Question 2#

You have been asked to evaluate a 42-year-old white male smoker who presented to the emergency department with sudden onset of crushing substernal chest pain, nausea, diaphoresis, and shortness of breath. His initial ECG revealed ST segment elevation in the anteroseptal leads. Cardiac enzymes were normal. The patient underwent emergent cardiac catheterization, which revealed only a 25% stenosis of the left anterior descending (LAD) artery. No percutaneous intervention was performed. Which of the following interventions would most likely reduce his risk of similar episodes in the future?

A) Placement of a percutaneous drug-eluting coronary artery stent
B) Placement of a percutaneous non–drug-eluting coronary artery stent
C) Beginning therapy with an ACE inhibitor
D) Beginning therapy with a beta-blocker
E) Beginning therapy with a calcium-channel blocker

Correct Answer is E


This patient’s presentation and minimal coronary artery disease are most consistent with Prinzmetal variant angina. Prinzmetal angina is caused by severe spasm of an epicardial coronary artery. The area of vasospasm is often near a nonhemodynamically significant atherosclerotic lesion. Patients tend to be smokers and are often younger than patients who present with atherosclerotic coronary artery disease. In this case, the patient’s mild LAD stenosis does not explain the degree of ischemia evidenced by the ST segment elevation. Percutaneous intervention has not been shown to be useful in management of Prinzmetal angina, as the culprit is transient vasospasm rather than fixed obstruction. Calcium-channel blockers are the mainstay of therapy to prevent recurrence of spasm. ACE inhibitors and beta-blockers do not prevent acute vasospasm. Of course, the patient should also be counseled to abstain from smoking.