Long-term use of methamphetamine has been associated with myocardi- tis, necrotizing vasculitis, pulmonary hypertension, and car- Because methamphetamine and cocaine have similar pathophysiological effects, treatment of patients with ACS associated with methamphetamine and cocaine use should theoretically be similar. See Online Data Supplement 33 for additional information about cocaine and methamphetamine users. 7.11. Vasospastic (Prinzmetal) Angina: Recommendations Class I or in combination with long- are useful to treat and reduce the frequency of vasospastic angina. (Level of Evidence: B) 2. Treatment with HMG-CoA reductase inhibi- cessation of tobacco use,761,762 and addition- al atherosclerosis risk factor modification762,763 are useful in patients with vasospastic angina. (Level of Evidence: B) 3. Coronary angiography (invasive or noninvasive) is recommended in patients with episodic chest pain ac- companied by transient ST-elevation to rule out se- vere obstructive CAD. (Level of Evidence: C) Class IIb 1. Provocative testing during invasive coronary angiog- raphy may be considered in patients with suspect- ed vasospastic angina when clinical criteria and non- invasive testing fail to establish the diagnosis.764 767 (Level of Evidence: B) Vasospastic (Prinzmetal) angina chest pain typically occurs without provocation, is associated with ST-elevation, and usu- ally resolves spontaneously or with rapid-acting nitroglycerin. Vasospastic angina may also be precipitated by emotional stress, hyperventilation, exercise, or the cold. It results from coronary vasomotor dysfunction leading to focal spasm,768 which may occasionally be multifocal within a single vessel and rarely involves >1 vessel. Vasospastic angina occurs with normal coronary arteries, nonobstructive CAD, and obstruc- tive CAD, but prognosis is least favorable with the latter. ST-elevation indicates transmural ischemia and corresponds to the distribution of the involved artery.769 A circadian varia- tion is often present; most attacks occur in the early morn- The most prominent coronary risk factor is smoking. 