Cardiac syndrome X is a historic term for microvascular angina, angina with signs associated with decreased blood flow to heart tissue but with normal coronary arteries. The use of the term CSX can lead to the lack of appreciation of how microvascular angina is a debilitating heart related pain condition with the increased risk of heart attack and other heart problems. Many mainly women can have difficulty accessing the specialist care of a cardiologist for this reason. Some studies have found increased risk of other vasospastic disorders in cardiac microvascular angina parients, such as migraine and Raynaud's phenomenon. It is treated with beta-blockers, such as metoprolol however beta blockers can make coronary spasms worse. This is a distinct diagnosis from Prinzmetal's angina.
Signs and symptoms
While there is no formal definition of microvascular angina, the general consensus is that it entails all of the following:
Angina: This usually does not cause dysfunction on echocardiogram and can last longer than that of heart disease.
Abnormal cardiac stress test: ST changes are typically similar to those of coronary artery disease, and the opposite of those of Prinzmetal's angina. Myocardial perfusion imaging can be abnormal in 30% of patients.
Coronary angiogram: Normal
Other causes of chest pain must be ruled out, including:
There is no specific known cause for microvascular angina but rather a multitude of risk factors that act together. It is believed that the lack of blood flow caused by a microvascular disease and enhanced pain perception are two of the factors that may cause it. The microvascular dysfunctions refer to the abnormalities in the very small blood vessels of the heart. The narrowing of these vessels may lead to lack of oxygen in specific areas of the cardiac muscle causing chest pain. Several studies have shown that patients living with microvascular angina may have an enhanced pain perception, and usually feel more intense chest pain than individuals without microvascular angina. The risk factors include abdominal obesity, meaning excessive fat tissue in and around the abdomen, atherogenic dyslipidemia which is a blood fat disorder, and elevated blood pressure. Other risk factors are insulin resistance or intolerance to glucose, prothrombotic state or proinflammatory state. Older people are more at risk to develop this condition, and there is some evidence that suggests that there are genetic mutations that predispose to the syndrome. Women are more prone to this condition than men, as well as those who have a history of heart disease in the family.
Pathophysiology
In a large percentage of patients, there is a finding of systemic microvascular abnormalities, causing reduced blood flow in the microvasculature of the cardiac muscles. When the blood vessels constrict and fail to dilate there is decreased oxygen levels to the cardiac muscles resulting in hypoxia which lead to chest pain. While numerous physiological mechanisms have been proposed, none have been proven.
Diagnosis
Microvascular angina is a diagnosis of exclusion. Typically this will necessitate both a clinical diagnosis, appropriate stress testing, and a coronary angiogram that meet the above criteria. Cardiac MRI can be used to diagnose microvascular angina. Studies are ongoing to validate this approach. There is growing evidence that microvascular angina is caused by a functional disorder of the microvessels, coronary microvascular dysfunction. Blood vessels either fail to dilate or constrict in response to various stressors such as exercise, the cold or emotional stress. An angiogram with acetylcholine can demonstrate microvascular dysfunction which can affect the microvessels and larger coronary arteries leading to either microvascular angina or coronary artery spasms. These are considered discrete conditions though some individuals can be effected by both. Microvascular angina can be diagnosed using different tests and exams, but it is mainly a diagnosis of exclusion. However, sedentary and overweight individuals with a family history of type 2 diabetes should be tested regularly to determine whether they have irregular levels of glucose or lipids, or blood pressure abnormalities, factors which are usually associated with microvascular angina. A first test to be taken is an exercise stress test which shows if the heart is not getting blood during exertion. Angiograms may be useful and conclusive when microvascular angina they offer a detailed image of the heart. However, they cannot detect potential abnormalities in the small arteries, and the doctor may ask for more tests in order to rule out other heart conditions, such as Prinzmetal's angina which has similar symptoms.
Differential diagnosis
Chest pain caused by microvascular angina is most of the time unpredictable and it can occur when at rest and/or during exercise. The pain associated with microvascular angina is normally more intense and it lasts for longer periods of time compared to pain caused by other conditions. For example, a stable angina causes chest pain that goes away when at rest. Another difference is that while chest pain caused by any type of stable angina is relieved with nitroglycerin, this drug is not effective in most patients with microvascular angina.
Treatment
calcium channel blockers - specifically nifedipine and diltiazem can be effective.
beta blockers - also work. Can make coronary spasms worse
L-Arginine - increases release of NO at vascular level, thus leading to vasodilatory effect
Ranolazine - shown to improve angina and myocardial ischemia
Statins
Aspirin
Clopidogrel
ACE inhibitors and ARBs
Lifestyle changes such as diet and exercise.
Pain Management through CBT, Mindfulness meditation, yoga and Tai Chi.
Microvascular angina is an chronic long term condition which increases the risk of heart attack and other cardiac events such as heart failure and frequent hospital admissions. The treatment consists of drugs, mainly to relieve chest pain, but a very important part of the treatment is regularly visiting the doctor and repeating the tests to make sure the condition was taken care of in full. The first step in managing Microvascular angina is the administration of nitrates which may relieve the chest pain. They are used because of their ability to relax the muscles of the heart and blood vessels. However, they prove to be inefficient in as many as half of patients. Alternative treatments may consist of calcium channel blockers or beta blockers which reduce chest pain by relaxing the muscle cells lining the artery and improving blood flow to the heart while lowering blood pressure. Aminophylline may also work, while estrogen can be effective in women. There is at present no known cure however a change in lifestyle is important. Patients should start following healthier diets which are low in saturated fats, and should participate in regular physical activities. However, any patient with a heart disease condition should first seek for a medical opinion before starting exercising. Quitting smoking is also highly recommended.
Incidence
The reasons why women are more prone than men to develop a Microvascular angina are still not clear. However, it is believed that hormones along with other risk factors unique to women play a very important role. The constant changing of the estrogen levels may be one of the reasons along with the changes brought by birth.
