Vasospasm (Arterial Spasm)

How vasospasm works

Arteries have a layer of smooth muscle that adjusts their width. In vasospasm, this muscle contracts excessively, often because of an overactive response to nerve signals, abnormal blood vessel lining (endothelial dysfunction), or chemicals such as those released by blood breaking down in the brain. Blood flow drops beyond the narrowed segment, starving tissues of oxygen until the spasm eases.

Types of vasospasm

Raynaud's phenomenon

The most common form. Small arteries in the fingers and toes spasm in response to cold or stress. The skin turns white, then blue, then red as blood returns, with numbness, tingling and throbbing. Primary Raynaud's occurs alone, usually in young women, and is benign. Secondary Raynaud's is linked to conditions such as scleroderma, lupus, vibration injury or certain drugs, and can cause ulcers. See Raynaud's phenomenon.

Coronary artery vasospasm

Spasm of a heart artery causes vasospastic (Prinzmetal or variant) angina: chest pain typically at rest, often between midnight and early morning, rather than with exertion. It can cause heart attacks and dangerous rhythms. Smoking, cocaine and amphetamines are major triggers. See coronary artery spasm.

Cerebral vasospasm

Arteries in the brain narrow 3 to 14 days after an aneurysmal subarachnoid hemorrhage, as blood products irritate the vessels. It can cause delayed cerebral ischemia, a type of stroke, with confusion, drowsiness, weakness or speech problems. This is monitored closely in intensive care.

Other types

• reversible cerebral vasoconstriction syndrome (RCVS): thunderclap headaches, often triggered by vasoactive drugs or after childbirth
• nipple vasospasm in breastfeeding, causing blanching and burning pain
• retinal vasospasm with brief vision loss, rare
• esophageal spasm is a muscle spasm, not a vascular one

Causes and triggers

• cold exposure
• emotional stress
• smoking and nicotine
• cocaine, amphetamines and other stimulants
• medicines: triptans and ergotamines for migraine, some ADHD stimulants, beta-blockers (in Raynaud's), certain chemotherapy drugs (5-fluorouracil, capecitabine)
• magnesium deficiency
• vibrating tools (hand-arm vibration syndrome)
• autoimmune connective tissue diseases

Diagnosis

• Raynaud's: clinical diagnosis, plus nailfold capillaroscopy and antibody tests to look for secondary causes
• Coronary spasm: ECG during symptoms showing temporary ST elevation, heart monitoring, and coronary angiography, sometimes with provocation testing in specialized centers
• Cerebral vasospasm: transcranial Doppler ultrasound, CT angiography or catheter angiography, and neurological checks

Treatment

Raynaud's

• keep the whole body warm, wear gloves and layers
• stop smoking
• calcium channel blockers such as nifedipine for frequent or severe attacks
• topical nitrates, PDE5 inhibitors or prostaglandin infusions for severe disease or ulcers

Coronary vasospasm

• calcium channel blockers are first-line
• nitrates for acute attacks and prevention
• stop smoking and avoid stimulants
• avoid non-selective beta-blockers, which can worsen spasm
• statins may help

Cerebral vasospasm

• nimodipine, a calcium channel blocker, after subarachnoid hemorrhage to improve outcomes
• maintaining blood volume and blood pressure
• endovascular treatment with angioplasty or intra-arterial vasodilators for severe spasm

Outlook

Primary Raynaud's is usually mild and manageable. Coronary vasospasm generally has a good outlook with treatment and avoidance of triggers, though a small number of people have heart attacks or arrhythmias. Cerebral vasospasm is a serious complication of brain bleeding and a major cause of disability after subarachnoid hemorrhage.

Frequently asked questions

What is vasospasm?

Vasospasm is a sudden, temporary tightening of an artery that reduces blood flow to the tissues it supplies. It can affect fingers and toes (Raynaud's), heart arteries (causing chest pain) or brain arteries (after bleeding in the brain).

What causes vasospasm?

Common triggers include cold, stress, smoking, cocaine and stimulant drugs, and certain medicines such as triptans and some chemotherapy drugs. Cerebral vasospasm is caused by blood irritating brain arteries after a subarachnoid hemorrhage.

What are the symptoms of coronary vasospasm?

It causes chest pain or pressure, usually at rest and often in the early morning, lasting minutes. It may come with sweating, nausea or palpitations. Any prolonged chest pain needs emergency care.

How is vasospasm treated?

Calcium channel blockers are the main treatment for Raynaud's and coronary vasospasm, with nitrates for heart spasm. Avoiding triggers such as cold, smoking and stimulants is essential. Cerebral vasospasm is managed in intensive care with nimodipine and other measures.

Is vasospasm dangerous?

It depends on the type. Primary Raynaud's is usually harmless. Coronary vasospasm can cause heart attacks or dangerous rhythms if untreated, and cerebral vasospasm can cause strokes after a brain bleed.