Standardizing Invasive Provocation Testing for Vasospastic Angina: A Systematic Review of Diagnostic Protocols and Clinical Practice

Sufyan Mohamed Khair; Owais Bin Qadeer Gill; Hina Ali Akbar; Roozina Shaikh; Syeda Wafa Zahra Naqvi; Mohammad Ahsan

doi:10.70749/ijbr.v3i1.557

Authors

Sufyan Mohamed Khair Emergency Department, Russell’s Hall Hospital, United Kingdom/University of Science and Technology, Sudan.
Owais Bin Qadeer Gill Department of Radiology, PINUM Cancer Hospital, Faisalabad, Punjab, Pakistan.
Hina Ali Akbar Department of Medicine, DHQ Hospital Kasur/Primary Secondary Healthcare Department, Punjab, Pakistan.
Roozina Shaikh Department of Community Medicine, Sindh Medical College/Jinnah Sindh Medical University Karachi, Pakistan.
Syeda Wafa Zahra Naqvi Holy Family Hospital/Rawalpindi Medical College, Islamabad, Pakistan.
Mohammad Ahsan Health Department, Sindh Government, Pakistan.

DOI:

https://doi.org/10.70749/ijbr.v3i1.557

Keywords:

Vasospastic Angina, Invasive Provocation Testing, Diagnostic Protocols, Standardization, Coronary Artery Spasm

Abstract

Objective: Vasospastic angina (VSA) is an underdiagnosed condition with significant implications for patient outcomes. This systematic review evaluates the diagnostic protocols and clinical practices surrounding invasive provocation testing for VSA, with a focus on standardization and its impact on clinical outcomes. Methods: The review adhered to PRISMA guidelines and included studies from 2014 to 2024 that addressed invasive provocation testing for VSA. A total of 1,342 records were screened, with nine studies meeting the inclusion criteria. Data extraction focused on diagnostic protocols, pharmacological agents, safety measures, and clinical outcomes. Results: The findings emphasize the need for standardized diagnostic protocols for VSA, such as the COVADIS criteria, which include nitrate-responsive angina, transient ischemic ECG changes, and documented coronary artery spasm. Pharmacological agents like acetylcholine and ergonovine are commonly used, though variability in dosage, administration, and monitoring compromises standardization. Invasive provocation testing demonstrated high diagnostic utility in differentiating VSA from other forms of ANOCA, facilitating targeted interventions like calcium channel blockers. However, safety concerns and lack of clinician awareness limit its widespread adoption. Geographic disparities further exacerbate the variability in clinical practices. Conclusion: Standardization of invasive provocation testing protocols is critical for enhancing diagnostic accuracy and patient outcomes in VSA. The adoption of uniform criteria, training for healthcare professionals, and integration into clinical guidelines are essential steps toward addressing the underdiagnosis of VSA. Future research should address geographic and systemic barriers to ensure equitable implementation of standardized diagnostic practices.

Downloads

Download data is not yet available.

References

Jenkins, K., Pompei, G., Ganzorig, N., Brown, S., Beltrame, J., & Kunadian, V. (2024). Vasospastic angina: A review on diagnostic approach and management. Therapeutic Advances in Cardiovascular Disease, 18. https://doi.org/10.1177/17539447241230400

Meeder, J. G., Hartzema-Meijer, M. J., Jansen, T. P., Konst, R. E., Damman, P., & Elias-Smale, S. E. (2021). Outpatient management of patients with angina with no obstructive coronary arteries: How to come to a proper diagnosis and therapy. Frontiers in Cardiovascular Medicine, 8. https://doi.org/10.3389/fcvm.2021.716319

Sharedalal, P., & Aronow, W. S. (2020). A review of diagnosis, etiology, assessment, and management of patients with myocardial infarction in the absence of obstructive coronary artery disease. Hospital Practice, 49(1), 12-21. https://doi.org/10.1080/21548331.2020.1817459

Feenstra, R. F., Seitz, A., Boerhout, C. B., Bukkems, L. B., Stegehuis, V. S., Teeuwisse, P. T., De Winter, R. D., Sechtem, U., Piek, J. P., Van de Hoef, T. V., Ong, P., & Beijk, M. B. (2022). Principles and pitfalls in coronary vasomotor function testing. EuroIntervention, 17(15), 1271-1280. https://doi.org/10.4244/eij-d-21-00402

Sueda, S., Hayashi, Y., Ono, H., Okabe, H., Sakaue, T., & Ikeda, S. (2024). Lack of class I Vasoreactivity testing for diagnosing patients with coronary artery spasm. Clinical Cardiology, 47(9). https://doi.org/10.1002/clc.70004

He, Z., Xu, X., Zhao, Q., Ding, H., & Wang, D. W. (2023). Vasospastic angina: Past, present, and future. Pharmacology & Therapeutics, 249, 108500. https://doi.org/10.1016/j.pharmthera.2023.108500

Kinoshita, Y., Saito, Y., Kikuta, Y., Sato, K., Taniguchi, M., Goto, K., Takebayashi, H., Haruta, S., & Kobayashi, Y. (2024). Safety and potential usefulness of sequential intracoronary acetylcholine and ergonovine administration for spasm provocation testing. Therapeutic Advances in Cardiovascular Disease, 18. https://doi.org/10.1177/17539447241233168

Wu, Y., Mao, W., Li, Y., Zhang, Q., Zhang, B., & Sheng, Z. (2022). Intra-brachial ergonovine, not acetylcholine, is associated with radial artery vasospasm in patients with coronary vasospasm. Acta Cardiologica, 78(1), 135-141. https://doi.org/10.1080/00015385.2022.2030552

Al-Worafi, Y. M. (2024). Angina management in developing countries. Handbook of Medical and Health Sciences in Developing Countries, 1-41. https://doi.org/10.1007/978-3-030-74786-2_4-1

Hosadurg, N., Watts, K., Wang, S., Wingerter, K. E., Taylor, A. M., Villines, T. C., Patel, A. R., Bourque, J. M., Lindner, J. R., Kramer, C. M., Sharma, G., & Rodriguez Lozano, P. F. (2024). Emerging pathway to a precision medicine approach for angina with Nonobstructive coronary arteries in women. JACC: Advances, 3(8), 101074. https://doi.org/10.1016/j.jacadv.2024.101074

Beck, S., Martínez Pereyra, V., Seitz, A., McChord, J., Hubert, A., Bekeredjian, R., Sechtem, U., & Ong, P. (2021). Invasive diagnosis of coronary functional disorders causing angina pectoris. European Cardiology Review, 16. https://doi.org/10.15420/ecr.2021.06

Tudurachi, A., Anghel, L., Tudurachi, B., Zăvoi, A., Ceasovschih, A., Sascău, R. A., & Stătescu, C. (2024). Beyond the obstructive paradigm: Unveiling the complex landscape of Nonobstructive coronary artery disease. Journal of Clinical Medicine, 13(16), 4613. https://doi.org/10.3390/jcm13164613

Gurgoglione, F. L., Vignali, L., Montone, R. A., Rinaldi, R., Benatti, G., Solinas, E., Leone, A. M., Galante, D., Campo, G., Biscaglia, S., Porto, I., Benenati, S., & Niccoli, G. (2024). Coronary spasm testing with acetylcholine: A powerful tool for a personalized therapy of coronary vasomotor disorders. Life, 14(3), 292. https://doi.org/10.3390/life14030292

Jewulski, J., Khanal, S., & Dahal, K. (2021). Coronary vasospasm: A narrative review. World Journal of Cardiology, 13(9), 456-463. https://doi.org/10.4330/wjc.v13.i9.456

Aparicio-Ortiz, A. D., Alonso-Jimenez, M. N., Espejel-Guzman, A., Cabello-Ganem, A., Serrano-Roman, J., Luna-Alcala, S., & Espinola-Zavaleta, N. (2024). Mechanical complications after myocardial infarction: A comprehensive review. World Journal of Cardiovascular Diseases, 14(01), 43-60. https://doi.org/10.4236/wjcd.2024.141005

Damluji, A. A., Van Diepen, S., Katz, J. N., Menon, V., Tamis-Holland, J. E., Bakitas, M., Cohen, M. G., Balsam, L. B., & Chikwe, J. (2021). Mechanical complications of acute myocardial infarction: A scientific statement from the American Heart Association. Circulation, 144(2). https://doi.org/10.1161/cir.0000000000000985

Ngo, V., Tavoosi, A., Natalis, A., Harel, F., Jolicoeur, E. M., Beanlands, R. S., & Pelletier-Galarneau, M. (2023). Non-invasive diagnosis of vasospastic angina. Journal of Nuclear Cardiology, 30(1), 167-177. https://doi.org/10.1007/s12350-022-02948-z

Soh, R. Y., Low, T., Sia, C., Kong, W. K., Yeo, T., Loh, P., & Poh, K. (2024). Ischaemia with no obstructive coronary arteries: A review with focus on the Asian population. Singapore Medical Journal, 65(7), 380-388. https://doi.org/10.4103/singaporemedj.smj-2023-116

Bhati, D., Deogade, M. S., & Kanyal, D. (2023). Improving patient outcomes through effective hospital administration: A comprehensive review. Cureus. https://doi.org/10.7759/cureus.47731

Fatima, L., Goyal, A., Yakkali, S., Jain, H., Raza, F. A., Peer, T., Kanagala, S. G., Sohail, A. H., & Malik, J. (2024). Precision medicine in myocardial infarction with non-obstructive coronary disease (MINOCA): A comprehensive review. Current Problems in Cardiology, 49(2), 102185. https://doi.org/10.1016/j.cpcardiol.2023.102185

Pereira, V. C., Silva, S. N., Carvalho, V. K., Zanghelini, F., & Barreto, J. O. (2022). Strategies for the implementation of clinical practice guidelines in public health: An overview of systematic reviews. Health Research Policy and Systems, 20(1). https://doi.org/10.1186/s12961-022-00815-4

Spiro, J., Ford, T. J., Yong, A., Zeitz, C., Beltrame, J. F., Watts, M., Somaratne, J., Farouque, O., Asrress, K., Ko, B., Sheikh, A., Ooi, E., Scott, P., Puri, A., Lambert, B., Yong, A., Ihdayhid, A., Singh, K., Ford, T., … Shetty, P. (2024). Protocol variation in functional coronary angiography among patients with suspected angina with non-obstructive coronary arteries: A nationwide snapshot of current practice within Australia and New Zealand. Heart, Lung and Circulation, 33(9), 1287-1296. https://doi.org/10.1016/j.hlc.2024.04.299

Huang, J., Steinberg, R., Brown, M. J., Rinfret, S., & Toleva, O. (2023). Invasive evaluation for coronary Vasospasm. US Cardiology Review, 17. https://doi.org/10.15420/usc.2022.33

Jenkins, K., Pompei, G., Ganzorig, N., Brown, S., Beltrame, J., & Kunadian, V. (2024). Vasospastic angina: A review on diagnostic approach and management. Therapeutic Advances in Cardiovascular Disease, 18. https://doi.org/10.1177/17539447241230400

Picard, F., Adjedj, J., Collet, J., Van Belle, E., Monsegu, J., Karsenty, B., Dupouy, P., Quillot, M., Bonnet, G., Gautier, A., Cayla, G., & Benamer, H. (2023). Pharmacological coronary spasm provocative testing in clinical practice: A French coronary atheroma and interventional cardiology group (GACI) position paper. Archives of Cardiovascular Diseases, 116(12), 590-596. https://doi.org/10.1016/j.acvd.2023.10.002

Hung, M., Yeh, C., Kounis, N. G., Koniari, I., Hu, P., & Hung, M. (2023). Coronary artery spasm-related heart failure syndrome: Literature review. International Journal of Molecular Sciences, 24(8), 7530. https://doi.org/10.3390/ijms24087530

Rehan, R., Wong, C. C., Weaver, J., Chan, W., Tremmel, J. A., Fearon, W. F., Ng, M. K., & Yong, A. S. (2024). Multivessel coronary function testing increases diagnostic yield in patients with angina and Nonobstructive coronary arteries. JACC: Cardiovascular Interventions, 17(9), 1091-1102. https://doi.org/10.1016/j.jcin.2024.03.007