Variant angina
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Understanding Variant Angina: Clinical Features, Diagnosis, and Prognosis
Introduction to Variant Angina
Variant angina, also known as Prinzmetal's angina, is a type of chest pain caused by transient spasms of the coronary arteries, leading to a temporary reduction in blood flow to the heart muscle. Unlike typical angina, which is often triggered by physical exertion or stress, variant angina usually occurs at rest and can be severe enough to wake patients from sleep.
Clinical Features of Variant Angina
Symptoms and Presentation
Patients with variant angina typically experience chest pain at rest, which is often more severe and of longer duration compared to classical angina. The pain can be cyclic, frequently occurring at the same time of day or night, and is accompanied by transient ST-segment elevations on an electrocardiogram (ECG). These episodes are not usually provoked by exercise or emotional stress .
Electrocardiographic Changes
Marked ST-segment elevations are a hallmark of variant angina, occurring during pain episodes and returning to baseline once the pain subsides. This transient elevation is similar to the acute injury pattern seen in myocardial infarction but without the permanent damage . Some patients may also experience ventricular arrhythmias, including ventricular tachycardia and fibrillation, which can be life-threatening .
Diagnostic Assessment
Coronary Arteriography
Coronary arteriography is crucial for diagnosing variant angina, as it helps identify the presence and extent of coronary artery obstructions. Patients can have a wide range of coronary artery conditions, from normal arteries to severe multi-vessel disease . This diagnostic tool is essential for determining the appropriate treatment strategy and assessing the risk of major cardiac events (MCE) .
Clinical and ECG Features
While certain clinical features, such as a history of angina at rest for more than three months, abnormal resting ECGs, and abnormal stress tests, can indicate variant angina, they are not always reliable for distinguishing between patients with and without significant coronary obstructions due to overlapping characteristics . Therefore, a comprehensive diagnostic approach, including coronary arteriography, is recommended .
Prognosis and Management
Prognostic Factors
The prognosis of variant angina varies significantly based on the presence of coronary artery disease. Patients with normal coronary arteries generally have an excellent prognosis, while those with significant coronary stenoses are at higher risk for adverse outcomes, including myocardial infarction and sudden death . The presence of diffuse ST-segment elevation on ECG during angina episodes is a significant predictor of major cardiac events.
Treatment Options
Management of variant angina involves both medical and, in some cases, surgical interventions. Calcium channel blockers and nitrates are commonly used to prevent coronary artery spasms and alleviate symptoms. In severe cases, especially those with life-threatening arrhythmias, the use of automatic cardioverter defibrillators or pacemakers may be necessary . Despite advancements in treatment, the lack of randomized trials and the tendency for spontaneous remissions make it challenging to establish standardized management guidelines.
Conclusion
Variant angina is a complex and variable condition characterized by spontaneous coronary artery spasms leading to chest pain at rest. Accurate diagnosis through coronary arteriography and careful monitoring of clinical and ECG features are essential for effective management. While the prognosis is generally good for patients without significant coronary artery disease, those with severe obstructions require more intensive treatment and monitoring to prevent life-threatening events. Continued research and clinical trials are needed to refine treatment strategies and improve patient outcomes.
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