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Refractory Vasospastic Angina — EECC MCQ

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HardCoronary Artery DiseaseRefractory Vasospastic AnginaEECC

A 50-year-old woman with Prinzmetal angina (vasospastic angina) confirmed on provocative testing is optimally treated with amlodipine 10 mg and ISMN 60 mg MR. Despite this, she has breakthrough nocturnal episodes. What additional agent may help?

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Correct answer: C — Add a second calcium channel blocker from a different class (e.g. diltiazem) — dual CCB therapy is used in refractory vasospastic angina; nicorandil (K-ATP channel opener with nitrate properties) is another option

Vasospastic angina management centres on calcium channel blockers (Class I — the cornerstone therapy, using high doses). For refractory cases, the 2024 ESC CCS Guidelines suggest: (1) dual CCB therapy — combining a dihydropyridine (amlodipine/nifedipine) with a non-dihydropyridine (diltiazem) from a different pharmacological subclass; (2) nicorandil (K-ATP channel opener + nitrate donor — dual vasodilatory mechanism); (3) long-acting nitrates (already in place). Importantly, beta-blockers should be AVOIDED in vasospastic angina — they can paradoxically worsen spasm by allowing unopposed alpha-adrenergic coronary vasoconstriction (removing the beta-2-mediated vasodilatory counterbalance). Breakthrough nocturnal episodes are characteristic of vasospastic angina (increased vagal tone at night, circadian variation in vascular tone).

Reference: ESC (2024): CCS Guidelines