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Historical Evolution of the Guideline Statements on Vasospastic Angina (Coronary Spastic Angina) and Coronary

Seiji Hokimoto1, Kenichi Tsujita2

  • 1Division of Cardiovascular Medicine, Social Insurance Omuta Tenryo Hospital, Japan.

Internal Medicine (Tokyo, Japan)
|May 24, 2026
PubMed

Insights

Ischemic heart disease management now includes vasospastic angina (VSA) and coronary microvascular dysfunction (CMD) for patients with non-obstructive coronary arteries. Guidelines increasingly recognize these conditions, improving diagnosis and treatment for angina/ischemia with non-obstructive coronary arteries (ANOCA/INOCA).

Area of Science:

  • Cardiology
  • Internal Medicine
  • Clinical Practice Guidelines

Background:

  • Traditional ischemic heart disease management targets obstructive epicardial coronary artery disease.
  • A significant number of patients with angina and ischemia lack significant coronary stenosis.
  • Vasospastic angina (VSA) and coronary microvascular dysfunction (CMD) are key causes of angina/ischemia with non-obstructive coronary arteries (ANOCA/INOCA).

Purpose of the Study:

  • To review the historical development of guideline-based understanding of VSA and CMD.
  • To discuss the clinical implications of evolving perspectives on VSA and CMD for contemporary practice.

Main Methods:

  • Literature review focusing on guideline evolution and diagnostic criteria.
  • Analysis of historical and recent clinical practice guidelines.
  • Synthesis of information on VSA and CMD diagnosis and management.

Main Results:

  • Japanese guidelines pioneered VSA diagnosis via spasm provocation testing.
  • International guidelines now emphasize CMD as a distinct entity.
  • Coronary functional assessment (invasive and non-invasive) is increasingly recommended for CMD.

Conclusions:

  • Guideline-based perspectives on VSA and CMD have evolved significantly.
  • Contemporary management of ANOCA/INOCA requires consideration of VSA and CMD.
  • Further integration of VSA and CMD assessment into clinical practice is essential.

Keywords:
ANOCAClinical guidelinesCoronary microvascular dysfunctionINOCAVasospastic angina

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