Coronary vasospasm

Patients with variant (Prinzmetal s) angina or cocaine-induced ACS may benefit from calcium channel blockers as initial therapy because they can reverse coronary vasospasm. /J-Blockers generally should be avoided in these situations because they may worsen vasospasm through an unopposed /T-blocking effect on smooth muscle. 

Side effects of triptans include paresthesias, fatigue, dizziness, flushing, warm sensations, and somnolence. Minor injection site reactions are reported with SC use, and taste perversion and nasal discomfort may occur with intranasal administration. Up to 15% of patients report chest tightness, pressure, heaviness, or pain in the chest, neck, or throat. Although the mechanism of these symptoms is unknown, a cardiac source is unlikely in most patients. Isolated cases of myocardial infarction and coronary vasospasm with ischemia have been reported. 

Use 5-HTi agonists only where a clear diagnosis of migraine has been established. Risk of myocardial ischemia or infarction and other adverse cardiac events Because of the potential of this class of compounds to cause coronary vasospasm, do not give these agents to patients with documented ischemic or vasospastic coronary artery disease (CAD). 

Uses Acute migraine Action S otonin 5-HTi rec tor antagonist Dose 1—2.5 mg PO once r eat PRN in 4 h 5 mg/24 h max -1- in mild renal/hepatic insuff, take w/ fluids Caution [C, M] Contra Sev e renal/hepatic impair, avoid w/ angina, ischemic heart Dz, uncontrolled HTN, cerebrovascular synds, CTgot use Disp Tabs SE Dizziness, sedation, GI upset, paresthesias, ECG changes, coronary vasospasm, arrhythmias Interactions T Effects W/ MAOIs, SSRIs T effects OF CTgot drugs X effects W7 nicotine EMS May T PR or CyT int val, monitor ECG OD May cause profound HTN and cardiac ischemia symptomatic and supportive... 

When coronary vasospasm occurs, the balance between oxygen supply and demand can be restored by relieving the spasm, thereby restoring normal coronary blood flow. Acute vasospasm has been successfully aborted through the use of nitroglycerin. In contrast, calcium entry blockers and long-acting nitrates have proved effective in the chronic therapy of coronary vasospasm. 

Variant angina Myocardial oxygen supply decreases due to coronary vasospasm may occur while patient is at rest Treated primarily with a calcium channel blocker... 

Van Spall HG, Overgaard CB, Abramson BL. Coronary vasospasm a case report and review of the literature. Can J Cardiol. 2005 21 953-957. 

Coronary vasospasm Intracranial hemorrhage or Stroke Ingestion of sympathomimetic agents Direct myocardial damage Cardiac contusion Direct current cardioversion Cardiac infiltrative disorders Chemotherapy Myocarditis Pericarditis... 

Coronary vasospasm, including apical ballooning syndrome... 

Endothelin has been implicated in myocardial infarction, coronary vasospasm and re-stenosis subsequent to percutaneous transluminal coronary angioplasty. The potent, prolonged coronary vasoconstrictor and mitogenic actions of endothelin are well-documented (see earlier section) and thus endothelin is certainly able to produce the biological effects seen in these disease states. Although a reduction in infarct size has been demonstrated in a rat model of myocardial infarction with an endothelin antibody [185], and with phosphoramidon [186], the argument for a role for endothelin in ischaemic heart disease has been based mainly on the finding of increased plasma endothelin levels in patients with myocardial infarction [187-190], coronary vasospasm [191, 192] and re-stenosis post-PTCA [193-195]. 

Overdose is common amongst users (up to 22% of heavy users report losing consciousness). The desired euphoria and excitement turns to acute fear, with psychotic symptoms, convulsions, hypertension, haemorrhagic storke, tachycardia, arrhythmias, hyperthermia coronary vasospasm (sufficient to present as the acute coronary syndrome with chest pain and myocardial infarction) may occur, and acute left ventricular dysfunction. Treatment is chosen according to the clinical picture (and the known mode of action), from amongst, e.g. haloperidol (rather than chlorpromazine) for mental disturbance diazepam for convulsions a vasodilator, e.g. a calcium channel blocker, for hypertension glyceryl trinitrate for myocardial ischaemia (but not a p-... 

Because of the ease of introducing intravenous and intra-arterial catheters and measuring blood flow and blood pressure, dogs are commonly used to conduct hemodynamic studies. These studies evaluate the effect of the test compound on systolic and diastolic blood pressure, heart rate, cardiac output, dp/dt, respiration, ECG, and ventricular pressure. From these data, effects desirable for treating angina pectoris, congestive heart failure, coronary vasospasm, and myocardial infarction can be detected. 

Of the patients who took amfepramone 25-75 mg/day, 12% were withdrawn from the study one developed coronary vasospasm and another atrial fibrillation. These poor results are comparable to those of earlier studies with methylphenidate in cocaine addicts (178,179). 

Myocardial ischemia has also been reported in susceptible patients. A Japanese group carried out dobutamine stress echocardiography in 51 patients with a presumptive diagnosis of variant angina (17). All had coronary vasospasm in response to intracoronary acetylcholine and seven also had chest pain and reversible ST segment elevation. One must incidentally wonder whether this procedure was entirely advisable. 

Burger AJ, Mannino S. 5-Fluorouracil-induced coronary vasospasm. Am Heart J 1987 114(2) 433-6. 

Yamamoto N, Nishigaki K, Ban Y, Kawada Y. Coronary vasospasm after interferon admmistration. Br J Urol 1998 81(6) 916-17. 

RuDusky BM. Acute myocardial infarction secondary to coronary vasospasm during withdrawal from industrial nitroglycerin exposure—a case report. Angiology 2001 52(2) 143. ... 

MOA Nitrates cause venous and arterial dilatation. However, venous dilatation is more evident because it increases venous pooling, therefore decreasing preload and reducing myocardial or gen demand, in addition, nitrates dilate epioirdial coronary arteries, consequently decreasing coronary vasospasm. 

N/V, dizziness, injection site pain. Cardiovascular coronary vasospasm, chest pain, ischemic Ml. 

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