Coronary Vasospasm

What are Coronary Vasospasms ?

There are some individuals who experience angina which is not caused by blockages of the coronary arteries. The coronary arteries temporarily constrict during a spasm, reducing the blood supply to the heart. The spasms are transient, coming and going, sometimes lasting for a few minutes or for much longer. These coronary vasospasms can be unprovoked occurring at rest rather than being brought on by exercise.

Variant Angina was the previously used term to describe this type of chest pain. In the 1950’s, Dr Myron Prinzmetal (Cardiologist), suggested that this type of chest pain was caused by a temporary spasm or narrowing in one or more of the coronary arteries – Coronary Artery Spasm.

The terms vasospastic angina and coronary vasospasm are now more frequently recognised and used. Coronary vasospasms usually affect the larger blood vessels of the heart. Some people also live with another type of angina which affects the function of the small blood vessels of the heart. This is known as microvascular angina.

Coronary vasospasms and microvascular angina are also known as Non-Obstructive Coronary Artery Disease (NOCAD) or Ischaemia with Non-Obstructive Coronary Arteries (INOCA).

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SYMPTOMSTRIGGERS

The Symptoms

Vasospastic angina affects both men and women.

  • Chest pain can be severe and prolonged – coming in clusters and lasting up to an hour or longer.
  • Chest pain at rest often breaking sleep between midnight and 6am.
  • Individuals are usually able to exercise.
  • Breathlessness.
  • Feeling faint or nauseated. Some have reported vomiting.
  • A feeling of tightness and heaviness in the chest – some women liken it to their bra feeling too tight.
  • Pain or discomfort which can be felt in the stomach, upper back between the shoulder blades, shoulders, jaw, face, arms, and hands.
  • Cold sweat.
  • A sense of unease which some describe as a “sense of doom”.
  • Extreme fatigue.

A prolonged vasospasm can cause an abnormal heart rhythm and even a heart attack. Both need urgent medical treatment. Sudden cardiac arrest has occurred in some individuals; however, this is rare. Seeking immediate medical attention for prolonged or differing symptoms and following the advice of health care professionals is imperative.

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Coronary Vasospasm Causes and Triggers

The causes of vasospastic angina are not fully understood, however, there are some triggers that can lead to a susceptible individual to experiencing coronary vasospasms. Triggers can include:

  • Cold weather or a sudden drop in temperature
  • Stress – both emotional and mental
  • Lack of sleep
  • Hyperventilation
  • A severe allergic reaction (Kounis Syndrome)
  • Smoking/vaping or second hand smoke
  • Inflammation of the inner lining of the blood vessels (Endothelium)
  • Some types of medications:
    • Beta Blockers
    • Anti-depressants
    • Anti-migraine
    • Chemotherapy
  • Recreational drugs such as cocaine, cannabis, and some stimulants
  • High alcohol intake
  • Adrenaline, Ephedrine, and pseudoephedrine which are found in some over the counter cold remedies and diet pills.
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Learn all about the symptoms, causes and triggers of vasospastic angina.

DIAGNOSISTREATMENT

Diagnosis of Coronary Vasospasm

A healthcare professional listening to a patient’s history of symptoms may suspect a patient has vasospastic angina and will refer the patient for further testing to confirm the diagnosis. 

An electrocardiogram (ECG) – a 12 lead recording of the electrical activity and rhythm of the heart – can, in some cases, detect the possible lack of blood supply to the heart.

Some of the following tests maybe offered depending on availability:

  • A 24-hour (or longer) continuous ECG
  • Exercise tolerance test
  • Transthoracic Doppler Echocardiography
  • Myocardial contrast Echocardiography
  • Positron Emission Tomography
  • Cardiac Magnetic Resonance Imaging
  • Invasive Angiography (cardiac catheterisation) to assess the function of the micro vessels using adenosine and a guidewire.
  • Assessment for vasospasms using a chemical such as acetylcholine to provoke a vasospasm.

Medical Treatment

There is no standard agreed treatment for Vasospastic Angina. It can sometimes be a process of trial and error working with a healthcare professional to find the best combination of medication that will work for each individual patient.

The usual treatment of Vasospastic angina is by taking medication to dilate and relax the blood vessels to help prevent further vasospasms. Some of the medications that have been found to be helpful in the successful management of vasospasms are:

  • Calcium channel blockers such as Diltiazem, Verapamil and Amlodipine
  • Nitrates, short acting sublingual (under the tongue) tablets or spray.
  • Longer acting nitrate tablets, patches or Intravenous (IV) Glyceryl trinitrate (GTN) to treat severe episodes of vasospasms.
  • Nicorandil (not available in the US)
  • Statins to improve the function of the endothelium
  • Aspirin or anti platelet medications.
  • Other medications that may be offered are Angiotensin-converting enzyme (ACE) inhibitors (e.g. Ramipril)
  • Angiotensin receptor blockers (ARB)s (e.g. candesartan)

Other Important Self-management Strategies

  • Adopting a heart healthy diet
  • Weight control
  • Exercise
  • Cessation of smoking/vaping or passive smoking
  • Seeking help to manage drug and/or alcohol problems
  • Proper management of other conditions such as diabetes, high blood pressure and cholesterol levels
  • Stress and anxiety management eg Cognitive behavioural therapy (CBT), Mindfulness meditation, Tai Chi, yoga, breathing and relaxation techniques

Expected Prognosis for Someone Living with Coronary Vasospasms

Some people do very well with the appropriate medication and lifestyle strategies. Approximately 20% of individuals continue to experience recurrent episodes of vasospasms. This can negatively affect the person’s quality of life.

It is, however, possible to find ways to live with vasospastic angina. The aim of International Hearts Spasms Alliance is to help everyone affected by heart spasms to live their best possible life.

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