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(Circulation. 2004;109:568-572.)
© 2004 American Heart Association, Inc.

Clinician Update

Pathophysiology and Management of Patients With Chest Pain and Normal Coronary Arteriograms (Cardiac Syndrome X)

Juan Carlos Kaski, MD, DSc

From the Coronary Artery Disease Research Unit, Cardiological Sciences, St George’s Hospital Medical School, London, UK.

Correspondence to Prof J.C. Kaski, Head, Cardiological Sciences, Director, Coronary Artery Disease Research Unit, Department of Cardiovascular Medicine, St George’s Hospital Medical School, Cranmer Terrace, London SW17 0RE, United Kingdom. E-mail jkaski@sghms.ac.uk

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 
Patients with cardiac syndrome X (CSX)—typical chest pain and electrocardiographic changes suggestive of myocardial ischemia despite normal coronary arteriograms–represent a diagnostic and therapeutic riddle. CSX is not associated with an increased mortality or an increased risk of cardiovascular events, but it often severely impairs quality of life and represents a substantial cost burden to the healthcare system. This syndrome of chest pain with normal coronary arteries encompasses a variety of pathogenic subgroups and is predominantly seen in postmenopausal women. Lack of understanding of the syndrome by the cardiovascular physician not infrequently results in discounting the clinical problem. Treatment remains elusive, but management strategies can improve the patient’s quality of life and reduce the financial burden imposed on health services.

Case Report:
A 55-year-old white female pharmacist underwent diagnostic coronary arteriography for the assessment of typical exertional chest pain, which had started 18 months previously and had gradually become more frequent and severe despite treatment with oral and sublingual nitrates and atenolol (50 mg daily). Central chest pain and dyspnea occurred at rest and with emotional stress and responded rather poorly to sublingual nitrate administration. ECG exercise stress test was positive (Figure 1), and transient perfusion defects were found on thallium-201 dipyridamole testing (Figure 2). She had long-lasting excruciating chest pain after dipyridamole infusion. Risk factors included a family history of coronary artery disease, a low-density lipoprotein-cholesterol level of 4.2 mmol/L, a high-density lipoprotein-cholesterol level 0.9 mmol/L, menopausal status, a previous history of smoking, body-mass index of 28 kg/m². . . [Full Text of this Article]

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