What Is Prinzmetal (Vasospastic) Angina?

When Spasm in a Coronary Artery Leads to Chest Pain

Prinzmetal angina, now more commonly called vasospastic angina or variant angina, differs from typical (classic) angina in several important respects. Its cause is different, and both a diagnosis and variant angina treatment tend to differ from classic angina.

Many vasospastic angina symptoms, such as chest pain and shortness of breath, are similar to those of classic angina. This is one reason for why people should see a healthcare provider in order to determine the cause.

This article explains Prinzmetal angina causes, the differences in who it affects and why they may have risk factors, as well as prognosis and treatment for the condition.

Senior with hands on chest
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What Is Prinzmetal Angina?

Angina is not always caused by the blockages produced by typical coronary artery disease (CAD). Sometimes angina can occur in people whose coronary arteries are entirely clear of atherosclerotic plaques. In some people, angina can occur because of a sudden spasm in one of the coronary arteries—the arteries that supply blood to your heart. 

Prinzmetal angina, or variant angina, is caused by such a spasm in a coronary artery. These spasms can produce ischemia (oxygen starvation) in the part of the heart muscle supplied by the affected artery, and the symptoms of angina follow.

While Prinzmetal angina can have important consequences, including heart attack and life-threatening cardiac arrhythmias, it can almost always be treated effectively, once it is correctly diagnosed.

Prinzmetal Angina Symptoms

The chest pain that people experience with Prinzmetal angina is indistinguishable from classic, typical angina caused by atherosclerosis. As with typical angina, people with Prinzmetal angina will often describe one or more of several symptoms, including:

  • Chest tightening or squeezing
  • Pain that may radiate to arms, shoulders, jaw, neck, upper abdomen, or back
  • A sense of pressure or fullness
  • A weight or knot in the chest
  • Aching or a burning sensation
  • Shortness of breath (dyspnea)
  • Nausea
  • Weakness or fatigue
  • Sweating (diaphoresis)
  • Heart palpitations

These symptoms often persist for 15 minutes or more. In contrast to typical angina, which usually occurs during exertion or stress, Prinzmetal angina more typically occurs while at rest.

In fact, people most frequently experience Prinzmetal angina at the quietest time of the day—between midnight and early morning.

Prinzmetal angina symptoms often lead people to believe they are having a heart attack. This makes them more likely to seek medical help, which can lead to an earlier diagnosis. The sooner this variant angina is diagnosed, the sooner it can be treated.

Who Gets Prinzmetal Angina?

Prinzmetal angina is more common in women than in men. People with this condition are often relatively young, quite healthy, and commonly have very few risk factors for typical heart disease—with the exception of smoking.

Smoking is a major factor in provoking angina in people with this condition because tobacco products can cause arterial spasm. The autonomic nervous system may play a role as well.

Cocaine or amphetamines can also provoke Prinzmetal angina. Substance abusers with Prinzmetal angina are much more likely to suffer permanent (or fatal) heart damage than non-substance abusers who have this condition.

Endothelial dysfunction, a condition in which the inner lining of the arteries does not work normally, may be a factor but is not the main cause. Endothelial dysfunction is also associated with cardiac syndrome xRaynaud's phenomenon, and migraine headaches. And as it turns out, people with Prinzmetal angina often are also migraine sufferers.

People with vasospastic angina risk factors that include smoking, or the use of cocaine or amphetamines, are more likely to experience more severe and potentially fatal heart damage.

How Prinzmetal Angina Is Diagnosed

Prinzmetal angina occurs when one of the major coronary arteries suddenly goes into spasm, temporarily shutting off blood flow to an area of heart muscle supplied by that artery. During these episodes, the electrocardiogram (ECG) shows elevations of the "ST segment"—the same ECG changes commonly seen with heart attacks. 

Nitrates usually relieve the spasm very quickly, returning the coronary artery back to normal.

In many cases, a person sees their healthcare provider after the angina has gone away. In these instances, diagnostic testing may include ambulatory ECG monitoring for a period of a few weeks (looking for spontaneous episodes of angina accompanied by ECG changes) or stress testing.

Vasospastic angina usually occurs at rest, but about 20% of people with this condition may have their angina provoked during an exercise test.

Sometimes, a procedure called cardiac catheterization with “provocative testing” is necessary to make a diagnosis. Because Prinzmetal angina is caused by coronary artery spasm rather than by a fixed blockage in the artery, the catheterization usually shows “normal” coronary arteries.

Further, because Prinzmetal angina is not the only kind of chest pain that can be seen with normal coronary arteries, making the correct diagnosis may require that the coronary artery spasm be provoked.

With a hyperventilation test, the patient is instructed to breathe deeply and rapidly for a full six minutes—which is much more difficult to do than it may sound—while an ECG is being continuously recorded, and echocardiography is done to look for signs of coronary artery spasm.

This test is especially useful in people who have frequent episodes of severe Prinzmetal angina. It tends not to be nearly as useful in those whose episodes are more sporadic or infrequent.

Acetylcholine and ergonovine are two drugs often used to attempt to induce coronary spasm during a cardiac catheterization. This kind of testing yields a correct diagnosis more reliably than the hyperventilation test. Testing with acetylcholine is considered safer than testing with ergonovine and is the preferred invasive provocative test.

In people with Prinzmental angina, additional testing may be used to "provoke" the same localized coronary artery spasm that causes their symptoms. This localized spasm can be seen during the catheterization procedure.

Outlook and Consequences

The outlook for people with Prinzmental angina is generally quite good, but this condition can lead to dangerous and potentially fatal cardiac arrhythmias. The type of arrhythmia provoked depends on which coronary artery is involved.

For example, if the right coronary artery is involved, it could cause a heart block. If the left anterior descending artery is involved, it might result in ventricular tachycardia.

While heart attacks are uncommon with Prinzmetal angina, they can occur and produce permanent heart muscle damage. Adequate treatment of Prinzmental angina greatly reduces the risk of such complications.


If you have Prinzmetal angina, it will be important for you (as it is for everyone) to control your cardiac risk factors. In your case, it is especially critical to avoid tobacco products, which are powerful stimulants of coronary artery spasm.

Calcium channel blockers are often the first line agent used for vasospastic angina treatment. If additional medication is required, a nitrate may be added to a calcium channel blocker.

Also, you might discuss the use of a statin (a class of drugs that not only lower cholesterol but also improve endothelial function) with your healthcare provider. Recent data suggest that statins can help to prevent coronary artery spasm.

Be aware that some drugs can lead to a coronary artery spasm. Generally, you should avoid many beta-blockers, and some migraine drugs like ​Imitrex (sumatriptan). Aspirin should be used with caution, as it may exacerbate vasospastic angina.

Once a person is placed on effective Prinzmetal angina treatment, they can expect to lead full and healthy lives with this condition.

A Word From Verywell

Prinzmetal angina is a rare condition that produces angina due to spasm in a coronary artery. While Prinzmetal angina can sometimes lead to severe consequences (especially in smokers or people who abuse cocaine or amphetamines), it can usually be treated very successfully once the correct diagnosis is made.

Frequently Asked Questions

  • What triggers Prinzmetal angina?

    Some causes are known, such as smoking, cocaine use, and alcohol. The increased use of legalized marijuana also may trigger variant angina. There are many other causes under study, including chemotherapy drugs that can cause vascular endothelial damage and dysfunction.

  • Is Prinzmetal angina life-threatening?

    It can be. These coronary vasospasms may lead to complications such as sudden cardiac death, lethal heart arrhythmias, and heart attack. People who receive treatment, and who do not smoke or drink alcohol, have high survival rates and a generally good prognosis.

  • What are the typical signs of Prinzmetal angina?

    Chest pain, shortness of breath, and the related symptoms of classic angina are much the same with variant angina, but they occur more often at rest and in younger people. Some studies suggest up to 4 million people in the United States live with this type of condition (mainly vasospastic angina or coronary microvascular dysfunction), with more women affected than men.

5 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Ong P, Athanasiadis A, Borgulya G, et al. Clinical usefulness, angiographic characteristics, and safety evaluation of intracoronary acetylcholine provocation testing among 921 consecutive white patients with unobstructed coronary arteries. Circulation 2014; 129:1723. DOI: 10.1161/CIRCULATIONAHA.113.004096

  2. Matta A, Bouisset F, Lhermusier T, et al. Coronary artery spasm: new insightsJournal of Interventional Cardiology. 2020;2020:e5894586. doi:10.1155/2020/5894586

  3. Jewulski J, Khanal S, Dahal K. Coronary vasospasm: A narrative reviewWorld J Cardiol 2021; 13(9): 456-463 doi:10.4330/wjc.v13.i9.456

  4. Kim HL, Jo SH. Current Evidence on Long-Term Prognostic Factors in Vasospastic Angina. J Clin Med. 2021 Sep 21;10(18):4270. doi:10.3390/jcm10184270.

  5. Fu B, Wei X, Lin Y, Chen J, Yu D. Pathophysiologic Basis and Diagnostic Approaches for Ischemia With Non-obstructive Coronary Arteries: A Literature Review. Front Cardiovasc Med. 2022 Mar 17;9:731059. doi:10.3389/fcvm.2022.731059

Additional Reading
  • Beltrame JF, Crea F, Kaski JC, et al. International Standardization of Diagnostic Criteria for Vasospastic Angina. Eur Heart J 2015. DOI:10.1093/eurheartj/ehv351

  • JCS Joint Working Group. Guidelines for Diagnosis And Treatment Of Patients With Vasospastic Angina (Coronary Spastic Angina) (JCS 2013). Circ J 2014; 78:2779.

  • Stern S, Bayes de Luna A. Coronary Artery Spasm: a 2009 Update. Circulation 2009; 119:2531.

  • Kusama Y, Kodani E, Nakagomi A, et al. Variant Angina and Coronary Artery Spasm: the Clinical Spectrum, Pathophysiology, and Management. J Nippon Med Sch 2011; 78:4.

By Richard N. Fogoros, MD
Richard N. Fogoros, MD, is a retired professor of medicine and board-certified in internal medicine, clinical cardiology, and clinical electrophysiology.