Cardiac Syndrome X – Update 2014

Cardiac Syndrome X (CSX), a condition characterized by angina-like chest discomfort, ST segment depression during exercise, and normal coronary epicardial arteries at angiography, has the highest prevalence in post-menopausal women. Historically CSX was considered to be a benign condition but recent reports have shown that individuals with CSX have a higher prevalence of adverse cardiovascular events compared to control subjects and a poor quality of life. Diagnosis of CSX is often difficult and expensive because the diagnosis is primarily one of exclusion. Furthermore, treatment of CSX is challenging because the underlying pathogenesis of the condition is not well understood. The two most popular theories of pathogenesis are coronary microvascular dysfunction, in which symptoms are thought to result from myocardial ischemia secondary to abnormal coronary microvasculature function, and abnormal cardiac pain sensitivity, in which symptoms are thought to be a result of myocardial hypersensitivity and exaggerated pain perception. Treatment options include traditional anti-ischemic medications such as nitrates, beta-blockers, and calcium channel antagonists. Furthermore, other anti-ischemic medications such as ranolazine, angiotensin-converting enzyme inhibitors, and statins can be used. Analgesic medications such as xanthine derivatives and tricyclic antidepressants have also shown efficacy. Non-pharmacological treatments include cognitive behavioral therapy, enhanced external counterpulsation, neurostimulation, stellate ganglionectomy, and lifestyle modifications. Studies have shown the efficacy of individual treatments but guidelines outlining the best course of therapy are lacking.