Ktenopoulos N, Milaras N, Apostolos A, Tsioufis K, Toutouzas K, Sideris S. When coronary spasm reflects systemic vascular disease: Prognostic insights from endothelial dysfunction. World J Cardiol 2026; 18(8): 120150 [DOI: 10.4330/wjc.120150]
Corresponding Author of This Article
Nikias Milaras, MD, First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, Vasilisis Sofias 14, Athens 11527, Greece. nikiasmilaras@gmail.com
Research Domain of This Article
Cardiac & Cardiovascular Systems
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editorial
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Ktenopoulos N, Milaras N, Apostolos A, Tsioufis K, Toutouzas K, Sideris S. When coronary spasm reflects systemic vascular disease: Prognostic insights from endothelial dysfunction. World J Cardiol 2026; 18(8): 120150 [DOI: 10.4330/wjc.120150]
Nikolaos Ktenopoulos, Anastasios Apostolos, Konstantinos Tsioufis, Konstantinos Toutouzas, First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, Athens 11527, Greece
Nikias Milaras, Skevos Sideris, Department of Cardiology, “Hippokration” General Hospital, Athens 11527, Greece
Author contributions: Ktenopoulos N and Milaras N contributed to conceptualization and writing - original draft preparation; Apostolos A, Tsioufis K, Toutouzas K, and Sideris S contributed to writing - review and editing. All authors have read and agreed to the published version of the manuscript.
AI contribution statement: The AI-assisted tool ChatGPT was used only to support language polishing, editing for clarity, grammar, readability and organization of the text. AI-assisted tools were used only for language polishing and writing assistance, including improving grammar, phrasing, readability and clarity. No AI tool was used for statistical analysis, data analysis, generation of results, or creation of scientific conclusions.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Nikias Milaras, MD, First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, Vasilisis Sofias 14, Athens 11527, Greece. nikiasmilaras@gmail.com
Received: February 24, 2026 Revised: April 10, 2026 Accepted: May 13, 2026 Published online: August 26, 2026 Processing time: 191 Days and 1.6 Hours
Abstract
Vasospastic angina (VSA) has traditionally been regarded as a largely benign coronary syndrome when treated with vasodilator therapy and lifestyle modification. However, a subset of patients experiences recurrent ischemic events, heart failure or even sudden cardiac death, underscoring the need for reliable and clinically accessible prognostic markers. In this context, the study by Teragawa et al published in the World Journal of Cardiology provides important evidence that peripheral vascular endothelial dysfunction, assessed noninvasively by brachial artery flow-mediated dilation (FMD), is independently associated with adverse long-term outcomes in patients with angiographically confirmed VSA. This retrospective analysis demonstrates that reduced FMD (< 3.7%) identifies a higher-risk VSA phenotype characterized by advanced age, elevated natriuretic peptide levels and significantly increased rates of major adverse cardiovascular events. Notably, endothelial dysfunction outperformed several traditional spasm-related angiographic markers, including focal spasm, in multivariable prognostic modeling. These findings reinforce the concept that VSA is not merely a focal epicardial disorder but rather a manifestation of systemic vascular pathology, in which endothelial health plays a central role. Beyond its mechanistic implications, the study has important clinical ramifications. FMD is widely available, noninvasive and reproducible when performed according to established standards, making it an attractive tool for risk stratification in everyday practice. Incorporating endothelial function assessment into the evaluation of patients with VSA may allow for more individualized surveillance strategies and more aggressive modification of cardiovascular risk factors in those at highest risk. While the single-center, retrospective design necessitates cautious interpretation, this work meaningfully advances the field by bridging vascular biology with clinical outcomes. Future multicenter and prospective studies will be essential to validate optimal FMD thresholds and to determine whether therapeutic strategies aimed at improving endothelial function can translate into improved prognosis in VAS.
Core Tip: In patients with vasospastic angina, impaired brachial artery flow-mediated dilation independently predicts adverse cardiovascular events and outperforms conventional angiographic spasm markers. These data support the concept that coronary spasm reflects systemic endothelial pathology rather than isolated epicardial hyperreactivity, highlighting the potential role of endothelial function testing in clinical risk stratification.
