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Refractory Prinzmetal Angina Treated with Cyproheptadine
- Alison D. Schecter, MD;
- James H. Chesebro, MD; and
- Valentin Fuster, MD, PhD
- From Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts. Requests for Reprints: Valentin Fuster, MD, PhD, Cardiovascular Institute, Mount Sinai Medical Center, Box 1030, One Gustave Levy Place, New York, NY 10029. Acknowledgments: The authors thank Dr. Arthur Kennish for help in preparing this report.
Serotonin, 5-hydroxytryptamine, is an important modulator of coronary vascular tone [1]. It is avidly taken up from the plasma by platelets, stored in dense granules, and released during platelet aggregation and activation. Serotonin causes vasodilatation in normal coronary arteries and mild vasoconstriction in patients with stable angina. In patients with Prinzmetal or variant angina (a syndrome of chest pain at rest associated with ST elevation), serotonin at physiologic concentrations causes an exaggerated response of occlusive vasospasm [2]. We successfully treated two patients who had documented severe refractory variant angina with cyproheptadine (Periactin; Merck & Co., West Point, Pennsylvania), a nonselective serotonergic antagonist.
Case Reports
Patient 1
A 65-year-old Spanish man with a history of labile hypertension and mild hyperlipidemia had his first episode of chest pain in 1986 when he presented to a hospital in Spain with ST-segment elevations in V2 to V4 associated with an episode of ventricular tachycardia. He responded to intravenous nitroglycerin and had serial normal levels of creatine kinase. Subsequent coronary angiography showed normal coronary anatomy. He was discharged on isosorbide dinitrate (40 mg every 8 hours for 4 years). From 1986 through 1989, the patient had several episodes of atypical chest pain. In 1990, the patient had a crescendo anginal pattern and again presented with ST elevation in V2 to V6 and had no evidence of infarction. From 1990 to the present, there were nine emergency …
