent lower extremity claudication; however, it does not play a role in management of vasospastic angina. (Choice D) Benzodiazepines (eg, lorazepam) can be useful in management of cocaine-induced coronary vasospasm, but they are not used for vasospastic angina. (Choice E) Omeprazole is useful in treating gastroesophageal reflux disease (GERD); however, chest pain accompanied by diaphoresis and ST elevation on ECG is not consistent with GERD. (Choice F) As adrenergic stimulation of beta-2 receptors dilates coronary arteries and alpha-1 stimulation constricts them, nonselective beta blockers (eg, propranolol) can worsen coronary vasospasm and should be avoided in patients with vasospastic angina. (Choice G) Ranolazine is an antianginal drug that decreases myocardial calcium level by inhibiting late-phase sodium influx into ischemic cardiomyocytes. It is effective in treating stable angina due to atherosclerotic CAD, but is not used in treating vasospastic angina. Educational objective: Vasospastic angina results from hyperreactivity of intimal smooth muscle, leading to intermittent coronary artery vasospasm. Calcium channel blockers (eg, diltiazem, amlodipine) cause coronary artery vasodilation and are the preferred pharmacologic treatment. References: Mechanisms of coronary artery spasm. (http://www.ncbi.nlm.nih.gov/pubmed/22007100) International standardization of diagnostic criteria for vasospastic angina. (http://www.ncbi.nlm.nih.gov/pubmed/26245334) Pharmacotherapy of vasospastic angina. (http://www.ncbi.nlm.nih.gov/pubmed/27081186)

A 37-Year-Old Woman Comes to the Clinic Due to Occasional