PubMed · 15014192
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Junya Ako, Yasuhiro Honda, Peter J Fitzgerald. 2004-03-11. Conditions associated with ST-segment elevation.. https://doi.org/10.1056/nejm200403113501118
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Variant angina, defined as spontaneous angina pectoris associated with transient ST-segment elevation, has proved to be caused usually by episodic coronary spasm since Prinzmetal and his associates described a form of angina quite different from classic Heberden angina pectoris in 1959. Currently, coronary artery spasm is defined as reversible coronary stenosis, which limits coronary blood flow under resting conditions, and it plays an important role in ischemic heart disease, particularly in variant angina. Data available in respect of coronary vasospasm showed that it is closely related to atherosclerotic coronary artery disease, since intravascular ultrasound studies reveal atherosclerotic plaques in almost any spastic segment. Risk factors for coronary artery disease and coronary vasospasm, however, differ profoundly. Cigarette smoking is the only established risk factor. Although several candidates and predisposing factors, such as serotonin, histamine, thromboxane, and endothelin, have been described, the mediators and the pathogenesis of the disease remain unknown. There are abundant studies that inflammation plays an important role in the initiation, development as well as evolution of atherosclerosis, suggesting that atherosclerosis is an inflammation disease. The evidence regarding the role of inflammatory pathways in different clinical entities of coronary artery disease has significantly been accumulated. And also, primary studies have showed that inflammation may be a contributor for variant angina or vasospastic coronary disease is at least partially driven by inflammation. Although much more research is obviously needed, primary evidence provide us with some direction for that research.
High doses of calcium antagonists and nitrates are the treatment of choice in vasospasm angina when no stenosis or mild stenosis is present. In ca. 5-30% patients this kind of treatment is not effective. We present five cases of variant angina with acute coronary syndrome in patients despite standard pharmacological treatment. These patients also did not respond for intracoronary nitroglycerine injection. They were successfully treated with stent implantation in place of vasospasm. Our observations indicate that early enough interventional treatment prevent myocardial infarction. In one case in which stent placement was performed 12 h after clinical manifestation myocardial infarction with Q waves and enzymes release occurred. In others, accurately treated with stent implantation, coronary spasm did not produce myocardial damage. We did not see any clinical and biochemical evidence of myocardial infarction.
Patients with variant angina represent a diagnostic and therapeutic dilemma. Variant angina is a disease with various causes, variations in treatment guidelines and variable prognosis. In an era of robotic cardiac surgery and automatic cardioverter defibrillators, it is regrettable that we lack enough information on the optimal management of this entity. Lack of randomised trials and a tendency for spontaneous remissions makes interpretation of results difficult. We review the pathophysiology, presentation and recent developments in medical and surgical management of variant angina. Literature is full of conflicting data and it is difficult to make specific recommendations.