What question did this study set out to answer?

The study aims to identify the optimal sequence of spasm provocation testing and coronary microvascular function testing in diagnosing CMD.

January 10, 2026Journal of Coronary Artery Disease0 citationsOpen Access

Optimal Timing of Pharmacological Spasm Provocation During Interventional Diagnostic Procedures

HTHiroki TeragawaFutaba (Japan)YHYu HashimotoFutaba (Japan)ATAkane TsuchiyaHiroshima University

Key Result

Performing coronary microvascular function tests before spasm provocation tests may risk underdiagnosis of vasospastic angina due to vasodilatory effects.

Key Points

The study aims to identify the optimal sequence of spasm provocation testing and coronary microvascular function testing in diagnosing CMD.
Reviewed existing literature on spasm provocation test (SPT) and coronary microvascular function test (CMVFT) sequencing.
Analyzed advantages and disadvantages of performing SPT before or after CMVFT.
Discussed the impact of pharmacological agents on test results and the implications for diagnosis.
Performance of SPT before CMVFT may lead to confounding due to vasospasm severity and pharmacological effects.
Conducting CMVFT prior to SPT could help avoid reduced spasm inducibility and improve diagnosis accuracy.
Identified the need for evidence-based protocols to standardize diagnostic procedures for INOCA patients.

Structured PICO

Population

Patients undergoing interventional diagnostic procedures for suspected ischemia and nonobstructive coronary artery disease (INOCA)

Intervention

Sequencing strategies of spasm provocation test (SPT) and coronary microvascular function test (CMVFT)

The optimal sequence of spasm provocation and coronary microvascular function testing in INOCA remains debated, highlighting the need for standardized evidence-based protocols to guide individualized therapeutic strategies.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

Coronary microvascular dysfunction (CMD) is increasingly recognized as a clinically significant cause of angina in patients with ischemia and nonobstructive coronary artery disease (INOCA). Therefore, CMD has gained considerable attention in contemporary cardiovascular medicine. A comprehensive assessment of INOCA includes both the spasm provocation test (SPT), which can diagnose vasospastic angina (VSA), and coronary microvascular function test (CMVFT), which is used to evaluate CMD. However, the optimal sequence of these tests during interventional diagnostic procedures remains under debate. Several institutions perform SPT followed by CMVFT after nitrate administration. However, this approach raises concerns regarding the potential confounding effects of vasospasm severity, use of pharmacological agents, development of procedure-related complications on CMVFT measurements, and the frequency of CMD. Conversely, performing CMVFT prior to SPT might reduce the subsequent spasm inducibility attributed to the vasodilatory or endothelial-modulating effects of diagnostic agents, potentially leading to the underdiagnosis of VSA. This review comprehensively examined the advantages and disadvantages of each sequencing strategy, thereby emphasizing existing gaps in standardization and proposing future directions for optimizing the diagnostic algorithm in patients undergoing interventional diagnostic procedures for suspected INOCA. Establishing evidence-based protocols is essential for accurate phenotyping and for guiding individualized therapeutic strategies in this complex patient population.

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