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Question:

What are the best treatment options for Prinzmetal’s Angina?

From Australia - my wife has suspected Prinzmetal Angina, but we're not experiencing a great deal of success with treatment. She currently takes Verapamil (240mg night, 160mg morning), and 20mg Pariet for reflux. The Verapamil has been the most successful drug by far, but we still experience frequent chest pain (cramping, crushing feeling), difficulty breathing, irregular heartbeat, and even in some occasions eye pain. During her most recent pregnancy (6 months ago), she had capillaries in both eyes collapse and damage part of the retina which was attributed to a spasm.

I'm desperate for a direction to travel. Our local specialists have all but stopped helping, because we've tried nearly all the readily available treatments (excluding beta-blockers due to adverse reactions). We need some fresh eyes, and help. Any suggestions? 

submitted by Nick from Adelaide, Australia on 1/23/2013

Answer:

by Texas Heart Institute cardiologist, Michael J. Mihalick, MD  

Michael J. Mihalick, MDDear Nick,
My first recommendation would be to confirm the diagnosis of Prinzmetal's angina. The gold standard would be to visualize spasm of the coronary arteries during a typical attack. Provocative tests can be done, but would be quite dangerous in your wife's case and, in my opinion, are out of the question. The next best thing is to document ECG changes during chest pain which can be accomplished by wearing an event monitor. Elevation of the ST segment of the ECG signal during chest pain is diagnostic. The treatment is nitroglycerine (both short and long acting). Calcium channel blockers such as diltiazem or verapamil are also effective. Since some of the damage can result from blood clots triggered by the spasm, drugs like aspirin may be helpful. I have never used other stronger anticoagulants for fear of increasing bleeding risk.

Your wife appears to have a particularly severe case which involve spasm of other smooth muscle structures such as the esophagus as well as other blood vessels. Some patients have been reported to have asthma as well. This condition is thought to be caused by malfunction of the cells lining the blood vessels (endothelial cells). Drugs are being developed that affect endothelial function and may prove to be of benefit in the treatment of Prinzmetal's angina. I'm afraid there is not much else to offer at this time.  Until then, I recommend the following, in coordination with and direction by her physician:

1. Be sure you are dealing with vasospastic angina and not another condition such as a vasculitis that may respond to a different treatment.
2. Push the doses of nitrates and calcium channel blockers (CCBs) to the maximum. If one CCB is ineffective, try another.
3. Add aspirin.
4. Avoid situations that may be triggers.
5. See your cardiologist periodically since new therapies may come along at any time.

In my experience this condition often goes into remission. In your wife's case it could have been triggered by factors related to pregnancies, but this is only a guess on my part. However, if that is true, her symptoms may improve with time.  

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Updated January 2013
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