Coronary Vasospastic Angina: A Review of the Pathogenesis, Diagnosis, and Management

Vasospastic angina (VSA) is an under-appreciated cause of chest pain. It is characterised by transient vasoconstriction of the coronary arteries and plays a significant role in the pathogenesis of stable angina and acute coronary syndromes. Complex mechanistic pathways characterised by endothelial dysfunction and smooth muscle hypercontractility lead to a broad spectrum of clinical manifestations ranging from recurrent angina to fatal arrhythmias. Invasive provocation testing using intracoronary acetylcholine or ergonovine is considered the current gold standard for diagnosis, but there is a wide variation in protocols amongst different institutions. Conventional pharmacological therapy relies on calcium channel blockers and nitrates; however, refractory VSA has limited options. This review evaluates the pathophysiology, diagnostic challenges, and management strategies for VSA. We believe global efforts to standardise diagnostic and therapeutic guidelines will improve the outcomes for affected patients.

Automated summary

Vasospastic angina (VSA) is an underestimated cause of chest pain, characterized by temporary vasoconstriction of the coronary arteries. Its complex pathophysiology involves endothelial dysfunction and smooth muscle hypercontractility, leading to a wide range of clinical manifestations. Invasive provocation testing using acetylcholine or ergonovine is considered the gold standard for diagnosis, but protocols vary across institutions. Conventional pharmacological therapy relies on calcium channel blockers and nitrates, with limited options for refractory VSA. Global efforts to standardize diagnostic and therapeutic guidelines are expected to improve patient outcomes.