Guideline sources The following summarized guidelines for the evaluation and management of vasospastic angina are prepared by our editorial team based on guidelines from the Japanese College of Cardiology (JCC/CVIT/JCS 2023), the European Society of Cardiology (ESC 2021; 2020), and the American Heart Association (AHA/ACC 2014). 1 2 3 4 Calculator Calculator Calculat Coronary Vasomotion Disorders Japanese Coronary Spasm Asso NYHA f Guidelines 1. Diagnostic investigations Electrocardiogram monitoring: consider obtaining ambulatory ECG recording, preferably 12- lead monitoring, in patients with suspected vasospastic angina. C Coronary flow reserve assessment: https://web.pathway.md/diseases/recjjixf6qilHjovc 1/5 6/29/23, 3:24 AM Vasospastic angina Pathway Consider obtaining physiological evaluation by measuring coronary flow reserve and index of microcirculatory resistance for diagnosis and predicting prognosis in patients with suspected INOCA. C Consider obtaining coronary flow reserve and index of microcirculatory resistance evaluation using a guide wire in patients with angina pectoris and demonstrated myocardial ischemia but no significant stenosis of the epicardial coronary arteries. C Consider assessing Doppler blood flow in the left anterior descending branch by TTE for coronary flow reserve assessment. C Coronary CTA: consider obtaining coronary computed tomographic angiography to rule out obstructive coronary artery disease in patients with suspected vasospastic angina. C Cardiac MRI: Consider obtaining stress myocardial perfusion MRI for the evaluation of microvascular angina in patients with stable chronic chest pain but no significant stenosis in the epicardial coronary arteries. C Consider obtaining cardiac MRI with gadolinium contrast to explore the underlying etiology of troponin-positive nonobstructive coronary arteries. C Cardiac PET: consider obtaining 13N-ammonia-positron emission tomography to assess myocardial perfusion for the evaluation of microvascular angina in patients with stable chronic chest pain but no significant stenosis in the epicardial coronary arteries. C Cardiac scintigraphy: consider obtaining iodine-123- -methyl-P-iodophenyl-pentadecanoic acid myocardial scintigraphy in patients with suspected vasospastic angina. C Vascular endothelial function testing: consider obtaining vascular endothelial function testing for diagnosis and predicting prognosis in patients with suspected INOCA, including vasospastic angina and coronary microvascular dysfunction. C 2. Diagnostic procedures Coronary angiography: obtain coronary angiography (invasive or noninvasive) in patients with episodic chest pain accompanied by transient ST-segment elevation to rule out severe obstructive coronary artery disease. B Coronary provocative testing, general indications: As per JCC/CVIT/JCS 2023 guidelines, obtain pharmacological coronary spasm provocation testing in patients with suspected vasospastic angina based on symptoms but not diagnosed with coronary spasm by noninvasive evaluation. B Show 3 more As per ESC 2020 guidelines: Consider obtaining intracoronary provocation testing to identify coronary and diagnose the site and mode of spasm in patients with normal findings or nonobstructive lesions on coronary arteriography and a clinical picture of coronary spasm. C Consider obtaining provocative testing with intracoronary acetylcholine and ECG monitoring during coronary angiography to assess for microvascular vasospasm if coronary arteries are either angiographically normal or have moderate stenoses with preserved instantaneous wave-free ratio/fractional flow reserve. C https://web.pathway.md/diseases/recjjixf6qilHjovc 2/5 6/29/23, 3:24 AM Vasospastic angina Pathway As per ACC/AHA 2014 guidelines, consider obtaining provocative testing during invasive coronary angiography in patients with suspected vasospastic angina when clinical criteria and noninvasive testing fail to establish the diagnosis. C Intravascular ultrasound/optical coherence tomography: consider obtaining intravascular ultrasound/optical coherence tomography to search for mechanisms of coronary spasm and observe the presence of atherosclerotic lesions in the coronary spasm site. C Coronary provocative testing (INOCA): consider obtaining pharmacological coronary spasm provocation testing during coronary angiography to confirm the presence of coronary microvascular spasm in patients with angina pectoris and demonstrated myocardial ischemia but no significant stenosis of the epicardial coronary arteries. C Coronary provocative testing (MINOCA): consider obtaining coronary spasm provocation testing during acute coronary angiography if alternative conditions (such as plaque disruption and spontaneous coronary artery dissection) have been definitely ruled out, taking into account adequate safety considerations. C Show 2 more Coronary provocative testing (post-PCI): consider obtaining coronary spasm provocation testing with acetylcholine or ergonovine in patients with persistent or recurrent angina after PCI, after excluding significant coronary stenosis by coronary angiography. C 3. Medical management Calcium channel blockers: As per ESC 2021 guidelines, consider administering CCBs in patients with suspected/confirmed vasospastic angina. C As per AHA 2014 guidelines, consider administering CCBs alone or in combination with long- acting nitrates to treat and reduce the frequency of vasospastic angina. B Administer long- acting CCBs and nitrates in patients with coronary artery vasospasm. B Nitrates: As per ESC 2021 guidelines, consider administering nitrates in patients with suspected/confirmed vasospastic angina. C As per AHA 2014 guidelines, consider administering CCBs alone or in combination with long- acting nitrates to treat and reduce the frequency of vasospastic angina. B Administer long- acting CCBs and nitrates in patients with coronary artery vasospasm. B Beta-blockers: avoid using -blockers in patients with suspected/confirmed vasospastic angina. D Statins: offer statins in patients with vasospastic angina. B Aspirin: do not use aspirin in patients with vasospastic angina without significant organic stenosis. D 4. Nonpharmacologic interventions Smoking cessation: https://web.pathway.md/diseases/recjjixf6qilHjovc 3/5 6/29/23, 3:24 AM Vasospastic angina Pathway As per JCS 2023 guidelines, advise smoking cessation in patients with vasospastic angina. A As per AHA 2014 guidelines, advise cessation of tobacco use and modification of other atherosclerosis risk factors in patients with vasospastic angina. B 5. Therapeutic procedures Intracoronary fasudil administration: consider administering intracoronary fasudil in patients with refractory coronary spasm. C Implantable cardioverter-defibrillator: consider performing implantable cardioverter defibrillator implantation in patients with pre-existing VT/VF, including out-of-hospital cardiac arrest associated with coronary spasm, when refractory to medical therapy C or when medical therapy is effective. C 6. Surgical interventions Stellate ganglion block and/or thoracic sympathectomy: consider performing stellate ganglion block and/or thoracic sympathectomy in patients with refractory or severe vasospastic angina. C 7. Follow-up and surveillance Cardiac rehabilitation: Offer comprehensive cardiac rehabilitation after INOCA in the absence of contraindications. A Advise moderate-to-vigorous aerobic exercise ( 30 min, at least thrice weekly). B Clinical findings Patient demographics Symptoms Asian ethnicity Chest pain Japanese Chest pain at rest Fainting Past medical history Nausea Myocardial infarction Social history Vital signs Alcohol consumption Tobacco use Hypotension Tachypnea ECG findings St-segment depression St-segment elevation https://web.pathway.md/diseases/recjjixf6qilHjovc 4/5 6/29/23, 3:24 AM Vasospastic angina Pathway U wave inversion References 1. Amsterdam EA, Wenger NK, Brindis RG et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Dec 23;64 24):e139-e228. Open 2. Seiji Hokimoto, Koichi Kaikita, Satoshi Yasuda et al. JCS/CVIT/JCC 2023 Guideline Focused Update on Diagnosis and Treatment of Vasospastic Angina Coronary Spastic Angina) and Coronary Microvascular Dysfunction. Circ J. 2023 Mar 10. Open 3. Jean-Philippe Collet, Holger Thiele, Emanuele Barbato et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021 Apr 7;42 14 1289 1367. Open 4. Juhani Knuuti, William Wijns, Antti Saraste et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020 Jan 14;41 3 407 477. Open 5. John F Beltrame, Filippo Crea, Juan Carlos Kaski et al. International standardization of diagnostic criteria for vasospastic angina. Eur Heart J. 2017 Sep 1;38 33 2565 2568. Open 6. Yusuke Takagi, Jun Takahashi, Satoshi Yasuda et al. Prognostic stratification of patients with vasospastic angina: a comprehensive clinical risk score developed by the Japanese Coronary Spasm Association. J Am Coll Cardiol. 2013 Sep 24;62 13 1144 53. Open https://web.pathway.md/diseases/recjjixf6qilHjovc 5/5