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cardio.nstemi.prinzmetal-vasospastic.v1

Prinzmetal / vasospastic angina presenting as NSTE-ACS

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.nstemi.core.v1 — narrowed to vasospastic angina (Prinzmetal) per JCS 2014 PMID 24654470 + Ong COVADIS 2017 PMID 29032362. Coronary artery vasospasm produces transient transmural ischemia (transient ST elevation that resolves with pain) and troponin elevation if spasm prolonged. Demographics: younger (40–60), female-predominant (Japanese > Caucasian), smoking, magnesium deficiency, hyperventilation, cocaine, marijuana. Diagnosis pivots on ECG capture during pain + intracoronary acetylcholine provocation (20–100 µg) — gold-standard per Ong COVADIS. Hyperventilation challenge and ergonovine provocation are alternatives. Coronary angiography typically normal or only mild atherosclerosis. Treatment fundamentally different from atherothrombotic NSTE-ACS: CCB FIRST-line (diltiazem 240–360 mg/d or amlodipine 5–10 mg/d) + long-acting nitrate (isosorbide mononitrate 30–60 mg/d ER) + statin + magnesium repletion + smoking cessation MANDATORY. AVOID β-blocker monotherapy (unopposed α paradox per JCS 2014). DAPT not routine — only if intracoronary thrombus on OCT or PCI performed. ASA controversial in pure vasospastic without CAD (high-dose may inhibit endogenous prostacyclin per JCS 2014). Inherits parent ACS triage at ED entry; pivots once vasospastic pattern confirmed. ICD evaluation if VF during spasm (JCS 2014 Class IIa). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 14 etiology variant.

Entry points (5)

  • imaging
    Transient ST elevation captured on ECG during chest pain that resolves with pain — pathognomonic for vasospastic angina (JCS 2014 PMID 24654470)
    transient_st_elevation_during_pain_that_resolves
  • lab_abnormality
    hsTn rise/fall with angiography showing normal or mild atherosclerosis (<50%) — vasospasm-mediated NSTEMI (overlap with MINOCA framework)
    hstn_rise_with_normal_or_mild_cad_angio
  • symptom
    Rest chest pain (often at night / early morning) in younger patient (40–60), female predominance, smoking history — classic vasospastic pattern (JCS 2014)
    rest_chest_pain_at_night_or_early_morning_in_younger_patient
  • history
    Intracoronary acetylcholine provocation (20–100 µg) reproduces ECG changes + symptoms — gold-standard diagnostic per Ong COVADIS criteria PMID 29032362
    positive_acetylcholine_provocation_test
  • history
    Cocaine / marijuana / 5-FU exposure with chest pain — substance-induced vasospasm pattern
    cocaine_or_marijuana_or_5fu_use_with_chest_pain

Required inputs (14)

  • agerequired
    demographic • used at CONTEXT
    Vasospastic angina enriched 40–60 y; younger than typical NSTE-ACS; informs differential weighting
  • sexrequired
    demographic • used at CONTEXT
    Female predominance (especially Japanese); informs pre-test probability
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension during spasm episode → cardiogenic shock screen; mostly normotensive between episodes
  • hrrequired
    vital • used at CONTEXT
    Bradycardia or pause during inferior-territory spasm; tachycardia suggests sympathetic trigger (cocaine)
  • hs_troponin_serialrequired
    lab • used at INITIAL_WORKUP
    Defines NSTEMI per 4th UDMI rise/fall criteria; many vasospastic episodes have flat troponin (UA pattern)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Gates contrast load for cath / acetylcholine provocation; KDIGO 2026 baseline
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline before any AC; rule out anemia as supply-demand contributor
  • magnesiumrequired
    lab • used at INITIAL_WORKUP
    Magnesium deficiency is a documented vasospasm trigger per JCS 2014; replete to >2.0
  • urine_drug_screenrequired
    lab • used at INITIAL_WORKUP
    Cocaine / amphetamine / marijuana — common substance-induced vasospasm triggers; informs cessation pathway
  • ecg_serial_q15min_during_painrequired
    imaging • used at INITIAL_WORKUP
    ECG capture during pain is the diagnostic key — transient ST elevation that RESOLVES with pain resolution; serial q15 min × 1 h during symptomatic episodes
  • angio_with_provocationrequired
    imaging • used at BRANCHING_WORKUP
    Coronary angiography typically normal or mild; intracoronary acetylcholine provocation 20–100 µg reproduces spasm — gold-standard diagnostic per Ong COVADIS
  • tterequired
    imaging • used at INITIAL_WORKUP
    Echo for LV function between episodes (usually preserved); during episode may show transient regional dysfunction matching spasm territory
  • smoking_status_pack_yearsrequired
    history • used at CONTEXT
    Smoking is the single most important modifiable risk factor; cessation is mandatory per JCS 2014
  • medication_review_for_vasoconstrictor_exposurerequired
    history • used at CONTEXT
    Triptans, ergot derivatives, 5-FU, cocaine, decongestants — discontinue if implicated

12-phase flow (12)

  1. 1FRAME
    Confirm vasospastic angina per JCS 2014 PMID 24654470 + Ong COVADIS 2017 PMID 29032362 — transient ST elevation that resolves OR positive acetylcholine provocation; coronary angiography typically normal or only mild atherosclerosis
    inputs: ecg_serial_q15min_during_pain, hs_troponin_serial
    advance: Vasospastic pattern confirmed
  2. 2ENTRY
    Triage as ACS during initial ED encounter; sublingual nitroglycerin both diagnostic and therapeutic; if pattern strongly vasospastic and pain resolves with nitrate, defer aggressive antithrombotic load until cath result
    inputs: age, sex
    actions: acs_pathway
    advance: ED triage complete
  3. 3CONTEXT
    Demographic, smoking status, medication review (triptan, ergot, 5-FU, cocaine), substance use, hyperventilation triggers, cold exposure history, family history of sudden death (long QT mimics)
    inputs: sbp, hr, creatinine_egfr, smoking_status_pack_years, medication_review_for_vasoconstrictor_exposure
    advance: Context complete
  4. 4RED_FLAGS
    VF/VT during spasm episode (highest sudden-death risk); refractory spasm despite max CCB + nitrate; β-blocker exposure error (unopposed α paradox); cardiogenic shock during prolonged spasm
    inputs: sbp
    actions: cocaine_chest_pain, cardiogenic_shock, chest_pain
    advance: Red-flag screen complete
  5. 5INITIAL_WORKUP
    Serial ECG q15 min during pain (essential — capture transient ST elevation); 0/1-h hsTn; BMP + Mg + CBC + UDS; CXR (dissection screen); echo for LV function
    inputs: ecg_serial_q15min_during_pain, hs_troponin_serial, creatinine_egfr, cbc, magnesium, urine_drug_screen, tte
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: Initial workup complete
  6. 6BRANCHING_WORKUP
    Coronary angiography + intracoronary acetylcholine provocation (gold-standard); hyperventilation challenge or ergonovine provocation if acetylcholine unavailable; cMRI if MINOCA overlap suspected
    inputs: angio_with_provocation
    actions: acute_valvular_emergency
    advance: Provocation result documented
  7. 7DIFFERENTIAL
    Vasospastic angina (Prinzmetal) vs cocaine-induced vasospasm vs microvascular dysfunction vs MINOCA vs atherothrombotic NSTE-ACS vs takotsubo vs Brugada / long-QT mimics vs early repolarization
    advance: Diagnosis committed
  8. 8RISK_STRATIFICATION
    HEART / TIMI / GRACE band-mapped — vasospastic patients often score low (no obstructive CAD), but VF history during spasm upgrades risk substantially; ICD evaluation indicated if VF during spasm per JCS
    inputs: age, sbp, hr, creatinine_egfr, hs_troponin_serial
    actions: calc.heart, calc.timi_nstemi, calc.grace
    advance: Risk band documented
  9. 9TREATMENT
    CCB FIRST-LINE (diltiazem 240–360 mg/d or amlodipine 5–10 mg/d); long-acting nitrate (isosorbide mononitrate 30–60 mg/d ER) for refractory spasm; high-intensity statin per AHA; smoking cessation MANDATORY; magnesium repletion; AVOID β-blocker monotherapy; ASA only if atherosclerotic substrate confirmed; AC only if intracoronary thrombus on OCT
    inputs: creatinine_egfr, cbc, magnesium
    advance: Vasospastic regimen initiated + smoking cessation pathway started
  10. 10DISPOSITION
    Telemetry for ≥24 h to capture vasospasm episodes; CICU if VF during spasm or cardiogenic shock; ambulatory ECG (Holter / patch) at discharge if telemetry inconclusive
    advance: Disposition documented
  11. 11MONITORING
    Continuous telemetry; symptom diary with pain timing; daily Mg + BMP; trigger avoidance education; smoking cessation pharmacotherapy initiation
    inputs: creatinine_egfr, magnesium
    actions: panel.cardiac, panel.renal
    advance: Monitoring orders + cessation pharmacotherapy started
  12. 12FOLLOWUP
    Cardiology follow-up at 2–4 wks; sustained CCB + nitrate adherence (recurrence common without it per JCS); smoking cessation reinforcement at every visit; re-evaluate ICD candidacy if VF during spasm; cardiac rehab if atherosclerotic substrate co-exists
    advance: Outpatient follow-up booked + cessation plan documented