This handout is for prinzmetal / vasospastic angina presenting as nste-acs. Your care team identified this based on: transient st elevation captured on ecg during chest pain that resolves with pain — pathognomonic for vasospastic angina (jcs 2014 pmid 24654470).
Other reasons your team may use this plan: hstn rise/fall with angiography showing normal or mild atherosclerosis (<50%) — vasospasm-mediated nstemi (overlap with minoca framework); rest chest pain (often at night / early morning) in younger patient (40–60), female predominance, smoking history — classic vasospastic pattern (jcs 2014); intracoronary acetylcholine provocation (20–100 µg) reproduces ecg changes + symptoms — gold-standard diagnostic per ong covadis criteria pmid 29032362.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| amlodipine | 5–10 mg | PO | daily | JCS 2014 PMID 24654470 + Ong COVADIS — long-acting DHP CCB is first-line; recurrence common without sustained therapy |
| diltiazem | 120–240 mg ER → titrate to 240–360 mg/d | PO | daily ER | JCS 2014 — non-DHP CCB targets coronary spasm; preferred when concomitant tachycardia or microvascular component |
| verapamil | 80–120 mg TID or 240 mg ER | PO | TID or ER daily | JCS 2014 — alternative non-DHP CCB; avoid in severe LV dysfunction or AV block |
| isosorbide_mononitrate | 30–60 mg ER | PO | daily ER with nitrate-free interval | JCS 2014 — add long-acting nitrate to CCB for refractory spasm; nitrate-free interval (10–14 h) prevents tolerance |
| nitroglycerin | 0.4 mg SL q5 min × 3 | SL | PRN acute episode | JCS 2014 — sublingual nitroglycerin is both diagnostic and therapeutic; relief within minutes is supportive of vasospastic etiology |
| atorvastatin | 40–80 mg | PO | daily | AHA + endothelial benefit; PROVE-IT PMID 15007110 extrapolated; vasospastic patients often have accelerated atherosclerosis |
| magnesium_oxide | 400 mg | PO | daily–BID until Mg >2.0 | JCS 2014 — magnesium repletion reduces spasm frequency in deficient patients |
| aspirin | 81 mg | PO | daily | AHA — ASA only if atherosclerotic substrate confirmed; controversial in pure vasospastic without CAD because high-dose ASA may inhibit endogenous prostacyclin and worsen spasm (JCS 2014 caution) |
| carvedilol | 3.125 mg BID | PO | BID | JCS 2014 + AHA 2008 — pure β-blocker monotherapy AVOIDED (unopposed α paradox); mixed α/β carvedilol acceptable WITH concomitant CCB if HFrEF develops |
| ticagrelor | 180 mg load → 90 mg BID | PO | BID × 12 mo | PLATO PMID 19717846 — DAPT only if intervention or thrombus; not routine in pure vasospastic |
Plan: Vasospastic angina (Prinzmetal) — CCB FIRST-line + long-acting nitrate + statin + magnesium repletion + smoking cessation; AVOID β-blocker monotherapy (JCS 2014 + Ong COVADIS 2017)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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
Guideline: JCS 2014 Vasospastic Angina Guideline (PMID 24654470); Ong et al COVADIS criteria 2017 (PMID 29032362); 2025 ACC/AHA ACS Guideline (Rao); ESC 2023 ACS (Byrne PMID 37622670)