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Emergency Medicine

Recurrent Angina After Alcohol Consumption

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JAMA Internal Medicine

Published Online: January 3, 2023

Challenges in Clinical Electrocardiography

Article Information and Disclosures

Caifeng Fan, MD¹;

Hao Wang, MD¹;

Yunfei Gu, MD¹

Author Affiliations

¹Department of Cardiology, Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang, Henan Province, China

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A patient in their 50s was admitted with recurrent abdominal pain and syncope after drinking alcohol. They had this problem for 2 years but experienced worsening on admission. The patient was a smoker and had alcohol overconsumption for about 20 years. The average alcohol intake was 250 g/wk. They had hypertension diagnosed 3 months prior to admission. On admission, high-sensitivity troponin I was 0.01 ng/mL (to convert to μg/L, multiply by 1) and serum potassium was 4.6 mEq/L (to convert to mmol/L, multiply by 1), both of which were in normal range. The patient’s Holter was shown in the Figure.

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Prinzmetal angina is a type of variant angina with transient ST-segment elevation caused by the spasm of coronary arteries.¹ The variant angina, different from the classic one which is often provoked by exertion, occurs mostly at rest and can be precipitated by cold, coffee, emotional agitation, alcohol, and other factors. Takizawa et al³ found that 26.8% of patients with variant angina pectoris have alcohol ingestion. A recent large-scale trial⁴ has also shown that alcohol consumption is a risk factor for coronary artery spasm. Sato et al⁵ reported a case of such variant angina, where chest pain occurred each time 10 to 11 hours after alcohol ingestion, when blood concentration of alcohol had already decreased to 0, indicating a withdrawal from an acute exposure of alcohol as a possible trigger to coronary spasm. Although the mechanism of such variant angina is unclear, alcohol-induced vascular endothelial dysfunction is associated with coronary spasm.³^- 5 This includes alcohol-induced elevation in plasma endothelin-1 and decrease in plasma prostaglandin F1 alpha and cyclic guanosine monophosphate.³^- 5 The present patient might have experienced endothelial dysfunction due to long-term smoking and alcohol use. Moreover, the high prevalence of aldehyde dehydrogenase 2 deficiency in East Asian populations may predispose patients to alcohol-induced vasospasm.⁶

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Article Information

Corresponding Author: Yunfei Gu, MD, Department of Cardiology, Luoyang Central Hospital Affiliated to Zhengzhou University, 288 Zhongzhouzhong Rd, Henan Province, Luoyang 471000, China (yunfeigu@126.com).

Published Online: January 3, 2023. doi:10.1001/jamainternmed.2022.5411

Conflict of Interest Disclosures: None reported.

Additional Contributions: The authors thank all the staff members in our institution. The authors thank Tong Liu, MD, Second Hospital of Tianjin Medical University. Guo-Liang Li, MD, The First Affiliated Hospital of Xi’an Jiaotong University and Yang-Zhen Shao, MD, Sahlgrenska University Hospital, Gothenburg, Sweden. for their helpful comments. These individuals were not compensated for their contributions.

References

Prinzmetal M , Kennamer R , Merliss R , Wada T , Bor N . Angina pectoris I: a variant form of angina pectoris; preliminary report. Am J Med. 1959;27:375-388. doi:10.1016/0002-9343(59)90003-8 PubMed Google Scholar Crossref

JCS Joint Working Group. Guidelines for diagnosis and treatment of patients with vasospastic angina (coronary spastic angina) (JCS 2013). Circ J. 2014;78(11):2779-2801. doi:10.1253/circj.CJ-66-0098 PubMed Google Scholar Crossref

Takizawa A , Yasue H , Omote S , et al. Variant angina induced by alcohol ingestion. Am Heart J. 1984;107(1):25-27. doi:10.1016/0002-8703(84)90128-5 PubMed Google Scholar Crossref

Sohn SM , Choi BG , Choi SY , et al. Impact of alcohol drinking on acetylcholine-induced coronary artery spasm in Korean populations. Atherosclerosis. 2018;268:163-169. doi:10.1016/j.atherosclerosis.2017.11.032 PubMed Google Scholar Crossref

Sato A , Taneichi Y , Sekine I , et al. Prinzmetal’s variant angina induced only by alcohol ingestion. Clin Cardiol. 1981;4(4):193-195. doi:10.1002/clc.4960040408 PubMed Google Scholar Crossref

Seki T , Okayama H , Isoyama S , et al. The role of alcohol dehydrogenase 2 and aldehyde dehydrogenase 2 genotypes in alcohol-induced vasospastic angina. Tohoku J Exp Med. 1999;187(4):311-322. doi:10.1620/tjem.187.311 PubMed Google Scholar Crossref

Nishizaki M , Arita M , Sakurada H , et al. Polymorphic ventricular tachycardia in patients with vasospastic angina–clinical and electrocardiographic characteristics and long-term outcome. Jpn Circ J. 2001;65(6):519-525. doi:10.1253/jcj.65.519 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
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1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.