Clinical Presentation and Treatment Response in Women With Acetylcholine‐Confirmed Coronary Spasm: A Single‐Center Observational Study

BACKGROUND: Coronary vasomotor disorders are frequently underdiagnosed in women with angina and non-obstructive coronary arteries. We investigated clinical presentation, diagnostic delay, spasm subtype, and patient-reported treatment response in women with acetylcholine-confirmed coronary spasm. METHODS: This single-center observational study included women with a positive intracoronary acetylcholine provocation test who completed a locally developed questionnaire on symptoms, triggers, comorbidities, medication tolerance, and treatment response. Epicardial spasm was defined as ≥ 90% epicardial diameter reduction with symptom reproduction and ischemic ECG changes; microvascular spasm as symptoms and ischemic ECG changes with < 90% epicardial vasoconstriction. Diltiazem was initiated as first-line therapy, with amlodipine as an alternative. Regression analyses exploring therapeutic failure were considered exploratory because of the low event count. RESULTS: A total of 194 women were included (median age 60 years [IQR 52-67]). Chest pain/tightness was reported by 163/190 (85.8%), dyspnea by 70/135 (51.9%), and palpitations by 74/136 (54.1%). Epicardial/microvascular spasm was present in 110/187 (58.8%) and 77/187 (41.2%). Median symptom-to-diagnosis time was 24 months [IQR 8-90]. Diltiazem was prescribed in 162/194 (83.5%). Among respondents with follow-up data, symptom frequency decreased in 103/128 (80.5%), episode duration decreased in 91/118 (77.1%), and pain intensity decreased/resolved in 92/115 (80.0%). Therapeutic failure occurred in 8/106 (7.5%). Residual symptom burden remained common, with CCS class > II at follow-up in 65/124 (52.4%) and persistent complaints in 53/107 (49.5%). CONCLUSIONS: In women with acetylcholine-confirmed coronary spasm, symptom burden and diagnostic delay were substantial. Calcium-channel blocker therapy was associated with patient-reported symptom improvement among respondents with available follow-up data.