Vasospastic (Prinzmetal) angina
Rest angina with coronary artery spasm and transient ST-segment elevation on ECG. First-line therapy: calcium channel blockers and long-acting nitrates.
ICD-10 I20.13 drugs
Also known as: Variant angina, Prinzmetal angina
Drugs used for this condition
- ANitroglycerinFirst line · Organic nitrateLong-acting nitrates (nitroglycerin ointment, patch, sustained-release tablets, or isosorbide mono/dinitrate) prevent attacks in Prinzmetal vasospastic angina. ACC/AHA 2023 recommends combined calcium channel blockers and long-acting nitrates as baseline therapy. A 8–12-hour nitrate-free interval is preserved between doses to prevent tolerance.
- AVerapamilFirst line · Non-dihydropyridine calcium channel blockerVasospastic Prinzmetal angina responds to non-dihydropyridine and dihydropyridine calcium channel blockers. Verapamil reduces the frequency of coronary spasm and nitrate use in long-term therapy. ACC/AHA 2023 lists CCBs as first-line therapy combined with long-acting nitrates. Beta-blockers are contraindicated in vasospastic angina because they intensify spasm.
- BAmlodipineFirst line · Calcium channel blockers (dihydropyridines)Vasospastic (Prinzmetal) angina is one of the three indications for amlodipine in the AEMPS label. Calcium channel blockers are the basis of treatment: they relieve coronary artery spasm, while beta-blockers are avoided in pure vasospasm because they can worsen it (ESC 2024 chronic coronary syndromes guideline, Japanese JCS 2023 guideline). Data on amlodipine itself are limited: a small randomised trial in 52 patients showed fewer attacks and ischaemic episodes than placebo; most data exist for diltiazem and nifedipine. Amlodipine is therefore a first choice by class with a modest evidence base for the molecule itself. Attacks are relieved with nitroglycerin, and stopping smoking is essential. Contraindications and interactions are the same as in stable angina.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit