Prinzmetal (variant) angina is characterized by which feature?

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Prinzmetal angina is driven by a transient coronary vasospasm that abruptly reduces blood flow to the myocardium, causing ischemia without a fixed blockage. During the attack, the ischemia is transmural, so the ECG shows ST-segment elevation. This pattern often occurs at rest (sometimes nocturnally) and tends to resolve as the spasm relaxes, with relief after nitroglycerin or calcium channel blockers.

This distinguishes it from exertional angina, which arises from fixed atherosclerotic narrowing and typically presents with chest pain during activity, not at rest, and more often shows ST changes consistent with subendocardial ischemia (often ST depression or no ST elevation). While some patients may have some degree of coronary disease, the hallmark is the vasospasm with transient ST elevation rather than a fixed obstruction.