You can have angina without blockages

Sunday 19th July 2009: Angina with no blockages in the heart is called cardiac syndrome X. It is different from angina pectoris due to typical blockages in the heart arteries. It has three characteristic features, angina or angina-like chest pain on exercise; ST segment depression on ECG on treadmill exercise testing and normal coronary angiography, said Dr KK Aggarwal President Heart Care Foundation of India and Director IMAAKN Sinha Institute.  He was conducting a workshop for doctors at Moolchand Hospital here today.
Cardiac syndrome X should not be confused with the metabolic syndrome, which is also called syndrome X but refers to the constellation of insulin resistance, obesity, hypertension, diabetes, and dyslipidemia.
Cardiac syndrome X is suspected in patients with suspected stable ischemic chest pain. There are two other settings in which angina occurs with normal or near-normal coronary arteries (less than 50% stenosis) , which are not considered part of cardiac syndrome X. First, a minority of patients (9-14 percent) with an acute coronary syndrome have normal or near-normal coronary arteries. Second, some patients present with stress-induced heart enlargement.

Among patients with chest pain who are referred for coronary angiography, 15 to 20 percent have normal vessels or no vessel with ¡Ý50 percent stenosis.

There is a strong preponderance of women in patients with cardiac syndrome X, many of whom are peri-menopausal or postmenopausal. Patients are typically younger than those with angina due to coronary disease (mean age 50). The pain may be precipitated by effort, but also occurs at rest. The duration of anginal-type chest pain is often prolonged. The average duration of chest pain is more than 10 minutes in 53 percent, and more than 30 minutes in 35 percent. Many patients do not respond to sublingual nitrates.


 The possibility of cardiac syndrome X should be considered when a patient (often a postmenopausal or perimenopausal woman) describes effort-related anginal pain that lasts 10 minutes or longer after cessation of activity and that responds inconsistently to sublingual nitrates.

Patients with cardiac syndrome X with stable angina have a generally excellent prognosis, while those with acute coronary syndromes have an appreciable acute mortality although lower than that in patients with angiographic coronary disease.

There are no "set rules" for the treatment of cardiac syndrome X, and therapy should be tailored to the individual patient. Among patients with stable angina, one should start initial therapy with sublingual nitrates as needed, risk factor reduction, and reassurance of the patient regarding his or her condition. If this is ineffective, the administration of a beta blocker is often beneficial. A physical training program may improve exercise capacity and reduce the frequency of chest pain episodes.