What question did this study set out to answer?

Investigate the prevalence and implications of vasospastic angina mimicking obstructive coronary artery disease.

March 6, 2026Open Access

The Great Masquerader: Vasospastic Angina Mimicking Left Main Coronary Artery Disease

Key Result

Invasive functional testing in angina patients with non-obstructive coronary arteries identified coexistence of CMD and vasospastic angina, guiding precise therapy.

Key Points

Investigate the prevalence and implications of vasospastic angina mimicking obstructive coronary artery disease.
Invasive coronary angiography performed to assess for obstructive coronary artery disease.
Coronary computed tomography angiography used to evaluate coronary artery anatomy.
Functional assessment including coronary flow reserve and index of microcirculatory resistance.
Intracoronary acetylcholine test conducted to provoke vasospasm.
No critical stenosis found during coronary angiography despite exertional chest pain.
Coronary flow reserve measured at 2.0, indicating microvascular dysfunction.
Index of microcirculatory resistance recorded at 25, consistent with coronary microvascular dysfunction.
Severe focal vasospasm provoked in mid-left anterior descending artery, confirmed as vasospastic angina.

Structured PICO

Population

58-year-old male with exertional chest pain and exercise ECG changes typical of left main or multivessel CAD

Intervention

Invasive functional testing (CFR, IMR, and intracoronary acetylcholine provocation test)

Outcome

Diagnosis of coronary microvascular dysfunction and vasospastic angina

This case highlights the diagnostic and clinical importance of invasive functional testing in patients with angina and non-obstructive coronary arteries to identify mixed endotypes and guide therapy.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

A significant proportion of patients undergoing invasive coronary angiography for angina have no obstructive coronary artery disease (CAD). In such patients, coronary microvascular dysfunction (CMD) and vasospastic angina (VSA) represent key pathophysiological mechanisms. We report a case of a 58-year-old male with exertional chest pain and exercise ECG changes typical of left main or multivessel CAD. Coronary computed tomography angiography (CCTA) showed borderline stenosis of the distal left main coronary artery. Coronary angiography revealed no critical stenosis. A comprehensive functional assessment demonstrated reduced coronary flow reserve (CFR = 2.0) and an elevated index of microcirculatory resistance (IMR = 25), consistent with CMD. An intracoronary acetylcholine provocation test induced severe focal vasospasm of the mid-left anterior descending artery (LAD) with ST-segment elevation and anginal pain, promptly relieved by nitroglycerin, confirming VSA. This case highlights the diagnostic and clinical importance of invasive functional testing in patients with angina and non-obstructive coronary arteries (ANOCA/INOCA). The coexistence of CMD and VSA (two distinct but overlapping pathophysiological endotypes) is increasingly recognized as a marker of adverse prognosis. Functional coronary assessment should be considered in all patients with angina and non-obstructive coronary arteries, as identifying mixed endotypes enables precise, mechanism-guided therapy.

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