Unstable angina / non ST elevation myocardial infarction cardiovascular syndrome x: Difference between revisions
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{{ | {| class="infobox" style="float:right;" | ||
{{CMG}} | |- | ||
| [[File:Siren.gif|30px|link=Unstable angina/ NSTEMI resident survival guide]]|| <br> || <br> | |||
| [[Unstable angina/ NSTEMI resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] | |||
|} | |||
{{Unstable angina / NSTEMI}} | |||
{{CMG}}; '''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: | |||
The | ::*[[Anginal]]-type chest discomfort | ||
::*Objective evidence of [[ischemia]] | |||
::*Absence of obstructive [[CAD]] | |||
*This can be confirmed by provocative coronary angiographic testing with [[acetylcholine]] for coronary endothelium-dependent function and adenosine for non-endothelium-dependent microvascular function. | |||
*Other non-cardiac causes of [[chest pain]] such as [[esophageal dysmotility]], [[fibromyalgia]], and [[costochondritis]] should be ruled out. | |||
==Treatment== | |||
It is recommended that patients be reassured of the excellent intermediate-term prognosis and treated with long-acting nitrates. | *It is recommended that patients be reassured of the excellent intermediate-term prognosis and treated with long-acting [[nitrates]]. | ||
*If the patient continues to have episodes of chest pain, a [[calcium channel blocker]] or [[beta blocker]] can be started. | |||
*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%.<ref name="pmid8159194">{{cite journal |author=Cannon RO, Quyyumi AA, Mincemoyer R, ''et al.'' |title=Imipramine in patients with chest pain despite normal coronary angiograms |journal=N. Engl. J. Med. |volume=330 |issue=20 |pages=1411–7 |year=1994 |month=May |pmid=8159194 |doi= |url=}}</ref> | |||
*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)<ref name="pmid21444888">{{cite journal| author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE et al.| title=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. | journal=Circulation | year= 2011 | volume= 123 | issue= 18 | pages= e426-579 | pmid=21444888 | doi=10.1161/CIR.0b013e318212bb8b | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21444888 }} </ref>== | |||
===Cardiovascular <nowiki>“</nowiki>Syndrome X<nowiki>”</nowiki> (DO NOT EDIT)<ref name="pmid21444888">{{cite journal| author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE et al.| title=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. | journal=Circulation | year= 2011 | volume= 123 | issue= 18 | pages= e426-579 | pmid=21444888 | doi=10.1161/CIR.0b013e318212bb8b | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21444888 }} </ref>=== | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Medical therapy with [[nitrate]]s, [[beta blocker]]s, and [[calcium channel blocker]]s, alone or in combination is recommended in patients with cardiovascular [[syndrome X]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Risk factor reduction is recommended in patients with cardiovascular [[syndrome X]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|} | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] | |||
|- | |||
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Medical therapy with [[nitrate]]s, [[beta blocker]]s, and [[calcium channel blocker]]s for patients with non cardiac [[chest pain]] is not recommended. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|} | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | |||
|- | |||
= | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Intracoronary ultrasound]] to assess the extent of [[atherosclerosis]] and rule out missed obstructive lesions may be considered in patients with [[syndrome X]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' If no [[ECG]]s 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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|- | |||
= | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' [[Imipramine]] or [[aminophylline]] may be considered in patients with [[syndrome X]] for continued pain despite implementation of Class I measures. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|} | |||
==References== | ==References== | ||
{{ | {{Reflist|2}} | ||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
[[Category:Ischemic heart diseases]] | |||
[[Category:Intensive care medicine]] | |||
[[Category:Disease]] | |||
[[Category:Cardiology]] | |||
[[Category:Emergency medicine]] | |||
[[Category:Mature chapter]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Up-To-Date cardiology]] | |||
[[Category:Best pages]] |
Latest revision as of 00:33, 30 July 2020
Resident Survival Guide |
Unstable angina / NSTEMI Microchapters |
Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders |
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Antitplatelet Therapy |
Additional Management Considerations for Antiplatelet and Anticoagulant Therapy |
Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS |
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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:
- This can be confirmed by provocative coronary angiographic testing with acetylcholine for coronary endothelium-dependent function and adenosine for non-endothelium-dependent microvascular function.
- Other non-cardiac causes of chest pain such as esophageal dysmotility, fibromyalgia, and costochondritis should be ruled out.
Treatment
- It is recommended that patients be reassured of the excellent intermediate-term prognosis and treated with long-acting nitrates.
- If the patient continues to have episodes of chest pain, a calcium channel blocker or beta blocker can be started.
- 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
- ↑ 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) - ↑ 2.0 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.