Some observations on and controversies about coronary arterial spasm

•Coronary artery spasm still exists.•Pathophysiology is unclear.•Proving its diagnosis may be difficult.•Provocative testing during angiography is underutilized.•Calcium channel blockers are mainstay of treatment.

The pathogenesis, clinical features, diagnosis, and treatment of spasm of epicardial coronary arteries are reviewed briefly, especially with regard to some issues that remain controversial. For diagnosis, emphasis is placed on the need for objective observations during an attack, even if that requires an attempt at pharmacologic provocation during coronary arteriography, or during echocardiography when prior arteriography has demonstrated the absence of severe coronary stenosis.