Vasospastic angina: Pathophysiology, diagnosis, and emerging therapeutic approaches

Vasospastic angina (VSA) is a distinct endotype of ischemia with non-obstructive coronary arteries characterized by transient coronary artery spasm and myocardial ischemia in the absence of significant fixed stenosis. It is an underdiagnosed and often challenging condition that can lead to recurrent angina, myocardial infarction, and sudden cardiac death. VSA arises from a multifactorial interplay of endothelial dysfunction, vascular smooth muscle hyperreactivity, inflammation, and autonomic dysregulation. While calcium channel blockers and nitrates remain the mainstay of therapy, there is a growing body of evidence in the use of novel and emerging treatments including Rho-kinase inhibitors, endothelin receptor antagonists, and anti-inflammatory agents for refractory cases. Diagnostic evaluation relies on clinical features and, when necessary, invasive coronary pharmacological provocation testing. This narrative review examines the current understanding of VSA, discusses current international guideline-based diagnostic and therapeutic strategies, and highlights novel and investigational approaches that may broaden the treatment armamentarium against it.