Variant angina associated with a CGRP receptor antagonist: a case report

BackgroundCalcitonin gene-related peptide (CGRP) plays a pivotal role in migraine pathophysiology, and CGRP receptor antagonists are increasingly used for acute and preventive treatment. While considered to have minimal cardiovascular risk, real-world safety data remain limited, particularly in patients with cardiovascular comorbidities. We report a rare case of variant angina associated with atogepant, a novel oral CGRP receptor antagonist.Case presentationA 57-year-old woman presented with new-onset, paroxysmal chest pain over three days, described as a squeezing sensation with diaphoresis, typically occurring during early morning hours and relieved by sublingual nitroglycerin. She had a history of hypertension and IgA nephropathy and had been using zolmitriptan for chronic migraine for several years. Atogepant 60 mg once daily was initiated four days prior to reduce triptan use. On symptom onset, troponin I was mildly elevated but normalized by admission. Coronary angiography revealed no fixed stenosis or thrombosis. Given the clear clinical presentation, further spasm provocation testing was not performed, and variant angina was diagnosed. As no other causes of coronary vasospasm were identified, atogepant was discontinued, and diltiazem with a long-acting nitrate was prescribed. She remained symptom-free during follow-up.ConclusionsThis case suggests that atogepant may be associated with coronary vasospasm in patients with cardiovascular risk factors. Given CGRP's role as a potent vasodilator, its blockade may predispose to vasospasm in vulnerable individuals. Caution and close monitoring are warranted when prescribing CGRP receptor antagonists, particularly in those with cardiovascular comorbidities.