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Suggest Treatment For Prinzmetal Angina
Question: I have Prinzmetal's angina. I am 57 yo and it started 3 years ago. I have fainted frequently in my life and have been told I have PSVT (diagnosed when i was 40). I was born with a mild Mitral mumur. I take a nightly vaso dilator pill for the angina. I have fainted again recently. I am systemically hypermobile (EDIII). I have seen a doctor who questions the PSVT and possibly the Prinzmetals. I lead a normal life and wan to ignore these problems but my family are concerned that I will work too hard and risk a heart attack. Am I at greater risk than the next person and if so how should manage myself?
Brief Answer:
I would recommend as follows:
Detailed Answer:
Hello!
Thank you for asking on HCM!
I understand your concern and would explain that in your clinical situation it is necessary to avoid all possible triggering factors of Prinzmetal's angina like:
- psychological stress and anxiety
- physical stress
- hyperventilation
- smoking
- extremely cold weather
-some drugs and substances, which cause vasoconstriction (ephedrine-based products, cocaine, etc).
This disorder is usually related to a dysfunction of the endothelial cells of the coronary arteries , but sometimes an underlying atherosclerotic disease of cororany arteries may induce their spasms.
So if these episodes are frequently repeated and not dominated by vasodilatatory drugs, it is recommendable performing a coronary angio CTscan or even better a coronary angiography to exclude possible coronary artery disease, associated to prinzmetal’s angina.
Regarding PSVT you should know that sometimes it may be related to cardiac ischemia. But it may also be just a concidence finding, related to structural changes of the conduction system (like accessory pathways associated with mitral valve prolaps, etc)
Do you have a mitral valve prolaps (is there any evidence based on your echo report and the fact that you have a mitral murmur)?
Depending on the type of PSVT, it is indicated the underlying therapy (antiarrhythmics,etc).
If there are suspicions for accessory conductance pathways, it is recommended a cardiac electrophysiological study and the possible ablation.
Could you upload an ECG when on PSVT and another normal ECG (without arrhythmia?)
Regarding the risk of a possible heart attack, it is not to be ignored.
If you have chest pain, shortness of breath etc, you should use vasodilatatory pills (nitroglycerine) and go to the ER for an urgent check up, because this disorder could not also cause a myocardial infarct but also induce severe cardiac arrhythmia (like ventricular arrhythmia), which would be lifethreatening.
You should discuss with your attending physician on the above mentioned issues.
Hope to have been helpful!
Feel free to ask any other questions, whenever you need!
Best regards,
Dr. Iliri
I would recommend as follows:
Detailed Answer:
Hello!
Thank you for asking on HCM!
I understand your concern and would explain that in your clinical situation it is necessary to avoid all possible triggering factors of Prinzmetal's angina like:
- psychological stress and anxiety
- physical stress
- hyperventilation
- smoking
- extremely cold weather
-some drugs and substances, which cause vasoconstriction (ephedrine-based products, cocaine, etc).
This disorder is usually related to a dysfunction of the endothelial cells of the coronary arteries , but sometimes an underlying atherosclerotic disease of cororany arteries may induce their spasms.
So if these episodes are frequently repeated and not dominated by vasodilatatory drugs, it is recommendable performing a coronary angio CTscan or even better a coronary angiography to exclude possible coronary artery disease, associated to prinzmetal’s angina.
Regarding PSVT you should know that sometimes it may be related to cardiac ischemia. But it may also be just a concidence finding, related to structural changes of the conduction system (like accessory pathways associated with mitral valve prolaps, etc)
Do you have a mitral valve prolaps (is there any evidence based on your echo report and the fact that you have a mitral murmur)?
Depending on the type of PSVT, it is indicated the underlying therapy (antiarrhythmics,etc).
If there are suspicions for accessory conductance pathways, it is recommended a cardiac electrophysiological study and the possible ablation.
Could you upload an ECG when on PSVT and another normal ECG (without arrhythmia?)
Regarding the risk of a possible heart attack, it is not to be ignored.
If you have chest pain, shortness of breath etc, you should use vasodilatatory pills (nitroglycerine) and go to the ER for an urgent check up, because this disorder could not also cause a myocardial infarct but also induce severe cardiac arrhythmia (like ventricular arrhythmia), which would be lifethreatening.
You should discuss with your attending physician on the above mentioned issues.
Hope to have been helpful!
Feel free to ask any other questions, whenever you need!
Best regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you so much for the fulsome answer. I have had an angiograph which showed that the arteries are very good and clear of atherosclerosis. The doctor I consulted at that point said that he did not believe in Prinzmetals and so said that there was nothing wrong and to go away and lead a normal life. My own GP prescribed the Diltiazem 180g which has worked very well in reducing the angina.
My mild mitral regurgitation was diagnosed as a child and confirmed with an echo 3 years ago.
Recent ECG was normal, although during an exercise stress test of 3 years ago I was stopped, even though I felt fine, as the technician was concerned that the "ST???" wave was wrong. I was told that that can be a false positive in women and not to worry.
I have had a 24 hour BP monitor in the last month and I it was 110/60 or lower diastolic more than 50% of the time.
Cholesterol ratio is 3.2, total is 6.2, HDL 1.96 and LDL 3.8.
I am delighted that so many of the tests are good but what upsets me is the fact 4 cardiologists have made different diagnoses over the years and the next one then dismisses the validity of the previous diagnosis and says that they don't believe in the existence of the condition and then give me another answer to the symptoms. I feel unsure how to manage things/who to believe. I feel that I am being a hyperchondriac if I am careful but don't want to ignore potentially life threatening symptoms. Certainly the angina (pain between shoulder blades, chest pain and jaw pain) is worse in the middle of the night with no provocation and when stressed emotionally or in cold wind and going up hills. It usually eases with the nitro spray but often needs 2 doses 10 mins apart. I can go weeks with no angina on the diltiazem and then 4-5 weeks of angina x3 a week.
My husband tells me not to work so hard but I want to do lots of things and not fret about my health, so most of the time I don't tell him I have had the angina.
Thank you so much for the help. I feel that some of the doctors want to question their colleagues for an ego trip.
My mild mitral regurgitation was diagnosed as a child and confirmed with an echo 3 years ago.
Recent ECG was normal, although during an exercise stress test of 3 years ago I was stopped, even though I felt fine, as the technician was concerned that the "ST???" wave was wrong. I was told that that can be a false positive in women and not to worry.
I have had a 24 hour BP monitor in the last month and I it was 110/60 or lower diastolic more than 50% of the time.
Cholesterol ratio is 3.2, total is 6.2, HDL 1.96 and LDL 3.8.
I am delighted that so many of the tests are good but what upsets me is the fact 4 cardiologists have made different diagnoses over the years and the next one then dismisses the validity of the previous diagnosis and says that they don't believe in the existence of the condition and then give me another answer to the symptoms. I feel unsure how to manage things/who to believe. I feel that I am being a hyperchondriac if I am careful but don't want to ignore potentially life threatening symptoms. Certainly the angina (pain between shoulder blades, chest pain and jaw pain) is worse in the middle of the night with no provocation and when stressed emotionally or in cold wind and going up hills. It usually eases with the nitro spray but often needs 2 doses 10 mins apart. I can go weeks with no angina on the diltiazem and then 4-5 weeks of angina x3 a week.
My husband tells me not to work so hard but I want to do lots of things and not fret about my health, so most of the time I don't tell him I have had the angina.
Thank you so much for the help. I feel that some of the doctors want to question their colleagues for an ego trip.
Brief Answer:
I would explain as follows:
Detailed Answer:
Hello again!
I understand your concern and would like to explain that sometimes this type of angina it is under diagnoses or misdiagnosed. This is because the coronary spasms are non persistent and it is difficult to capture these changes on the cardiac tests.
There are specified diagnostic criteria for prinzmetal’s angina :
1) rest angina
2) reversible ST changes (elevation or depression)
and/or
3) spontaneous/provoked coronary spasm on angiography.
The tests used to diagnose this disorder (besides the medical history and symptoms) are:
-Ambulatory 24-48 ECG monitoring may be useful, particularly during a hot phase of the condition, for detecting episodes of ST segment changes as well as associated arrhythmias.
-Exercise ECG stress testing is typically negative but during the hot phase, exercise-induced spasm may occur in half of the variant angina patients . It is true that the changes found in your case may be nonspecific.
-Coronary angiography is useful to assess the presence of obstructive coronary artery disease.
-Provocative coronary spasm testing: this provocative testing has primarily been undertaken during coronary angiography, where spasm can be promptly identified and treated with intracoronary nitrates if necessary. Two most commonly employed substances are acetylcholine and ergonovine, which are injected inside the coronary arteries during angiography. The presence of inducible coronary spasm is assessed on the basis or ECG changes and/or severe coronary constriction seen on the images, in response to the provocative stimulus.
You should discuss with your doctor one the above tests (mainly the provocative coronary spasm testing, which is one of the diagnostic criteria for this disorder).
An ambulatory 24-48 hour ECG monitoring may be helpful.
Anyway, I agree on the therapy. Diltiazem is a calcium channel blocker, which is very effective in preventing the coronary spasms.
Best regards,
Dr. Iliri
I would explain as follows:
Detailed Answer:
Hello again!
I understand your concern and would like to explain that sometimes this type of angina it is under diagnoses or misdiagnosed. This is because the coronary spasms are non persistent and it is difficult to capture these changes on the cardiac tests.
There are specified diagnostic criteria for prinzmetal’s angina :
1) rest angina
2) reversible ST changes (elevation or depression)
and/or
3) spontaneous/provoked coronary spasm on angiography.
The tests used to diagnose this disorder (besides the medical history and symptoms) are:
-Ambulatory 24-48 ECG monitoring may be useful, particularly during a hot phase of the condition, for detecting episodes of ST segment changes as well as associated arrhythmias.
-Exercise ECG stress testing is typically negative but during the hot phase, exercise-induced spasm may occur in half of the variant angina patients . It is true that the changes found in your case may be nonspecific.
-Coronary angiography is useful to assess the presence of obstructive coronary artery disease.
-Provocative coronary spasm testing: this provocative testing has primarily been undertaken during coronary angiography, where spasm can be promptly identified and treated with intracoronary nitrates if necessary. Two most commonly employed substances are acetylcholine and ergonovine, which are injected inside the coronary arteries during angiography. The presence of inducible coronary spasm is assessed on the basis or ECG changes and/or severe coronary constriction seen on the images, in response to the provocative stimulus.
You should discuss with your doctor one the above tests (mainly the provocative coronary spasm testing, which is one of the diagnostic criteria for this disorder).
An ambulatory 24-48 hour ECG monitoring may be helpful.
Anyway, I agree on the therapy. Diltiazem is a calcium channel blocker, which is very effective in preventing the coronary spasms.
Best regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you. Can I summarise. Continue with the med diltiazem, nitro spray as required, avoid stress and cold weather and live normally except when i have angina and rest until the pain has gone. Ignore the fact I do or don't have an arrhythmia/ mitral valve regurgitation as they will not be adversely be affecting my heart health if they are mild and deal with vaso valgal fainting as it occurs but not view it as a heart risk as things are at present.
I don't think that the diagnostic tests will, or can, be offered to me from our health providers here.
Many thanks for your thorough and considered advice. It has been most useful and reassuring.
With Best Wishes.
I don't think that the diagnostic tests will, or can, be offered to me from our health providers here.
Many thanks for your thorough and considered advice. It has been most useful and reassuring.
With Best Wishes.
Brief Answer:
You are welcome!
Detailed Answer:
Hi!
I hope to have clarified some clue issues to discuss with your attending cardiologist.
You are right to repeat the preventive measures which may avoid possible vaso-spastic angina bouts, as they are important precautions to consider.
Anyway, I will be at your disposal if you have further uncertainties regarding your heart issues.
Wishing you a pleasant weekend!
Kind regards,
Dr. Iliri
You are welcome!
Detailed Answer:
Hi!
I hope to have clarified some clue issues to discuss with your attending cardiologist.
You are right to repeat the preventive measures which may avoid possible vaso-spastic angina bouts, as they are important precautions to consider.
Anyway, I will be at your disposal if you have further uncertainties regarding your heart issues.
Wishing you a pleasant weekend!
Kind regards,
Dr. Iliri
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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