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Vasospastic Angina — EECC MCQ

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ModerateCoronary Artery DiseaseVasospastic AnginaEECC

A 48-year-old woman presents with recurrent chest pain at rest, typically occurring in the early morning hours and lasting 5-10 minutes, relieved by sublingual glyceryl trinitrate. Her resting ECG during pain shows transient ST-segment elevation in the inferior leads which resolves when the pain settles. Coronary angiography shows angiographically normal coronary arteries. What is the most appropriate long-term pharmacological management?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Diltiazem 240 mg modified-release once daily and isosorbide mononitrate 60 mg once daily

Explanation lettering: D = shown as B · E = shown as D · B = shown as E

This is vasospastic (Prinzmetal) angina. The 2024 ESC CCS Guidelines recommend calcium channel blockers (diltiazem or a dihydropyridine CCB) as first-line therapy for vasospastic angina, with long-acting nitrates as add-on therapy. Beta-blockers (A) are not recommended as they may worsen vasospasm by allowing unopposed alpha-adrenergic coronary vasoconstriction. Ivabradine (C) has no role in vasospasm. Ranolazine (D) is for refractory angina in obstructive CAD. Nicorandil alone (E) may be helpful adjunctively but the first-line combination should be a CCB with a long-acting nitrate.

Reference: ESC (2024): Guidelines for the Management of Chronic Coronary Syndromes