TREATMENT OF CORONARY ARTERY SPASM
AND VARIANT ANGINA PECTORIS
• All patients should be treated for acute attacks and maintained on prophylactic treat-
ment for 6 to 12 months after the initial episode. Aggravating factors such as alcohol
or cocaine use and cigarette smoking should be stopped.
• Nitrates are the mainstay of therapy, and most patients respond rapidly to sublingual
nitroglycerin or ISDN. IV and intracoronary nitroglycerin may be useful for patients
not responding to sublingual preparations.
• Because CCBs may be more effective, have few serious adverse effects, and can
be given less frequently than nitrates, some authorities consider them the agents
of choice for variant angina. Nifedipine, verapamil, and diltiazem are all equally
effective as single agents for initial management. Patients unresponsive to CCBs
alone may have nitrates added. Combination therapy with nifedipine plus diltiazem
or nifedipine plus verapamil may be useful in patients unresponsive to single-drug
regimens.
• β-Blockers have little or no role in the management of variant angina because they
may induce coronary vasoconstriction and prolong ischemia.
EVALUATION OF THERAPEUTIC OUTCOMES
• Subjective measures of drug response include number of painful episodes, amount
of rapid-acting nitroglycerin consumed, and symptomatic improvement in exercise
capacity (ie, longer duration of exercise or fewer symptoms at the same exercise
110
SECTION 2 | Cardiovascular Disorders
level). Once patients have been optimized on medical therapy, symptoms should
AND VARIANT ANGINA PECTORIS
• All patients should be treated for acute attacks and maintained on prophylactic treat-
ment for 6 to 12 months after the initial episode. Aggravating factors such as alcohol
or cocaine use and cigarette smoking should be stopped.
• Nitrates are the mainstay of therapy, and most patients respond rapidly to sublingual
nitroglycerin or ISDN. IV and intracoronary nitroglycerin may be useful for patients
not responding to sublingual preparations.
• Because CCBs may be more effective, have few serious adverse effects, and can
be given less frequently than nitrates, some authorities consider them the agents
of choice for variant angina. Nifedipine, verapamil, and diltiazem are all equally
effective as single agents for initial management. Patients unresponsive to CCBs
alone may have nitrates added. Combination therapy with nifedipine plus diltiazem
or nifedipine plus verapamil may be useful in patients unresponsive to single-drug
regimens.
• β-Blockers have little or no role in the management of variant angina because they
may induce coronary vasoconstriction and prolong ischemia.
EVALUATION OF THERAPEUTIC OUTCOMES
• Subjective measures of drug response include number of painful episodes, amount
of rapid-acting nitroglycerin consumed, and symptomatic improvement in exercise
capacity (ie, longer duration of exercise or fewer symptoms at the same exercise
110
SECTION 2 | Cardiovascular Disorders
level). Once patients have been optimized on medical therapy, symptoms should
