ST Elevation in Prinzmetal’s Angina

ST Elevation in Prinzmetal’s Angina

ST elevation in Prinzmetal’s angina occurs during pain and disappears when pain subsides. Prinzmetal’s angina is due to coronary vasospasm producing transmural or subepicardial ischemia which produces ST segment elevation, while subendocardial ischemia in conventional angina produces ST segment depression.

Coexistence of atherosclerotic coronary artery disease and coronary vasospasm can complicate clinical picture. In  a report, an elderly patient presented with features of ST elevation inferior wall myocardial infarction [1]. He underwent emergency balloon angioplasty of proximal and distal right coronary artery. At two week follow up, patient complained of recurrent chest pain and ECG showed ST elevation in inferior leads. Repeat coronary angiography showed subtotal occlusion of proximal right coronary artery. Intracoronary nitroglycerine administration showed relief of obstruction consistent with coronary vasospasm.

About one third cases of coronary vasospasm occurs without associated coronary artery disease while two third have associated coronary artery disease.

According to a consensus statement the most important ECG change during a focal coronary vasospasm is peaked and symmetrical T wave. This may be seen in about half of the cases. If spasm persists, progressive ST elevation is noted, which resolves later [2]. The incidence of Prinzmetal’s angina has come down due to the use of calcium channel blockers for the treatment of hypertension and decrease in smoking.

References

1. Pratik Choksy, Rebecca Napier, Gyanendra K Sharma. Prinzmetal Angina: An Unrecognized Cause of Recurrent ST Elevation Myocardial Infarction. J Cardiol Cases. 2012 Jun 15;6(5):e130-e132.
2. Antonio Bayés de Luna, Iwona Cygankiewicz, Adrian Baranchuk, Miquel Fiol, Yochai Birnbaum, Kjell Nikus, Diego Goldwasser, Javier Garcia-Niebla, Samuel Sclarovsky, Hein Wellens, Günter Breithardt. Prinzmetal Angina: ECG Changes and Clinical Considerations: A Consensus Paper. Ann Noninvasive Electrocardiol. 2014 Sep;19(5):442-53.