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Vasospastic angina

Key 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).
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Guidelines

1.Diagnostic investigations

Electrocardiogram monitoring: consider obtaining ambulatory ECG recording, preferably 12-lead monitoring, in patients with suspected vasospastic angina.
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  • Coronary flow reserve assessment

  • Coronary CTA

  • Cardiac MRI

  • Cardiac PET

  • Cardiac scintigraphy

  • Vascular endothelial function testing

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.
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  • Coronary provocative testing (general indications)

  • Intravascular ultrasound/optical coherence tomography

  • Coronary provocative testing (INOCA)

  • Coronary provocative testing (MINOCA)

  • Coronary provocative testing (post-PCI)

3.Medical management

Calcium channel blockers: as per ESC 2021 guidelines, consider administering CCBs in patients with suspected/confirmed vasospastic angina.
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  • Nitrates

  • Beta-blockers

  • Statins

  • Aspirin

4.Nonpharmacologic interventions

Smoking cessation: as per JCS 2023 guidelines, advise smoking cessation in patients with vasospastic angina.
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5.Therapeutic procedures

Intracoronary fasudil administration: consider administering intracoronary fasudil in patients with refractory coronary spasm.
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  • ICD

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.
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7.Follow-up and surveillance

Cardiac rehabilitation
Offer comprehensive cardiac rehabilitation after INOCA in the absence of contraindications.
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Advise moderate-to-vigorous aerobic exercise (≥ 30 min, at least thrice weekly).
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