Vasospastic Angina with Epicardial Coronary Spasm: What to Do When Calcium Channel Blockers Have Not Worked

Clinical scenario

This protocol applies to patients with vasospastic angina presenting with anginal symptoms and ischaemic ECG changes, in whom acetylcholine testing has confirmed epicardial (macrovascular) coronary spasm. A positive test is defined by symptoms together with ischaemic ECG changes and an angiographic coronary lumen reduction of ≥ 90%.

Previous treatment — inadequate response

Calcium channel blocker (calcium antagonist) therapy — the established first-line approach for epicardial vasospastic angina — has not achieved adequate control of anginal symptoms or prevention of ischaemia. This protocol addresses the structured next step when that treatment goal is not met.

Next-line approach (partial)

A nitrate-based therapeutic approach is indicated at this stage. The clinical target is prevention of recurrent vasospastic episodes.

Complete agent selection and the full treatment algorithm are contained in the structured protocol.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1093/eurheartj/ehae177

The test is considered positive for macrovascular spasm if symptoms occur, accompanied by ischaemic ECG changes and an angiographic ≥90% reduction of the coronary lumen.

In patients with either epicardial or microvascular spasm following Ach testing, calcium antagonists should be considered as first-line therapy.

Nitrates should be considered to prevent recurrent episodes.

View source ↗