1. health and fitness
2. disease

4/17/2015
Karen Sopko, M.D.
NMHI Non-Invasive Cardiologist
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Angiogram Review
Large vessel spasm
Missed lesions
Congenital Anomalies
Myocardial Bridges
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Missed lesions
Diffuse disease
Eccentric Plaques
Flush occlusions
Vessel foreshortening
aorto-ostial lesions
overlapping side branches
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Congenital Coronary Anomalies
Origin of circumflex arising from the right coronary artery or right sinus of Valsalva
Left coronary artery arising the the right sinus of Valsalva
RCA arising from the left sinus of Valsalva
Large coronary arteriovenous or cardiopulmonary fistulae
Myocardial Bridges
consist of segments of the LAD that course from their subepicardial
surface location into the myocardial tissue and then back out
transient systolic constriction occurs
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Aortic valvular disease
Other cardiac
causes of chest
Hypertrophic cardiomyopathy
pain
Dilated cardiomyopathy
Hypertension
Pericardial disease
Takatsubo Cardiomyopathy
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Non-cardiac causes of chest
pain
Gastrointestinal: reflux, esophageal spasm, esophagitis, hiatal hernia, gastritis
Musculoskeletal: costochondritis, fibromyalgia, shoulder, cervical/thoracic spine
referred pain
Cardiac Syndrome X
Angina Pectoris (typical chest pain)
positive exercise electrocardiogram for myocardial ischemia
angiographically smooth coronary arteries
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Cardiac Syndrome X
Approx. 20-30% of pts undergoing angiography for angina like chest pain have non
obstructive CAD
It is more common in women than men
occurs is perimenopausal and postmenopausal women
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Cardiac Syndrome X
no definitive conclusions regarding the exact pathogenesis of the condition
Patient population is heterogenous and therefore physiological explanation is
probably multifactorial.
Have a good cardiovascular prognosis
Women w/Syndrome X
Increased atherosclerotic burden at 10 yr f/u in women who displayed coronary
endothelial dysfunction
WISE study showed that these patients often have atherosclerosis on IVUS and face
a 2.5% annual rate adverse cardiac events.
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Theories
Impaired coronary flow reserve
Microvascular spasm
patchy prearteriolar vasoconstriction
disease of the small arteries
More Theories
pain due to excessive adenosine effect w/o ischemia
psychological disorders
hormonal deficiency
abnormal endothelial function
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Myocardial ischemia
Cannon et al. tested pts w/a vasoconstrictor, ergonovine during atrial pacing
pts w/CP during pacing showed significantly lower coronary venous flow, a higher coronary resistance and a higher LVEDP.
pts who had a abnormal vasodilator reserve showed reduced EF during exercise compared with pt’s with appropriate vasodilator reserve
Conclusion: result of abnormalities of the small coronary arteries or microcirculation.
Canon RO III. Bonow RO, Bacharach SL et al. Left ventricular dysfunction in patients with angina pectoris, normal epicardial coronary arteries, and abnormal vasodilator reserve. Circulation 1985; 71: 21826.
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Endothelial Function
Egashira et al. tested pts w/Syndrome X vs. pts w/ atypical CP and normal cors w/o ST segment depression. Compared response to intracoronary acetylcholine.
noted a marked reduction in response to acetylcholine in pts w/Syndrome X, suggesting impaired endothelium-dependent vasodilation
response was limited to the smaller coronary vessels and no difference found in larger coronary arteries
gashira K, Inou T, Hirooka Y, Yamada A, Urabe Y, Takeshira A. Evidence of impaired endothelium-dependent coronary vasodilation in patients with angina pectoris and normal coronary angiograms. N Engl J Med 1993; 328: 165964
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Pain perception
Turiel et al. found that patients with syndrome X had a
significantly lower threshold and tolerance for forearm ischemia
and electrical skin stimulation than pts w/confirmed CAD.
Turiel M, Galassi AR, Glazier JJ, Kaski JC, Maseri A. Pain threshold and tolerance in women with syndrome X and women with stable angina pectoris. Am J Cardiol 1987; 60: 5037.
Insulin Resistance
Dean et al. found that a glucose tolerance test provoked hyperinsulinemia in patients
w/Syndrome X, but not in normal controls.
any relationship between insulin resistance and Syndrome X may be incidental; just
related to the patient and having independent risk factors themselves.
Dean JD, Jones CJ, Hutchison SJ, Peters JR, Henderson AH. Hyperinsulinaemia and microvascular angina (syndrome X). Lancet 1991; 337: 45657.
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Menopause and Hormonal
Influence
most common in postmenopausal women
possible link between syndrome and estrogen
deficiency based on studies exploring impact of HRT:
found that 17B estradiol reduced CP frequency in
women w/Syndrome X.
need to carefully evaluate risk/benefit ratio of
starting HRT, given ovarian/breast CA risk and risk for
obstructive CAD.
Psychological Factors
women w/Syndrome X have higher levels of anxiety
and depression than CHD pts and healthy age-matched
women.
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Treatment
No definitive physiological cause, so no effective
treatment regimen
Anecdotal: nitrates, calcium channel blockers,
adenosine triphosphate-sensitive potassium channel
openers (nicorandil), theophylline, beta blockers.
Imipramine, benzodiazepines
Conclusions
20-30% of patients undergoing cardiac angiography will have
normal findings.
If patients continue to have TYPICAL chest pain despite normal
coronary arteries by angiography, will need reassessment by
Cardiology once non-cardiac reasons are ruled out.
Cardiac Syndrome X is still a condition with no clear cut
physiological explanation
May need multidisciplinary approach with Pain
specialist/Anesthesia and Psychiatrist.
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