Unstable angina / non ST elevation myocardial infarction cardiovascular syndrome x

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Cardiovascular "Syndrome X"

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Smita Kohli, M.D.

Overview

Cardiovascular syndrome X refers to patients with angina or angina-like discomfort with exercise, ST-segment depression on exercise testing, and normal or nonobstructed coronary arteries on angiography. This entity should be differentiated from the metabolic syndrome X or metabolic syndrome, which describes patients with insulin resistance, hyperinsulinemia, dyslipidemia, hypertension, and abdominal obesity. It also should be differentiated from noncardiac chest pain.

Cardiovascular Syndrome X in UA / NSTEMI

  • Syndrome X is more common in women than in men.
  • The cause of the discomfort and ST-segment depression in patients with syndrome X is not well understood. The most frequently proposed causes are:
  • Impaired endothelium dependent arterial vasodilatation with decreased nitric oxide production,
  • Impaired microvascular dilation (non-endothelium-dependent),
  • Increased sensitivity to sympathetic stimulation, or
  • Coronary vasoconstriction in response to exercise.
  • Recently, there is increasing evidence that these patients frequently also have an increased responsiveness to pain and an abnormality in pain perception.

Diagnosis

  • The diagnosis of syndrome X is suggested by the triad of:

Treatment

  • It is recommended that patients be reassured of the excellent intermediate-term prognosis and treated with long-acting nitrates.
  • Beta blockers and calcium channel blockers have been found to be effective in reducing the number of episodes of chest discomfort. Nitrates can be helful in half of the patients.
  • Imipramine, 50 mg daily has been successful in some chronic pain syndromes, including syndrome X, reducing the frequency of chest pain by 50%.[1]
  • Transcutaneous electrical nerve stimulation and spinal cord stimulation can offer good pain control.
  • Statin therapy and exercise training have improved exercise capacity, endothelial function, and symptoms in some studies.

2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction (DO NOT EDIT)[2]

Cardiovascular “Syndrome X” (DO NOT EDIT)[2]

Class I
"1. Medical therapy with nitrates, beta blockers, and calcium channel blockers, alone or in combination is recommended in patients with cardiovascular syndrome X. (Level of Evidence: B)"
"2. Risk factor reduction is recommended in patients with cardiovascular syndrome X. (Level of Evidence: B)"
Class III
"1. Medical therapy with nitrates, beta blockers, and calcium channel blockers for patients with non cardiac chest pain is not recommended. (Level of Evidence: C)"
Class IIb
"1. Intracoronary ultrasound to assess the extent of atherosclerosis and rule out missed obstructive lesions may be considered in patients with syndrome X. (Level of Evidence: B)"
"2. If no ECGs during chest pain are available and coronary spasm cannot be ruled out, coronary angiography and provocative testing with acetylcholine, adenosine, or methacholine and 24 h ambulatory ECG may be considered. (Level of Evidence: C)"
"3. If coronary angiography is performed and does not reveal a cause of chest discomfort, and if syndrome X is suspected, invasive physiological assessment (i.e., coronary flow reserve measurement) may be considered. (Level of Evidence: C)"
"4. Imipramine or aminophylline may be considered in patients with syndrome X for continued pain despite implementation of Class I measures. (Level of Evidence: C)"
"5. Transcutaneous electrical nerve stimulation and spinal cord stimulation for continued pain despite the implementation of Class I measures may be considered for patients with syndrome X. (Level of Evidence: B)"

References

  1. Cannon RO, Quyyumi AA, Mincemoyer R; et al. (1994). "Imipramine in patients with chest pain despite normal coronary angiograms". N. Engl. J. Med. 330 (20): 1411–7. PMID 8159194. Unknown parameter |month= ignored (help)
  2. 2.0 2.1 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE; et al. (2011). "2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 123 (18): e426–579. doi:10.1161/CIR.0b013e318212bb8b. PMID 21444888.

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