Unstable angina / non ST elevation myocardial infarction cardiovascular syndrome x: Difference between revisions
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'''Associate Editor-In-Chief:''' Smita Kohli, M.D. | |||
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==Overview of Cardiovascular Syndrome X in UA / NSTEMI== | ==Overview of Cardiovascular Syndrome X in UA / NSTEMI== | ||
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. 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 endotheliumdependent 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 anginal-type chest discomfort, objective evidence of ischemia, and 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 noncardiaccauses of angina like chest pain,such as esophageal dysmotility, fibromyalgia, and costochondritis, should be ruled out. Intermediate-term prognosis is reported to be excellent. | |||
===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. Both 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. | |||
==ACC / AHA Guidelines (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=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/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>== | ==ACC / AHA Guidelines (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=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/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>== | ||
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Overview of Cardiovascular Syndrome X in UA / NSTEMI
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. 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 endotheliumdependent 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 anginal-type chest discomfort, objective evidence of ischemia, and 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 noncardiaccauses of angina like chest pain,such as esophageal dysmotility, fibromyalgia, and costochondritis, should be ruled out. Intermediate-term prognosis is reported to be excellent.
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. Both 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.
ACC / AHA Guidelines (DO NOT EDIT) [2]
| “ |
Class I1. 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 IIb1. 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) Class III1. Medical therapy with nitrates, beta blockers, and calcium channel blockers for patients with non cardiac chest pain is not recommended. (Level of Evidence: C) |
” |
See Also
Sources
- The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction [2]
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; et al. (2007). "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/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". JACC. 50 (7): e1–e157. PMID 17692738. Text "doi:10.1016/j.jacc.2007.02.013 " ignored (help); Unknown parameter
|month=ignored (help)