A 34-year-old male smoker with a history of migraine attacks presents with recurrent episodes of rest angina occurring in clusters at night. During an episode, transient ST elevation is recorded that resolves completely with pain relief. Coronary angiography between episodes shows angiographically normal coronaries. Which therapy is the mainstay of long-term treatment?
- A Diltiazem combined with isosorbide mononitrate ✓
- B Propranolol
- C Aspirin plus low-dose atenolol
- D Ramipril alone
Explanation
This is vasospastic (Prinzmetal) angina, caused by focal coronary spasm producing transient transmural ischemia with reversible ST elevation. Calcium channel blockers such as diltiazem or amlodipine, often combined with long-acting nitrates, are the mainstay because they prevent smooth-muscle contraction in the arterial wall. Non-selective beta blockers like propranolol are contraindicated since unopposed alpha-mediated vasoconstriction can worsen spasm. Revascularization offers no benefit with normal coronaries, and ACE inhibition does not address the spastic mechanism.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.