Vasospastic angina (Prinzmetal angina): symptoms, triggers and treatment

Angina is chest pain or tightness caused when the heart does not get enough blood. The NHS says this is usually due to coronary heart disease, where the arteries are narrowed or blocked by fatty deposits, but it can also be caused by blood vessels in the heart tightening when they should not, which it names as vasospastic or microvascular angina.

The British Heart Foundation (BHF) describes vasospastic angina as a spasm in a coronary artery that suddenly narrows it. It is also known as Prinzmetal angina, variant angina or coronary artery spasm. It can occur alongside microvascular angina, which affects the tiny arteries within the heart muscle, and coronary artery disease can make it worse.

The distinction matters because the usual picture of angina, pain on exertion that eases with rest, does not fit. The BHF says vasospastic angina usually comes on at rest and that spasms can come in clusters of two or three.

The BHF describes the pain as a squeezing or tightening in the chest. It may be felt in the chest, arm or jaw, and can be severe or mild, even just a sense of unease. The NHS lists the usual angina features of tightness, squeezing or pressure, or a dull ache, which may also make you feel sick, breathless, dizzy or sweaty, and says attacks usually last less than 10 minutes.

• Pain or discomfort in the chest, arm or jaw, usually at rest and often in the early morning or late at night.

• Pain that can also be felt in the back, shoulders, neck or stomach.

• Pain that can be eased by taking medication.

• Sickness in some people.

• Spasms that may come in clusters of two or three.

The BHF says it is not yet known what causes vasospastic angina, but several triggers are recognised. These may also make symptoms worse and increase the number of attacks. It advises keeping a diary of triggers to share with your doctor.

The NHS says to call 999 now if you have been diagnosed with angina and have chest pain that does not stop after resting for a few minutes or taking your angina medicine, if you get sudden chest pain that does not go away, if pain spreads to the arm, neck, jaw, shoulder, stomach or back, or if you have chest pain and feel sweaty, sick, lightheaded or short of breath. You could be having a heart attack.

The NHS angina action plan is to stop and rest, use your prescribed glyceryl trinitrate (GTN), take another dose after 5 minutes if needed, and call 999 if you still have symptoms 5 minutes after the second dose. It says to get help from NHS 111 if you have chest pain that comes and goes, or if diagnosed angina feels worse than before, is happening more often, lasts longer or happens at rest. The BHF notes that if a spasm does not stop it can lead to an abnormal heart rhythm or, rarely, a heart attack.

The NHS says a GP who suspects angina will refer you to a heart specialist, and tests may include blood tests, an ECG, checking oxygen levels and scans such as an angiogram, MRI or CT. For vasospastic angina the BHF lists an ECG, ideally taken at the time of chest pain, and a coronary angiogram.

In the angiogram a chemical called acetylcholine is injected, which should normally make blood vessels relax. If they do not relax and instead go into spasm, the BHF says the doctor may be able to diagnose coronary artery spasm. Because the pain comes and goes, catching it on a recording can be difficult, which may be one reason the condition is under-diagnosed.

The BHF says treatment is with sublingual glyceryl trinitrate (GTN) tablets or spray, which in most cases relieves symptoms quickly, and you may also be given a calcium channel blocker such as verapamil, amlodipine or diltiazem to help prevent or reduce the number of spasms. These medicines relax the coronary arteries to allow more blood to flow. It says it is a long-term condition to be monitored by a cardiologist, specialist nurse or GP, and that acute episodes may need admission to hospital.

Lifestyle measures are described in both the BHF and NHS pages: stop smoking, keep to a healthy weight, be active, limit alcohol to under 14 units a week, manage stress and anxiety, and control blood pressure, cholesterol and blood sugar. The NHS advises avoiding triggers such as stress, cold temperatures and large meals and always carrying your angina medicine.

The BHF says that for some people vasospastic angina appears and then goes away after some years, while for others it stays for many years. Living with it can lead to anxiety, depression and in some cases post-traumatic stress disorder, and you may need psychological support or a referral to a pain management service.

The NHS says that with treatment angina symptoms should improve over time, and that if symptoms are well controlled angina will not usually have a big impact on life, although jobs involving heavy physical activity or driving buses, coaches or lorries may be affected and the DVLA may need to be told. NHS cardiology services provide diagnosis and follow-up; private cardiology clinics can arrange the same tests in general terms, but an acute attack is always an NHS emergency.