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Acetylcholine Provocation for Vasospasm — EECC MCQ

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ModerateCoronary Artery DiseaseAcetylcholine Provocation for VasospasmEECC

A 50-year-old man presents with chest pain at rest, dynamic ST-T changes, and troponin rise. Coronary angiography shows no obstructive CAD. Acetylcholine provocation test during angiography induces focal coronary spasm with chest pain and ischaemic ECG changes. What is the diagnosis?

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Correct answer: B — Vasospastic angina (Prinzmetal angina) confirmed by provocative testing — acetylcholine provocation is the gold standard for diagnosing epicardial coronary vasospasm in patients with ischaemia and non-obstructive coronary arteries (INOCA)

INOCA/ANOCA (ischaemia/angina with non-obstructive coronary arteries) encompasses several endotypes: (1) epicardial vasospasm (vasospastic angina/Prinzmetal); (2) microvascular spasm; (3) microvascular dysfunction (impaired CFR); (4) combinations. Provocative testing with intracoronary acetylcholine (ACh) is the gold standard per the 2024 ESC CCS Guidelines (Class IIa): ACh provokes: epicardial spasm (>90% focal reduction with symptoms + ECG changes = positive), microvascular spasm (symptoms + ECG changes without epicardial spasm). Alternative provocative agents: ergonovine (IV or IC), hyperventilation. Treatment for confirmed vasospastic angina: (1) CCBs (high-dose — first-line, Class I); (2) long-acting nitrates (second-line); (3) avoid beta-blockers (may worsen spasm); (4) avoid cocaine, triptans, ergot alkaloids. The COVADIS (Coronary Vasomotor Disorders International Study) criteria standardise the diagnostic approach.

Reference: ESC (2024): CCS Guidelines; COVADIS Criteria