Question 30

Question:

A 45 year-old woman presents with a two-week history of recurrent left-sided chest pain occasionally radiating to her left arm. She notes this has happened intermittently for the past five years, but is somewhat worse over the past six months. She has no significant medical history and takes no medication aside from a multivitamin. She denies alcohol and cigarette use. Physical exam reveals a healthy appearing woman of normal weight, in no apparent distress. Auscultation of the heart and lungs is unremarkable. An office EKG is normal; it was without the ST changes noted on EKG two weeks ago during her first episode of chest pain. What is the most appropriate pharmacologic treatment?

Correct Answer: D.  Nifedipine

This patient is suffering from variant (Prinzmetal’s) angina, characterized by atypical chest pain in an otherwise healthy individuals without significant risk factors for coronary artery disease. Its pathophysiology is thought to be related to coronary artery vasospasm resulting from autonomic dysregulation and possibly endothelial dysfunction. This is similar to other conditions characterized by vasospasm, including Raynaud’s syndrome. Like Raynaud’s, variant angina is particularly amenable to calcium channel blockers.
Aspirin (choice A) should be used with caution and preferably avoided in individuals with variant angina because it decreases production of prostacyclin. (Per UpToDate.)
ACE inhibitors such as enalapril (choice B) are a reasonable choice for patients with CHF or hypertension in the setting of diabetes mellitus, but is not first-line therapy for variant angina. Similar for metoprolol (choice C).
Nonspecific beta-blockers like propranolol (choice E) are contraindicated because they can actually exacerbate variant angina. This is possibly due to interference with the autonomic dysfunction that underlies the condition.