Q&A Medicine>>>>>Cardiology
Question 4#

A 28-year-old woman frantically presents to the Emergency Department in the middle of the night with chest discomfort that awoke her from sleep. She has experienced similar episodes a few times before, always at night, but never as bad as this. She reports a history of migraines but denies any other medical history, including heart disease. Her medications include NSAIDs as needed and OCPs. She smokes a half pack of cigarettes a day but denies any alcohol or drug use. She admits that she gets “stressed out” a lot but believes that overall she lives a healthy lifestyle. Laboratory values show normal CK and troponin. An ECG shows ST elevations and she is taken for coronary angiography that does not show any significant coronary occlusions.

What is the most appropriate treatment for this patient?

A) Alprazolam
B) Diltiazem
C) Alteplase
E) Reassurance

Correct Answer is B


Diltiazem. High-dose calcium channel blockers are the preferred treatment for Prinzmetal angina. Sublingual nitroglycerin may also be prescribed to relieve chest pain during attacks and to minimize frequent visits to the Emergency Department. Smoking cessation is important and should be addressed. 

This is a fairly classic presentation of Prinzmetal (variant) angina, which is caused by focal vasospasm of a coronary artery and typically occurs in young smokers that may have a history of other vasospastic disease (Raynaud, migraines, etc.). It usually occurs at night, and an ECG may show ST elevation as a result of transient myocardial ischemia that usually does not lead to infarction. During coronary angiography, vasospasm can be induced with the use of ergonovine, acetylcholine, or hyperventilation. Of note, this diagnosis can be differentiated from Takotsubo cardiomyopathy (can also present with ST elevations with normal coronary angiography) by the normal serum CK and troponin.

(A) Alprazolam is a benzodiazepine used for panic disorder. (C) Alteplase is a fibrinolytic used in acute myocardial infarction when PCI is unavailable. (D) NSAIDs may be used for viral pericarditis, but the sudden onset and recurrent description of the symptoms does not fit this diagnosis.