A 58-year-old man presents with recurrent episodes of angina at rest, occurring predominantly between midnight and early morning. During an episode, ECG shows transient ST elevation in leads II, III, and aVF that resolves spontaneously within 5 minutes. Troponin is mildly elevated. Which is the most appropriate long-term management?

• A Aspirin and atorvastatin
• B Beta-blocker and nitrates
• C Percutaneous coronary intervention to RCA
• D Calcium channel blocker and avoid smoking ✓

Explanation

This is variant (Prinzmetal) angina caused by coronary artery vasospasm, characterized by rest angina with transient ST elevation that resolves spontaneously. Calcium channel blockers are first-line therapy to prevent vasospasm. Smoking is a strong trigger and must be avoided. PCI is not indicated as there is no fixed obstructive lesion. Beta-blockers can paradoxically worsen vasospasm by allowing unopposed alpha-mediated coronary constriction.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.