Working Diagnosis:
Given the presentation of angina relieved with nitroglycerin, ECG changes, elevated troponin and coronary angiography without obstructive coronary artery disease, she was diagnosed with suspected vasospastic angina.

Treatment:
Her amlodipine dose was increased and nitroglycerin was prescribed to prevent and treat future episodes. A statin was recommended given elevated 10-year atherosclerotic cardiovascular disease (ASCVD) risk and evidence for prevention of coronary vasospasm. She was not prescribed a beta-blocker or aspirin as she had no evidence of coronary artery disease, and these can precipitate vasospasm.

Outcome:
She had no more episodes of chest pain. She was counseled on medication adherence and trigger avoidance. Adverse events (arrhythmia, myocardial infarction, sudden cardiac death) may occur in 25% of patients not on medication. As exercise was a likely trigger, she was counseled to avoid strenuous activity and referred to cardiac rehabilitation for a supervised and graded exercise program to further guide her return to physical activity.

Author's Comments:
Vasospastic angina is defined as nitrate responsive angina with several features: diurnal variation in exercise tolerance, hyperventilation as a trigger, or response to calcium channel blockers; transient ischemic ECG changes; and evidence of coronary artery spasm. As in this case, tests to induce spasm are often unavailable so a suspected diagnosis is made. The evaluation focuses on ruling out obstructive coronary artery disease however the two problems can be concurrent. Vasospastic angina is often spontaneous but can be triggered by exercise and other factors. This is a unique case of suspected vasospastic angina associated with exercise, possibly hyperventilation during stress, in a patient with risk factors for obstructive coronary artery disease.

Editor's Comments:
Vasospastic angina remains an underdiagnosed and undertreated condition. There are multiple reasons for this including; underrecognition of the signs and symptoms, lack of consensus on diagnostic criteria, and lack of availability of confirmatory provocative testing. Proper diagnosis and management is critical, given that treatment can prevent severe outcomes such as myocardial infarction and sudden cardiac death. Once diagnosed, the patient should be counseled to avoid potential triggers, which include smoking and vasoconstrictors. Effective pharmacologic management includes calcium channel blockers and nitrates. The long term prognosis is generally good when treated.

Another important consideration from this case is that it is prudent to work up chest pain even when the patient appears anxious or reports anxiety. While anxiety can cause non- cardiac chest pain, this should be a diagnosis of exclusion. There is also emerging evidence that anxiety disorders are associated with chest pain and non-obstructive coronary disease in women. Further investigation into this relationship and potential causality may assist in further treatment options and preventative strategies.

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