Coronary vasomotor dysfunction and diagnostic accuracy of COVADIS-Criteria: Data from the MICRO Registry

Ornela Velollari (Mainz)1, M. Olschewski (Mainz)1, H. Ullrich-Daub (Mainz)1, G. Gagno (Triest)2, J. Herzog (Mainz)1, S. Daub (Mainz)1, M. Knorr (Mainz)1, P. Lurz (Mainz)1, T. Gori (Mainz)1

1Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, Deutschland; 2Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (Asugi) And Department Of Medical Surgical And Health Science Kardiologie Triest, Italien



Coronary vasomotor dysfunction is an important differential diagnosis of angina with non-obstructive coronary artery disease (ANOCA) with a higher prevalence in women. The diagnostic process of vasospasm presents a clinical challenge, striving for accuracy. This analysis seeks to compare the diagnostic accuracy of the COVADIS criteria to new criteria based on hemodynamic assessment, in diagnosing coronary vasomotor disorder.

Keywords: coronary vasomotor dysfunction; epicardial spasm; microvascular spasm

This study analyzed data from the MICRO-Registry, a prospective cohort study on coronary vasomotion disorders. Patients with symptoms of angina (> CCS II) and suspicion of microvascular dysfunction from September 2020 until October 2023, underwent microvascular function assessment. Using a bolus-based thermodilution method, patients underwent acetylcholine provocation testing, to rule out coronary vasospasm. We analyzed data on the clinical characteristics for all patients with ANOCA, vasospasm and compared quality criteria between both methods.

172 patients (age 64.7 ± 10.9 years, 65% female) with symptoms of angina (CCS II-IV) were recruited in the study. 30 patients (19 (63%) women, p=0.822 vs men) were diagnosed with epicardial spasm according to COVADIS criteria, defined by > 90% angiographic vasoconstriction. 30 patients (21 (70%) women, p=0.514 vs men) were diagnosed with microvascular spasm according to COVADIS criteria, combination of angina after Ach-administration, ECG-changes with <90% angiographic vasoconstriction.

According to hemodynamic criteria, epicardial spasm was diagnosed by a ratio of Pd/Pa-Ach<0,8 and microvascular spasm if Ach-IMR>IMRrest. Here, 20 patients (13 (65%) women, p=0.991 vs men) displayed microvascular spasm and 13 patients (8 (62%) women, p=0.779 vs men) epicardial spasm.

11 (37%) patients according to COVADIS criteria were diagnosed with epicardial spasm from the following hemodynamic criteria, whereas only 2 (7%) patients without angiographic changes were diagnosed with epicardial spasm. 4 (13%) of the patients with microvascular spasm according to COVADIS criteria, were diagnosed as well according to hemodynamic criteria. A significant number of patients 15 (50%) were diagnosed with microvascular spasm only due to hemodynamic criteria. Comparing hemodynamic and COVADIS criteria concerning the diagnosis of microvascular spasm, there is a considerable discrepancy ((K) =0.003, p=0.730) and for epicardial spasm a fair agreement ((K) =0.454, p<0.001).

Using hemodynamic criteria as a reference diagnostics, there was a high sensitivity of 85%, specificity of 88%, a false omission rate of 12% for epicardial spasm and a low sensitivity of 21%, a high specificity of 82%, a false omission rate of 18% for microvascular spasm. COVADIS criteria showed a 75% accuracy for the diagnosis of microvascular spasm and 88% accuracy for epicardial spasm according to hemodynamic criteria.


Applying the COVADIS criteria 60 patients were diagnosed with vasospasm versus 33 patients according to hemodynamic criteria. 13% of patients with microvascular spasm displayed an increase of microvascular resistance after acetylcholine administration. There was a fair agreement between both diagnostic approaches for epicardial spasm and a very low one for microvascular spasm. Although women displayed a higher prevalence in coronary vasomotor dysfunction, sex was not a significant predictor factor.

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