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cardio.nstemi.prinzmetal-vasospastic.v1PRODUCTION
cardio.nstemi.prinzmetal-vasospastic.v1

Prinzmetal / vasospastic angina presenting as NSTE-ACS

cardiologyacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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

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Vasospastic pattern confirmed

Patient inputs (14)

Coronary angiography typically normal or mild; intracoronary acetylcholine provocation 20–100 µg reproduces spasm — gold-standard diagnostic per Ong COVADIS

Vasospastic angina enriched 40–60 y; younger than typical NSTE-ACS; informs differential weighting

Female predominance (especially Japanese); informs pre-test probability

Bradycardia or pause during inferior-territory spasm; tachycardia suggests sympathetic trigger (cocaine)

Smoking is the single most important modifiable risk factor; cessation is mandatory per JCS 2014

Triptans, ergot derivatives, 5-FU, cocaine, decongestants — discontinue if implicated

Defines NSTEMI per 4th UDMI rise/fall criteria; many vasospastic episodes have flat troponin (UA pattern)

Gates contrast load for cath / acetylcholine provocation; KDIGO 2026 baseline

Baseline before any AC; rule out anemia as supply-demand contributor

Magnesium deficiency is a documented vasospasm trigger per JCS 2014; replete to >2.0

Cocaine / amphetamine / marijuana — common substance-induced vasospasm triggers; informs cessation pathway

ECG capture during pain is the diagnostic key — transient ST elevation that RESOLVES with pain resolution; serial q15 min × 1 h during symptomatic episodes

Echo for LV function between episodes (usually preserved); during episode may show transient regional dysfunction matching spasm territory

Hypotension during spasm episode → cardiogenic shock screen; mostly normotensive between episodes

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningvf_or_vt_during_spasm_episode
    Sustained VF or VT during documented vasospasm episode — highest sudden-death predictor; ICD evaluation indicated per JCS 2014 Class IIa
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcardiogenic_shock_during_prolonged_spasm
    SBP <90 + lactate ≥2 during prolonged spasm episode — rare but life-threatening; large-territory transmural ischemia from sustained spasm
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebeta_blocker_exposure_error_in_vasospastic_angina
    Inadvertent β-blocker monotherapy administration to vasospastic patient — unopposed α paradox risk of worsened spasm
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererefractory_spasm_despite_max_CCB_and_nitrate
    Persistent symptomatic spasm episodes despite maximum-tolerated CCB + long-acting nitrate + Mg repletion + trigger avoidance
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresudden_cardiac_death_risk_with_concurrent_long_qt_or_brugada
    Vasospastic angina + family history of sudden death OR documented Brugada / long-QT pattern — elevated sudden-death risk; ICD evaluation regardless of VF history
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Vasospastic angina (Prinzmetal) — CCB FIRST-line + long-acting nitrate + statin + magnesium repletion + smoking cessation; AVOID β-blocker monotherapy (JCS 2014 + Ong COVADIS 2017)
axis: prinzmetal_vasospastic_phenotype
Selected axis "Vasospastic angina (Prinzmetal) — CCB FIRST-line + long-acting nitrate + statin + magnesium repletion + smoking cessation; AVOID β-blocker monotherapy (JCS 2014 + Ong COVADIS 2017)" by default fallback (first axis)
  • amlodipine
    first line
    dihydropyridine_ccb
    5–10 mg • PO • daily
    triggers: vasospastic_angina_confirmed, positive_acetylcholine_provocation
    JCS 2014 PMID 24654470 + Ong COVADIS — long-acting DHP CCB is first-line; recurrence common without sustained therapy
    rxcui 104416
  • diltiazem
    first line
    non_dihydropyridine_ccb
    120–240 mg ER → titrate to 240–360 mg/d • PO • daily ER
    triggers: vasospastic_angina_confirmed, concomitant_tachycardia_or_AF
    JCS 2014 — non-DHP CCB targets coronary spasm; preferred when concomitant tachycardia or microvascular component
    rxcui 3443
  • verapamil
    second line
    non_dihydropyridine_ccb
    80–120 mg TID or 240 mg ER • PO • TID or ER daily
    triggers: intolerance_of_diltiazem_or_amlodipine
    JCS 2014 — alternative non-DHP CCB; avoid in severe LV dysfunction or AV block
    rxcui 11170
  • isosorbide_mononitrate
    add on
    long_acting_nitrate
    30–60 mg ER • PO • daily ER with nitrate-free interval
    triggers: refractory_spasm_on_max_CCB, persistent_anginal_symptoms
    JCS 2014 — add long-acting nitrate to CCB for refractory spasm; nitrate-free interval (10–14 h) prevents tolerance
    rxcui 28004
  • nitroglycerin
    rescue
    nitrate_vasodilator
    0.4 mg SL q5 min × 3 • SL • PRN acute episode
    triggers: acute_vasospastic_episode
    JCS 2014 — sublingual nitroglycerin is both diagnostic and therapeutic; relief within minutes is supportive of vasospastic etiology
    rxcui 4917
  • atorvastatin
    first line
    statin_high_intensity
    40–80 mg • PO • daily
    triggers: vasospastic_angina_confirmed, concomitant_atherosclerotic_substrate
    AHA + endothelial benefit; PROVE-IT PMID 15007110 extrapolated; vasospastic patients often have accelerated atherosclerosis
    rxcui 83367
  • magnesium_oxide
    add on
    electrolyte_supplement
    400 mg • PO • daily–BID until Mg >2.0
    triggers: hypomagnesemia_or_borderline_low_Mg
    JCS 2014 — magnesium repletion reduces spasm frequency in deficient patients
    rxcui 6582
  • aspirin
    comorbidity specific
    antiplatelet_cox1
    81 mg • PO • daily
    triggers: concomitant_atherosclerotic_substrate_on_imaging
    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)
    rxcui 1191
  • carvedilol
    comorbidity specific
    mixed_alpha_beta_blocker
    3.125 mg BID • PO • BID
    triggers: concomitant_HFrEF_EF_lt_40_with_concurrent_CCB
    JCS 2014 + AHA 2008 — pure β-blocker monotherapy AVOIDED (unopposed α paradox); mixed α/β carvedilol acceptable WITH concomitant CCB if HFrEF develops
    rxcui 20352
  • ticagrelor
    comorbidity specific
    P2Y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 12 mo
    triggers: intracoronary_thrombus_on_OCT, PCI_performed_for_concurrent_atherosclerotic_lesion
    PLATO PMID 19717846 — DAPT only if intervention or thrombus; not routine in pure vasospastic
    rxcui 1116632

outpatient playbook — drug actions (4)

  1. 1. continue CCB + nitrate indefinitely
    amlodipine 10 mg or diltiazem ER 360 + isosorbide mononitrate 30–60 ER • PO • daily
    trigger: Vasospastic angina — recurrence common without sustained therapy
    JCS 2014
  2. 2. continue statin if atherosclerotic substrate
    atorvastatin 40–80 mg • PO • daily
    trigger: Concomitant atherosclerotic substrate
    AHA + PROVE-IT
  3. 3. continue smoking cessation pharmacotherapy until 6–12 mo abstinent
    varenicline or NRT • PO/transdermal • as scheduled
    trigger: Active smoker or recent quit
    USPSTF 2021
  4. 4. add ezetimibe if LDL above target
    10 mg • PO • daily
    trigger: LDL >70 on max statin (atherosclerotic substrate)
    IMPROVE-IT

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Transient ST elevation captured on ECG during chest pain that resolves with pain — pathognomonic for vasospastic angina (JCS 2014 PMID 24654470); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Prinzmetal / vasospastic angina presenting as NSTE-ACS** (cardio.nstemi.prinzmetal-vasospastic.v1).
Phenotype framing: 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
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **Vasospastic angina (Prinzmetal) — CCB FIRST-line + long-acting nitrate + statin + magnesium repletion + smoking cessation; AVOID β-blocker monotherapy (JCS 2014 + Ong COVADIS 2017)**.
1. amlodipine 5–10 mg PO daily (dihydropyridine_ccb, first line) — JCS 2014 PMID 24654470 + Ong COVADIS — long-acting DHP CCB is first-line; recurrence common without sustained therapy
2. diltiazem 120–240 mg ER → titrate to 240–360 mg/d PO daily ER (non_dihydropyridine_ccb, first line) — JCS 2014 — non-DHP CCB targets coronary spasm; preferred when concomitant tachycardia or microvascular component
3. verapamil 80–120 mg TID or 240 mg ER PO TID or ER daily (non_dihydropyridine_ccb, second line) — JCS 2014 — alternative non-DHP CCB; avoid in severe LV dysfunction or AV block
4. isosorbide_mononitrate 30–60 mg ER PO daily ER with nitrate-free interval (long_acting_nitrate, add on) — JCS 2014 — add long-acting nitrate to CCB for refractory spasm; nitrate-free interval (10–14 h) prevents tolerance
5. nitroglycerin 0.4 mg SL q5 min × 3 SL PRN acute episode (nitrate_vasodilator, rescue) — JCS 2014 — sublingual nitroglycerin is both diagnostic and therapeutic; relief within minutes is supportive of vasospastic etiology
6. atorvastatin 40–80 mg PO daily (statin_high_intensity, first line) — AHA + endothelial benefit; PROVE-IT PMID 15007110 extrapolated; vasospastic patients often have accelerated atherosclerosis
7. magnesium_oxide 400 mg PO daily–BID until Mg >2.0 (electrolyte_supplement, add on) — JCS 2014 — magnesium repletion reduces spasm frequency in deficient patients
8. aspirin 81 mg PO daily (antiplatelet_cox1, comorbidity specific) — 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)
9. carvedilol 3.125 mg BID PO BID (mixed_alpha_beta_blocker, comorbidity specific) — JCS 2014 + AHA 2008 — pure β-blocker monotherapy AVOIDED (unopposed α paradox); mixed α/β carvedilol acceptable WITH concomitant CCB if HFrEF develops
10. ticagrelor 180 mg load → 90 mg BID PO BID × 12 mo (P2Y12_inhibitor, comorbidity specific) — PLATO PMID 19717846 — DAPT only if intervention or thrombus; not routine in pure vasospastic

Setting playbook (outpatient) — Long-term sustained CCB + nitrate (recurrence common without it per JCS), smoking cessation maintenance, trigger avoidance, periodic re-evaluation; prognosis good with adherence; sudden death risk persists if VF during spasm history
11. continue CCB + nitrate indefinitely amlodipine 10 mg or diltiazem ER 360 + isosorbide mononitrate 30–60 ER PO daily — Vasospastic angina — recurrence common without sustained therapy (JCS 2014)
12. continue statin if atherosclerotic substrate atorvastatin 40–80 mg PO daily — Concomitant atherosclerotic substrate (AHA + PROVE-IT)
13. continue smoking cessation pharmacotherapy until 6–12 mo abstinent varenicline or NRT PO/transdermal as scheduled — Active smoker or recent quit (USPSTF 2021)
14. add ezetimibe if LDL above target 10 mg PO daily — LDL >70 on max statin (atherosclerotic substrate) (IMPROVE-IT)

Non-pharmacologic actions:
- Trigger avoidance reinforcement (smoking, cocaine, marijuana, hyperventilation, cold exposure, ergot, triptan, 5-FU)
- Cardiac rehab attendance reinforcement
- Mediterranean / DASH diet counseling
- Family history screen — long-QT / Brugada mimics

AVOID / contraindication checks:
- Beta_blocker_monotherapy_AVOID_in_vasospastic_angina (JCS 2014 + AHA 2008 + ACC/AHA 2025 Class III in cocaine context)
- Nitrate_AVOID_with_concurrent_PDE5_inhibitor_within_24h (sildenafil) or 48h (tadalafil)
- High_dose_ASA_CAUTION_in_pure_vasospastic_without_CAD (JCS 2014 — may inhibit endogenous prostacyclin)
- Verapamil_AVOID_in_severe_LV_dysfunction_or_AV_block (drug label)
- Triptan_and_ergot_AVOID_in_vasospastic_angina (vasoconstrictor — direct trigger)
- 5fu_chemotherapy_HOLD_during_acute_vasospastic_episode (oncology consult)

Monitoring

Regimen monitoring:
- Continuous ECG inpatient + ambulatory at discharge if events not captured
- Symptom diary with pain timing and triggers
- BMP + Mg q12 h × 24 h then daily
- BP + HR titration of CCB + nitrate
- Smoking cessation pharmacotherapy adherence

Setting (outpatient) monitoring:
- BMP + Mg annually
- Lipid annually
- BP + HR every visit
- Symptom diary review every visit

Follow-up plan: 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
- Close-out criterion: Outpatient follow-up booked + cessation plan documented

Monitoring phase: Continuous telemetry; symptom diary with pain timing; daily Mg + BMP; trigger avoidance education; smoking cessation pharmacotherapy initiation

Disposition

Current setting: outpatient — Long-term sustained CCB + nitrate (recurrence common without it per JCS), smoking cessation maintenance, trigger avoidance, periodic re-evaluation; prognosis good with adherence; sudden death risk persists if VF during spasm history

Disposition criteria:
- Lifelong follow-up; route to chronic CAD or HF engines if atherosclerotic substrate progresses

Escalation triggers (move to higher acuity):
- Recurrent severe chest pain → ED + reassess regimen
- Syncope or VF event → urgent EP for ICD re-evaluation
- Smoking relapse → urgent cessation specialist intensification

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Sustained VF or VT during documented vasospasm episode — highest sudden-death predictor; ICD evaluation indicated per JCS 2014 Class IIa
- [LIFE_THREATENING] SBP <90 + lactate ≥2 during prolonged spasm episode — rare but life-threatening; large-territory transmural ischemia from sustained spasm
- [SEVERE] Inadvertent β-blocker monotherapy administration to vasospastic patient — unopposed α paradox risk of worsened spasm

Citations

- 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) [PMID:24654470](https://pubmed.ncbi.nlm.nih.gov/24654470/)
- Cited evidence (PMID 29032362) [PMID:29032362](https://pubmed.ncbi.nlm.nih.gov/29032362/)
- Cited evidence (PMID 37622670) [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 30153967) [PMID:30153967](https://pubmed.ncbi.nlm.nih.gov/30153967/)
- Cited evidence (PMID 15007110) [PMID:15007110](https://pubmed.ncbi.nlm.nih.gov/15007110/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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) — PMID:24654470
  • Cited evidence (PMID 29032362) — PMID:29032362
  • Cited evidence (PMID 37622670) — PMID:37622670
  • Cited evidence (PMID 30153967) — PMID:30153967
  • Cited evidence (PMID 15007110) — PMID:15007110