A 38-year-old male smoker presents with recurrent episodes of chest pain at rest, always between midnight and early morning. During an episode, the ECG shows transient ST segment elevation that resolves completely with sublingual nitrate. Coronary angiography shows no fixed stenosis. Which is the first-line long-term treatment?

• A Aspirin plus clopidogrel alone
• B Propranolol with smoking cessation counseling
• C Amlodipine with smoking cessation counseling ✓
• D Ranolazine monotherapy

Explanation

Variant or vasospastic angina results from focal coronary artery spasm near an atherosclerotic plaque or in an angiographically normal vessel. Calcium channel blockers such as amlodipine or diltiazem are first-line therapy, combined with aggressive smoking cessation since smoking is the strongest risk factor. Beta blockers are relatively contraindicated because nonselective blockade removes beta-2 mediated vasodilation and can worsen spasm.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.