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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Vasospastic and microvascular angina

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Escalate

Treat new or prolonged rest pain with ECG change or troponin rise as possible ACS until excluded. Coronary spasm can cause infarction, syncope and ventricular arrhythmia and may require urgent monitored care.

Synopsis

Recognise angina with non-obstructive coronary arteries, identify vasospastic or microvascular endotypes and use mechanism-directed testing and treatment.

  • Non-obstructive coronary arteries do not make angina non-cardiac; consider epicardial spasm and coronary microvascular dysfunction.
  • Vasospastic angina often occurs at rest, particularly at night or early morning, with transient ST change and prompt nitrate response.
  • Microvascular angina may be exertional or occur at rest and can persist longer than classic obstructive angina.
  • Capture a 12-lead ECG during pain whenever possible and use serial troponin for prolonged or acute episodes.
  • If symptoms persist despite non-obstructive CTCA or angiography, ESC 2024 recommends invasive coronary functional testing to define endotypes and guide therapy.
  • Acetylcholine testing assesses epicardial and microvascular spasm; adenosine-based physiology assesses flow reserve and microvascular resistance.
  • Calcium-channel blockers are first-line for vasospasm; avoid unopposed beta-blockade in pure vasospastic disease.
  • Treat coexisting atherosclerotic risk and endothelial dysfunction even when no flow-limiting stenosis is present.

Key red flags

High-risk spasm

Syncope, ventricular arrhythmia, infarction or prolonged ST elevation during an episode requires urgent monitored specialist management.

Investigation priorities

01
12-lead ECG during symptomsFirst step

Document transient ischaemic change or arrhythmia.

Management branches

Preferred routeAcute rest pain

Current severe or prolonged symptoms

  1. Use the ACS pathway with ECG, serial troponin, monitoring and urgent assessment; give sublingual GTN when safe.
  2. Treat persistent ST elevation, arrhythmia or haemodynamic compromise as an emergency.
  3. Define obstructive, SCAD, embolic or other acute mechanisms with coronary imaging as indicated.
  4. Only settle on vasospasm after dangerous acute causes have been addressed.
Preferred routePersistent ANOCA or INOCA

Angina continues despite non-obstructive CTCA or angiography

  1. Reassess the symptom pattern, adherence, anaemia, arrhythmia, valve disease and non-cardiac alternatives without dismissing the pain.
  2. Use functional imaging when ischaemia or flow reserve remains untested.
  3. If symptoms persist despite guideline-derived therapy, refer for invasive coronary functional testing to identify endotypes.
  4. Explain the positive diagnosis and agree measurable symptom and function goals.

Key medicines

Glyceryl trinitrate sublingual spray400–800 micrograms under the tongue at symptom onset; repeat at 5-minute intervals if needed, to a maximum total of 3 sprays, then seek prompt medical help if unresolved.Avoid with hypotension, severe aortic stenosis or riociguat. Do not use within at least 24 hours of sildenafil or vardenafil or 48 hours of tadalafil; lack of response does not exclude ischaemia.
Amlodipine5 mg orally once daily, increased to 10 mg once daily according to response and tolerance.Hypotension, ankle oedema and severe outflow obstruction; it does not provide acute relief.
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Sources and review status8 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • ESC 2024 Guidelines for chronic coronary syndromes
  • NICE CG126: Stable angina management
  • Glyceryl trinitrate 400 micrograms spray SmPC
  • Amlodipine 5 mg tablets SmPC
  • Tildiem Retard 90 mg SmPC
  • Isosorbide mononitrate 30 mg prolonged-release tablets SmPC
  • Ranexa 375 mg SmPC
  • NHS: Common questions about glyceryl trinitrate

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom