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PubMed2000

Resolution of syndrome X after eradication of virulent CagA-positive Helicobacter pylori.

A 42-year-old man with chest pain was found to have ST depression in leads V1 through V4. The coronary arteries appeared normal on angiography. Positive results of ventricular pacing and acetylcholine test led to a diagnosis of syndrome X. Other studies revealed gastritis due to CagA-positive Helicobacter pylori. Classic therapy for angina did not resolve chest pain, but eradication of H. pylori led to disappearance of symptoms and negative test results.

Adult↗
PubMed1993

Spinal cord stimulation in angina pectoris with normal coronary arteriograms.

BACKGROUND: Patients with angina pectoris with normal coronary arteriograms, also known as Syndrome X (typical exercise-induced angina pectoris, positive exercise testing, and normal coronary arteriograms), are often difficult to treat with conventional forms of medical therapy. Spinal cord stimulation has been used in recent years for the treatment of severe angina pectoris refractory to conventional medical and surgical therapy in coronary artery disease. The aim of this study was to investigate the effects of spinal cord stimulation on angina pectoris with normal coronary arteriograms. METHODS: Twelve patients underwent five bicycle exercise tests, three tests without (control), and two tests with spinal cord stimulation treatment. RESULTS: The exercise tolerance of the patients increased (108 +/- 22 W versus 96 +/- 21 W; P < 0.001), the magnitude of ST-segment depression at comparable work load decreased (1.0 +/- 0.6 mm versus 1.5 +/- 0.9 mm; P < 0.01), time to angina increased (5.4 +/- 2.2 min versus 2.7 +/- 1.9 min; P < 0.01), and time to the appearance of ST-segment depression increased (3.5 +/- 1.9 min versus 2.4 +/- 1.6 min; P < 0.01). The rate-pressure product at maximum work load during treatment increased, compared with the maximum work load during the control session (28,038 +/- 6124 mmHg x bpm versus 25,222 +/- 4519 mmHg x bpm; P < 0.05) and the comparable work load during treatment (28,038 +/- th 6124 mmHg x bpm versus 24,795 +/- 5022 mmHg x bpm; P < 0.01). CONCLUSIONS: Spinal cord stimulation has beneficial effects in angina pectoris with normal coronary arteriograms in terms of relief of symptoms of angina pectoris and improvement of exercise tolerance. These effects may be associated with a reduction in myocardial ischemia.

Aged↗
PubMed1999

Comparison of trimetazidine with atenolol in patients with syndrome X: effects on diastolic function and exercise tolerance.

BACKGROUND: Trimetazidine has been shown to improve anginal symptoms without altering hemodynamic variables in patients with coronary artery disease. The aim of this study was to compare the effect of trimetazidine and atenolol upon symptoms, resting left ventricular filling dynamics and exercise tolerance. METHODS: Sixteen patients (3 males, 13 females, mean age 62 +/- 7 years) were randomized to receive trimetazidine for 2 weeks (20 mg 3 times daily) or atenolol (100 mg daily), according to a double-blind, randomized, cross-over, placebo-controlled design. At the end of each treatment period patients underwent symptom-limited exercise testing, an echocardiogram and a Doppler assessment of transmitral flow pattern. Daily life anginal symptoms were annotated on a diary throughout the study. Two patients discontinued trimetazidine because of severe palpitations and only 14 patients completed the study. RESULTS: Atenolol significantly reduced the number of anginal episodes as compared to placebo or trimetazidine (0.44 +/- 0.53, 4.8 +/- 4, 2.9 +/- 4.9, p < 0.01). On atenolol, the exercise test was negative in 8 patients, but none of the patients had a negative test while on trimetazidine. Atenolol increased both time to 1 mm ST segment depression (668 +/- 213 vs 838 +/- 81 s, p < 0.05) and Doppler-derived indices of ventricular filling (E/A ratio 0.87 +/- 0.20 vs 1.21 +/- 0.26, p < 0.05). CONCLUSIONS: These results confirm the beneficial effects of atenolol in improving symptoms, exercise performance and diastolic function in syndrome X patients. Trimetazidine did not exert any significant effect on any of the analyzed variables. Since trimetazidine has been previously shown to improve myocardial ischemia in patients with overt coronary artery disease to a similar extent of beta-blockers, it is likely that other mechanisms are responsible for angina in patients with syndrome X.

Adrenergic beta-Antagonists↗
PubMed2000

Cardiac syndrome X: an overview.

Not all patients with angina have myocardial ischemia. A sizable minority--up to 30% of angina patients studied at tertiary referral centers--have normal coronary angiograms. Such patients often undergo an expensive and extensive array of testing and treatment. Yet the prognosis is generally good, and symptomatic management may be effective.

Coronary Angiography↗
PubMed1996

Hyperventilation test in syndrome X.

The hyperventilation (HV) test has been extensively used in different forms of coronary artery disease. The purpose of this work was to investigate the response to HV in patients with syndrome X and compare HV with exercise (EX) test. The authors studied 20 patients with syndrome X (angina, a positive EX test, and normal coronary angiogram) and 20 healthy subjects who underwent HV and EX tests. In 7 patients, all women, angina and electrocardiographic (ECG) changes occurred during HV but in none of the controls. Patients with syndrome X and controls had a similar rate-pressure product (RPP) at rest and achieved a similar RPP with HV. The RPP achieved with HV in patients with syndrome X without ECG changes was significantly lower, 121.8 +/-29.1(mean +/-SD), than what was achieved by those with changes, 167.9 +/-42.9, P < 0.01. In patients with an abnormal response to HV the RPP at which angina and ECG changes occurred was similar to that where similar changes were observed during EX. There was a significant correlation of the RPPs between the two tests, r=0.82, P < 0.02. In contrast, in patients in whom no angina or ECG changes occurred, the RPP they achieved with HV was significantly lower than the anginal threshold during EX 204 +/- 47.4, P < 0.0001. In conclusion, a significant proportion of patients with syndrome X, mainly women, who achieve a high RPP with HV, develop angina and ECG changes during overbreathing. The close relation between EX and HV RPPs where these changes occur suggests an increased myocardial oxygen demand as the most likely underlying mechanism for this behavior.

Electrocardiography↗
PubMed1993

[A rare course of spastic angina with normal coronary arteries].

The authors report the case of a 65-year-old woman smoker monitored for spastic angina. A first coronary arteriogram in 1986 failed to reveal any significant coronary lesion and was complicated by reversible occlusive spasm of the anterior interventricular artery. A second coronary arteriogram 6 years later because of recurrence of angina revealed the development of 70% stenosis of the coronary segment affected by the spasm. Such an outcome is rarely reported in the literature and raise the question of a possible link between spasm and the progression of atheroma.

Aged↗
PubMed1996

Cardio-oesophageal reflex in humans as a mechanism for "linked angina'.

The aim of this study was to investigate the hypothesis that oesophageal acid stimulation reduces coronary blood flow in humans as a result of the presence of a cardio-oesophageal reflex which may provide a mechanism for "linked angina'. We studied the effect of oesophageal acid stimulation on coronary blood flow in 35 syndrome X patients and 24 heart transplant patients. A fine tube was positioned into the patient's distal oesophagus. An intracoronary Doppler catheter was positioned in the proximal left anterior descending coronary artery for coronary blood flow measurements. Oesophageal instillation of 0.1 M hydrochloric acid was performed (60 ml over 5 min) and the measurements were repeated. The coronary blood flow was significantly reduced by acid oesophageal stimulation in the syndrome X group [pre-acid 78.9 +/- 36.4 ml. min-1, post-acid 50.8 +/- 32.9 ml.min-1 (P = 0.0001)]. However, coronary blood flow in the heart transplant group, in whom the heart is denervated, was unaffected by acid infusion. We conclude that oesophageal acid stimulation can produce angina and significantly reduce coronary blood flow in humans. The lack of any significant effect in the heart transplant group, in whom the heart is denervated, suggests a neural reflex.

Adult↗
PubMed2003

Unappreciable myocardial bridge causing anterior myocardial infarction and postinfarction angina.

We report a case of anterior myocardial infarction in a middle-aged man without risk factors for atherosclerosis in whom myocardial bridge was diagnosed several years later. An abnormal wall motion during acute myocardial infarction masked the characteristic angiographic findings of myocardial bridge and rendered it unappreciable during the initial angiographic study.

Angioplasty, Balloon, Coronary↗
PubMed2001

Spinal cord stimulation in patients with refractory anginal pain and normal coronary arteries.

BACKGROUND: Spinal cord stimulation (SCS) has been shown to be effective in patients with refractory angina and coronary artery disease. No previous study assessed the clinical effects of SCS in patients with refractory angina who present angiographically normal coronary arteries. METHODS: SCS was performed in 7 patients (4 men, 3 women, mean age 59.3 +/- 11 years) with refractory angina and normal coronary arteries. Clinical status was assessed 1 month after SCS device implantation and at a mean follow-up of 11 months (range 2-17 months) by: 1) an estimate of the number of anginal attacks and nitrate consumption in the 2 weeks prior to implantation and to follow-up visits; 2) a score of quality of life by a visual analogic scale; 3) a five-item questionnaire assessing effort angina and satisfaction with treatment; 4) treadmill exercise testing. RESULTS: At the last follow-up the number of anginal episodes (p < 0.001) and nitrate consumption (p < 0.004) were both reduced by SCS. Visual analogic scale score improved from 2.1 +/- 0.98 to 9.0 +/- 0.9 (p < 0.001) at 1 month and to 6.4 +/- 2.3 (p < 0.01) at the last follow-up. Questionnaire analysis showed that mild (p = 0.006) and moderate (p = 0.000) physical activity, as well as patient satisfaction with anginal status (p = 0.000) and with current treatment (p = 0.000) all improved by SCS. Finally, time to 1 mm ST segment depression, time to angina, and exercise duration were all prolonged by SCS. CONCLUSIONS: Our data point out that SCS may considerably improve anginal symptoms and exercise tolerance in a significant number of patients with refractory angina and normal coronary arteries and therefore it should be considered as a valuable treatment option in this group of patients.

Electric Stimulation Therapy↗
PubMed1996

Failure to demonstrate myocardial ischaemia in patients with angina and normal coronary arteries. Evaluation by continuous coronary sinus pH monitoring and lactate metabolism.

BACKGROUND: Whether myocardial ischaemia is the mechanism underlying chest pain in patients with angina and normal coronary arteriograms is controversial. We sought to detect the presence of transient myocardial ischaemia using continuous monitoring of coronary sinus blood pH during atrial pacing. METHODS AND RESULTS: We studied 14 patients (eight women, six men, mean age 51 +/- 3 years) with typical exertional angina and normal coronary arteriograms and nine patients with coronary artery disease (two men, seven women, mean age 61 +/- 7 years). Of the 14 patients with normal coronary arteries, eight had a reduced coronary blood flow reserve (< 2.5-fold increase), 11 had an ischaemic-appearing response to exercise testing, six had reversible perfusion detects on exercise thallium scans and one had resting left bundle branch block. All patients underwent continuous pH monitoring of coronary sinus blood at rest and during incremental atrial pacing (up to 160 bpm). Coronary sinus oxygen saturation and myocardial lactate extraction ratio were also evaluated at rest and at peak pacing. Eleven patients with angina and normal coronary arteries and eight with coronary artery disease had angina during pacing. Both patients with angina and normal coronary arteries (n = 13) and patients with coronary artery disease (n = 9) showed a fall in coronary sinus pH (-0.02 +/- 0.02 vs -0.11 +/- 0.03 pH units, respectively, P < 0.01). Coronary sinus oxygen saturation expressed as a percentage dropped by 19 +/- 6% in patients with coronary artery disease and by 6 +/- 2% in patients with angina and normal coronary arteriograms (P < 0.05). Myocardial lactate extraction ratio decreased from 33 +/- 6% to -1.4 +/- 4% in patients with coronary artery disease and from 23 +/- 8% to 20 +/- 8% in those with angina and normal coronary arteriograms. Three patients with angina and normal coronary arteries had a drop in coronary sinus pH > 0.02 pH units (-0.043 +/- 0.006 pH units) and in coronary sinus oxygen saturation > 8% (16 +/- 3%) consistent with myocardial ischaemia. CONCLUSION: Despite severe chest pain and reduced coronary flow reserve after pacing, most patients with angina and normal coronary arteriograms do not show metabolic evidence of myocardial ischaemia.

Adult↗
PubMed2002

Treatment of medically uncontrolled coronary artery spasm in the normal coronary artery with coronary stenting.

We present a 53-year-old male with recurrent episodes of vasospastic angina and serious complications of coronary artery spasm including ventricular fibrillation and myocardial infarction, who was treated with coronary stenting at the site of ergonovine-induced coronary vasospasm where the coronary artery appeared angiographically normal, i.e., without evidence of atherosclerotic lesion.

Cardiovascular Agents↗
PubMed2000

Case 1. Cardiovascular dysfunction syndrome.

A 56-year-old woman is referred with angina. A number of sequential management strategies have been attempted with varying results. Upon examination of her case, it is clear that she has cardiovascular dysmetabolic syndrome and is thus at high risk for adverse cardiovascular events. Two opinions for further management are presented.

Antioxidants↗
PubMed2006

Cardiac syndrome X.

This article describes: 1) situations that can cause angina pectoris in the absence of formal atherosclerotic obstructive lesions: a) those that cause non-atherosclerotic coronary obstructions and b) those with normal coronary angiography, among them cardiac syndrome X (CSX); 2) the various definitions of CSX, particularly the definition of true CSX by Bertrand et al.: effort anginal pain plus positive exercise test, plus a second demonstration of myocardial ischemia (e.g. abnormal myocardial scintigraphy), plus normal coronary angiography; 3) the different pathogenic mechanisms that have been proposed for CSX, which suggest that the problem is mainly at the microvascular level; 4) the excellent survival prognosis of CSX; 5) the lack of any standard therapeutic protocol.

Humans↗
PubMed1993

Coronary flow reserve in patients with chest pain and normal coronary arteries.

BACKGROUND: Many studies have shown that coronary flow reserve is reduced in patients with chest pain and angiographically normal coronary arteries. The methods used to assess coronary blood flow have varied, but in nearly all reports dipyridamole has been used to bring about vasodilatation. This study was designed to assess whether the apparent impairment of coronary flow reserve seen with dipyridamole could be reproduced with either papaverine or adenosine, which induce maximum coronary blood flow by different mechanisms. METHODS: 25 patients with chest pain and angiographically normal coronary arteries were studied with an intracoronary Doppler flow probe and quantitative angiography to determine epicardial coronary artery area, coronary blood flow velocity, coronary flow reserve, and coronary vascular resistance index (CVRI, the ratio of resistance after intervention to basal resistance). All patients received papaverine 8 mg. Eight patients with positive exercise tests received intracoronary papaverine (8 and 10 mg), intracoronary adenosine (6, 20, 60 micrograms), and high-dose intravenous dipyridamole (0.84 mg/kg). RESULTS: The velocity ratio (peak after intervention: baseline) (mean (SEM)) after 8 mg papaverine was 3.3 (0.2) (n = 25) and the coronary flow reserve was 4.1 (0.3) (n = 25). There were no differences between patients with a positive (n = 16) or negative (n = 9) exercise test. In eight patients coronary flow reserve was measured after increasing doses of papaverine, adenosine, and dipyridamole. Coronary flow reserve was 4.5 (0.3) with papaverine, 4.8 (0.3) with adenosine, and 3.5 (0.4) with dipyridamole (p = 0.08 v papaverine and adenosine). CVRI was 0.22 (0.01) with papaverine, 0.21 (0.02) with adenosine, and 0.29 (0.03) with dipyridamole (p < 0.05 v papaverine, p = 0.09 v adenosine). CONCLUSIONS: These results indicate that measurement of coronary flow reserve and CVRI in patients with chest pain and normal coronary arteries depends on the pharmacological stimulus. Normal values were obtained with papaverine in all patients, irrespective of the exercise test response. In patients with a positive exercise test significantly lower values were obtained with dipyridamole than with papaverine, or adenosine. The reported impairment of coronary flow reserve in patients with angina and normal coronary arteries may reflect the variability in response to different pharmacological agents. The mechanism underlying this variability is unknown, but may involve an abnormality of adenosine metabolism in the myocardium.

Adenosine↗
PubMed2003

[Cardiovascular syndrome X and endothelial dysfunction].

Up to 30% of patients with chest pain who undergo coronary arteriography, have completely normal coronary angiograms. The subgroup with typical angina and a positive response to stress testing is generally included under the diagnosis of cardiovascular syndrome X. Several causes and mechanisms have been investigated in the past twenty years, to explain both chest pain and ischemic angina-like ST segment depression that are commonly observed in these patients. Clinical and pathogenic heterogeneity appears to be the main features of the syndrome. Among the suggested pathophysiological mechanisms, endothelial dysfunction of the coronary microcirculation features prominently. In this review, we present the available evidence regarding endothelial dysfunction in cardiovascular syndrome X.

Coronary Vessels↗
PubMed1996

Syndrome X: a discussion of angina and normal coronary arteries.

Syndrome X was diagnosed in a female patient who presented with typical angina and a non-Q wave myocardial infarction, yet demonstrated normal coronary arteries. Syndrome X has been described as an impairment in normal endothelial function of the coronary microvasculature, resulting in inappropriate vasoconstriction and inadequate coronary flow reserve. In this article we review pathophysiology, diagnosis, treatment, and prognosis in a single case.

Aged↗
PubMedDate not supplied

Gastric angina secondary to acute thrombosis of celiac artery.

We report a 48-year-old woman with foregut ischemia with splenic infarct due to isolated celiac artery obstruction. The patient presented with acute-onset pain in the epigastrium 10-15 min after every meal. Investigations revealed obstruction of the celiac artery by artheromatous plaque. This patient had an acute thrombosis, which responded to anticoagulation.

Acute Disease↗