Vasospastic angina: Pathophysiology, diagnosis, and emerging therapeutic approaches

Table 1 Coronary vasomotion disorders international study group criteria for diagnosis of vasospastic angina

COVADIS criteria for diagnosing vasospastic angina[14]
1 Nitrate responsive angina during spontaneous episode, with at least one of the following:
Rest angina – especially between night and early morning
Marked diurnal variation in exercise tolerance – reduced in morning
Hyperventilation can precipitate an episode
Calcium-channel blockers (but not -blockers) suppress episodes
2 Transient ischemic ECG changes during spontaneous episode, including any of the following in at least two contiguous leads:
ST segment elevation 0.1 mV
ST segment depression 0.1 mV
New negative U waves
3 Coronary artery spasm on invasive coronary angiography, defined as transient total or subtotal coronary artery occlusion (> 90% constriction) with angina and ischemic ECG changes, either spontaneously or in response to a provocative stimulus (typically acetylcholine, ergot, or hyperventilation)
Definite VSA: Criteria 1 + either criterion 2 or criteria 3 are fulfilled
Suspected VSA: Criteria 1 fulfilled but Criteria 2 is equivocal or unavailable, and Criteria 3 is equivocal

Coronary Vasomotion Disorders International Study Group criteria for diagnosing vasospastic angina. COVADIS: Coronary Vasomotion Disorders International Study Group; ECG: Electrocardiogram.

Table 2 Recommendations for provocative testing

COVADIS recommendations for provocative testing[14]
Class I (strong indications)
History suspicious of VSA without documented episode, especially if:
Nitrate-responsive rest angina and/or
Marked diurnal variation in symptom onset/exercise tolerance, and/or
Rest angina without obstructive coronary artery disease
Unresponsive to empiric therapy
Acute coronary syndrome presentation in the absence of a culprit lesion
Unexplained resuscitated cardiac arrest
Unexplained syncope with antecedent chest pain
Recurrent rest angina following angiographically successful PCI
Class IIa (good indications)
Invasive testing for non-invasive diagnosed patients unresponsive to drug therapy
Documented spontaneous episode of VSA to determine the ‘site and mode’ of spasm
Class IIb (controversial indications)
Invasive testing for non-invasive diagnosed patients responsive to drug therapy
Class III (contraindications)
Emergent acute coronary syndrome
Severe fixed multi-vessel coronary artery disease including left main stenosis
Severe myocardial dysfunction (Class IIb if symptoms suggestive of vasospasm)
Patients without any symptoms suggestive of VSA

Indications for provocative coronary artery spasm testing. Adapted from Coronary Vasomotion Disorders International Study group. COVADIS: Coronary Vasomotion Disorders International Study Group; VSA: Vasospastic angina.