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Background  Coronary artery spasm ( CAS ) is a well‐known endothelial dysfunction, and a major cause of vasospastic angina ( VSA ). The renin–angiotensin system ( RAS ) is known to be closely associated with endothelial function. However, there are only a few studies that investigated the impact of  RAS  inhibitor on long‐term clinical outcomes in  VSA  patients.    Methods and Results  A total of 3349 patients with no significant coronary artery disease, diagnosed with  CAS  by acetylcholine provocation test were enrolled for this study. Significant  CAS  was defined as having ≥70% narrowing of the artery after incremental injections of 20, 50, and 100 μg of acetylcholine into the left coronary artery. Patients were divided into 2 groups according to whether the prescription included  RAS  inhibitor or not ( RAS  inhibitor group: n=666, non‐ RAS  inhibitor group; n=2683). To adjust for any potential confounders that could cause bias, propensity score matching ( PSM ) analysis was performed using a logistic regression model. After  PSM  analysis, 2 matched groups (524 pairs, n=1048 patients, C‐statistic=0.845) were generated and their baseline characteristics were balanced. During the 5‐year clinical follow‐up, the  RAS  inhibitor group showed a lower incidence of recurrent angina (8.7% versus 14.1%,  P =0.027), total death (0.0% versus 1.3%,  P =0.045), and total major adverse cardiovascular events (1.0% versus 4.1%,  P =0.026) than the non‐ RAS  inhibitor group.    Conclusions  Chronic  RAS  inhibitor therapy was associated with lower incidence of cardiovascular events in  VSA  patients in the 5‐year clinical follow‐up.

Impact of Renin‐Angiotensin System Inhibitors on Long‐Term Clinical Outcomes of Patients With Coronary Artery Spasm