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Coronary Artery Spasm - Provocative Testing — EECC MCQ

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HardCoronary Artery DiseaseCoronary Artery Spasm - Provocative TestingEECC

A 47-year-old has recurrent nocturnal ST-elevation attacks despite maximally tolerated diltiazem and a long-acting nitrate. Provocation testing previously demonstrated multivessel epicardial spasm, and adherence and smoking abstinence are confirmed. Which additional anti-spasm treatment is most appropriate to discuss?

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Correct answer: C — Add nicorandil under specialist supervision

The best answer is “Add nicorandil under specialist supervision”. Nicorandil is a mechanistically appropriate adjunct for refractory vasospastic angina after calcium-channel-blocker and nitrate treatment has been optimised. “Replace diltiazem with propranolol monotherapy” is less appropriate because non-selective beta-blockade can intensify unopposed coronary vasoconstriction “Add high-dose aspirin as the principal vasodilator” is less appropriate because aspirin does not provide the required coronary vasodilator effect “Implant stents in every segment that spasmed” is less appropriate because provoked multivessel spasm is dynamic and cannot be treated by indiscriminate stenting “Stop the nitrate and use ivabradine alone” is less appropriate because ivabradine reduces sinus rate but does not suppress epicardial spasm

Reference: 2024 ESC Guidelines for chronic coronary syndromes. https://academic.oup.com/eurheartj/article/45/36/3415/7743115