Variant angina and sleep: a case report with therapeutic considerations

A 33 year old male with three years of increasingly frequent nocturnal angina pectoris was found on ECG tape monitoring to develop marked ST segment elevation followed by coarse ventricular tachycardia with subsequent spontaneous termination of the arrhythmia. Further evaluation included normal maximal exercise tolerance test, normal coronary arteriography and left ventricular angiography. Continuous nocturnal EEG, ECG, and blood pressure recordings on nitrate therapy revealed normal sleep patterns, development of sinus tachycardia with minimal muscular movement and a normal circadian decline in blood pressure. Therapy with progressive doses of 2% Nitroglycerin ointment has prevented further breakthrough in nocturnal angina pectoris. The association of nocturnal angina and sleep stages and the possibility of altering the coronary vasospasm by approaching the central neurophysiologic trigger rather than the peripheral coronary arteries is discussed.