Vasospastic and microvascular angina — Rapid

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.

Key red flags

High-risk spasm

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

Investigation priorities

12-lead ECG during symptomsFirst step

Document transient ischaemic change or arrhythmia.

Management branches

Preferred routeAcute rest pain

Current severe or prolonged symptoms

Use the ACS pathway with ECG, serial troponin, monitoring and urgent assessment; give sublingual GTN when safe.
Treat persistent ST elevation, arrhythmia or haemodynamic compromise as an emergency.

Preferred routePersistent ANOCA or INOCA

Angina continues despite non-obstructive CTCA or angiography

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.

Amlodipine5 mg orally once daily, increased to 10 mg once daily according to response and tolerance.

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