Case Study Treatment of Coronary Vasospasm

A 60-year-old man comes into the office complaining of chest pains that primarily occur in the early morning and do not appear to be associated with stress or exercise. Following coronary an-giography and a positive ergonovine test you determine that this patient has angina pectoris as a result of coronary artery spasm. How would you (1) treat the patient to alleviate the acute attacks when they occur and (2) treat chronically to prevent their reoccurrence?

Answer: Treat the patient with sublingual nitroglyc-erin for the acute attacks because of its rapid onset of action and its powerful vasodilating effect on the large epicardial conductance coronary arteries, which are normally the primary site of the spasm. For the chronic treatment there are two possibilities, an oral calcium channel blocker, such as am-lodipine or verapamil, or a long-acting nitrate preparation, such as the transdermal form of nitro-glycerin given once a day at bedtime to prevent the early morning episodes. (3-Adrenoceptor blockers are not used for patients with coronary vasospasm, as they may worsen the condition.

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