Makindo Medical Notes

💡 About Syndrome X (Cardiology)

• A recognised cause of angina-like chest pain despite normal coronary arteries on angiography.
• Also called Cardiac Syndrome X or Microvascular Angina.
• Prognosis is usually very good 👍, with low risk of major adverse cardiac events, though symptoms may persist.

⚙️ Aetiology & Pathophysiology

• Thought to involve microvascular dysfunction – impaired dilation of small coronary arterioles reduces myocardial perfusion.
• More common in middle-aged, postmenopausal females.
• May be influenced by oestrogen deficiency, endothelial dysfunction, autonomic imbalance.

🩺 Clinical Features

• Recurrent angina-like chest pain, often exertional but may also occur at rest.
• Pain may last longer than in typical angina and be less responsive to nitrates.
• Symptoms can impact quality of life but do not usually indicate high mortality risk.

🔍 Differentials

• Classic ischaemic heart disease (IHD) due to atherosclerosis.
• Oesophageal spasm, anxiety/panic disorders, musculoskeletal chest pain.

🧪 Investigations

• ECG (exercise stress test): ST depression may be seen.
• Troponin: Normal (no myocardial necrosis).
• Echocardiogram: Usually normal.
• Coronary angiography: Normal large epicardial arteries.
• Stress Echo / Myocardial perfusion imaging (Thallium): Often normal or inconclusive.

💊 Management

• ⚕️ Conventional anti-anginals (beta-blockers, calcium channel blockers, nitrates) – may help some patients.
• 💊 Newer agents: nicorandil, ivabradine, ranolazine can be useful for resistant symptoms.
• 👩‍🦱 Hormone Replacement Therapy (HRT) – may improve symptoms in postmenopausal women, especially if associated with vasomotor symptoms (e.g. hot flushes).
• 🧠 Pain modulation therapy: low-dose imipramine (tricyclic antidepressant) reduces central pain perception.
• 🌀 Cognitive Behavioural Therapy (CBT) & Hypnotherapy: can help reframe pain perception and reduce symptom burden.
• 🏃 Lifestyle optimisation: exercise, weight control, smoking cessation, stress management all improve vascular function.

📚 References

• Camm AJ, Lüscher TF, Serruys PW. ESC Textbook of Cardiovascular Medicine.
• Kaski JC. Cardiac syndrome X in women: the role of oestrogen deficiency. Heart 2006.
• European Society of Cardiology Guidelines

✨ Teaching Pearl: Cardiac Syndrome X reminds us that “normal coronary angiography does not always equal a benign diagnosis.” Microvascular dysfunction is increasingly recognised in women and requires a holistic, symptom-focused approach.