OBJECTIVE To discover what factors indicate spontaneous coronary artery spasms as a cause of myocardial ischaemia. METHODS In a retrospective analysis 15 of 1407 consecutive patients who had undergone coronary arteriography (six women and nine men; mean age 47 +/- 11 years) had acute ischaemia due to spontaneous coronary artery spasms. The clinical findings at the time of first investigation and during the follow-up period (mean of 29 [3-65] months) were evaluated. RESULTS The most common risk factors were hypercholesterolaemia (> or = 200 mg/dl) in ten patients (66%) and heavy nicotine consumption > or = 20 cigarettes per day) in eight patients (55%). Of the patients with angina at rest nine had reversible ST elevations, six had terminal T negativity in the ECG and an increased incidence of ventricular arrhythmias (n = 6). At time of hospitalization ten patients had acute myocardial ischaemia and five had signs of acute myocardial infarction (maximal creatine kinase concentration: 121-2980 U/l). Acute coronary angiography revealed circumscribed coronary artery constriction, reversible with nitroglycerin, with stenosis of < 70% in five patients and of > or = 70% in six, as well as intermittent vessel occlusion in four patients. Angiography showed smooth coronary artery walls in almost all instances. Angiographic evidence of circumscribed arteriosclerotic lesion with maximally 50% narrowing was present in six patients. CONCLUSIONS Especially in younger, male patients with hypercholesterolaemia and heavy smoking recurrent anginal pectoris at rest, with reversible ECG signs of myocardial ischaemia but without advanced coronary sclerosis, speaks for spontaneous coronary artery spasms as the cause.