Cardiac syndrome X

Cardiac syndrome X


Cardiac syndrome X (CSX) is defined by anginal chest discomfort, either conventional or atypical, without any indication of substantial coronary vascular abnormalities shown on angiography. It is thought to be a form of ischemic heart disease, with perimenopausal and postmenopausal women being the most common victims. It’s essential to get this ailment diagnosed and treated if you want to prevent its significant morbidity and consequences. The interprofessional team’s role in diagnosing and treating people with this condition is highlighted in this exercise, which also examines the evaluation and treatment of CSX.


Different mechanisms and ideas of the illness have been documented, even though the etiology and pathogenesis of CSX or microvascular angina are not fully known. Microvascular dysfunction of the coronary arteries, which restricts blood flow, is one of the leading causes of ischemia or typical or atypical angina. Hyperalgesia, or heightened heart pain sensitivity, is another frequently proposed explanation. It is considered in patients with classic anginal chest pain and microvascular malfunction of the coronary arteries following exercises but doesn’t show signs of myocardial ischemia.

Some individuals with CSX may also experience microvascular dysfunction and increased sensitivity to heart discomfort, while other CSX patients may have different underlying causes. Compared to the general population of (8%), those with CSX have a 30% higher likelihood of presenting with underlying metabolic comorbid disorders. The pathophysiology of CSX and coronary microvascular dysfunction may be influenced by several factors, including an increased sodium-hydrogen exchange in red blood cells (RBC), chronic inflammation with elevated C-reactive protein levels (CRP), and vascular or nonvascular smooth muscle dysfunction.


Although the actual prevalence of CSX is unknown, it is reported that women are more likely to have it (70%) than men. With a mean age of 48.5, it frequently affects perimenopausal or postmenopausal females between the ages of 45 and 55.

According to reports, CSX affects 10–20% of coronary angiography patients. In a significant study with 886 participants who had chest discomfort and were suspected of having a myocardial infarction, 41% of the female participants had non-significant results of the coronary vessels, which was much higher than the 8% of the male participants.

Causes of cardiac syndrome X

The reasons for cardiac syndrome X are yet unknown. However, they have been connected to;

  • Low amounts of the female hormone estrogen are crucial for preserving blood vessels.
  • A difficulty with how your body reacts to pain
  • A condition is known as microvascular angina (or small vessel disease) when the little blood vessels that supply your heart muscle with blood tighten or constrict.

Symptoms of cardiac syndrome X

Its symptoms resemble angina quite, and you could think you’re suffering a heart attack.

  • Your chest may feel heavy or tight.
  • Pain may radiate to your arms, neck, jaw, back, or stomach.
  • Nausea
  • Vomiting
  • Sweating
  • Dizziness
  • Shortness of breath
  • Issues with sleep
  • Fatigue
  • Not enough energy

How does cardiac syndrome X appear?

Numerous medical studies have put forth various methods as potential solutions to the problems of cardiac condition X. Any one of the following mechanisms, or potentially more than one, could be responsible for this disease.

Dysfunction of the endothelium:

It might occur as a result of microvascular angina. Numerous risk factors, including obesity, high blood cholesterol, and any inflammatory illness in the affected person, are connected to it. Low levels of HDL (high-density lipoprotein) in the blood will cause problems. Elevated blood levels of c- reactive protein will be a clinical sign. This amount of c- reactive protein is a reliable indicator of endothelial dysfunction.

  • Ischemia myocardial.
  • A resistance to insulin

Numerous investigations have demonstrated the tight relationship between hyperinsulinemia-related symptoms and cardiac syndrome X. The function of blood arteries is significantly improved by metformin. Surprisingly, it also benefits people without a diabetes diagnosis and those without a family history of the disease.

Erratic autonomic control:

Numerous investigations have established that patients experience aberrant pain perception. Even though these patients experience chest pain, their coronary angiography results were always expected.

Lack of estrogen:

According to research, women who receive estrogen replacement therapy significantly improve their health. The estrogen that has been replenished enhances blood vessels and heart health and lessens the incidence of heart problems like angina pectoris.

The essential points to be noted in cardiac syndrome X:

  1. History Taking:

No vital information can be gathered for patients with cardiac syndrome X. The patient’s age and gender are recorded to determine if she is a postmenopausal or perimenopausal female.

  1. An examination of the body:

The patients will exhibit classic anginal symptoms during the physical examination. The doctor must determine whether rest or Nitroglycerin sublingual delivery can relieve the symptoms; these patients’ coronary angiograms are standard, with no evidence of cardiac embolism, atherosclerosis, or inducible arterial spasm.

Diagnosis of cardiac syndrome X

According to cardiac syndrome X, cardiac valve illnesses like aortic or mitral valve stenosis could arise. Other disorders, including high blood pressure, digestive issues, or muscular pain, could also be present. The following laboratory tests are necessary for the diagnosis of the cardiac syndrome;

  • The electrocardiogram (ECG).
  • A heart stress test.
  • Radionuclide analysis.
  • Angiography of the heart.

More tests might be required to rule out any other illnesses that might produce the atypical symptoms.

Treatment of cardiac syndrome X

Lifestyle changes like diet, exercise, quitting smoking, and weight loss treats cardiac syndrome X (CSX). A heart-safe diet is also suggested.

Some treatment options include pharmacologic management using anti-ischemic drugs, analgesics for pain control, non-pharmacological management, and lifestyle changes. Beta-blockers, statin therapy, calcium channel blockers, ACE inhibitors, and anti-anginal drugs like ranolazine are a few examples of traditional anti-ischemic medications.

  • Sublingual nitrate therapy should be started for CSX and anginal chest discomfort patients. In patients with CSX, beta-blockers (propranolol, nebivolol, and carvedilol) have been reported to be 75% effective and enhance exercise tolerance and symptoms. Nebivolol and carvedilol, two more recent third-generation beta-blockers, are said to be possibly more effective than traditional beta-blockers and work by endothelial vasodilatory activity.
  • If a therapeutic response is not obtained with beta-blockers, calcium channel blockers (nifedipine, verapamil, and diltiazem) may be an alternate treatment. Calcium channel blockers are less successful than beta-blockers in treating CSX patients, even though they improve exercise tolerance and reduce angina attacks.
  • Ranolazine, a recent anti-anginal used in individuals with refractory angina and approved for chronic angina, has also been a beneficial treatment alternative. Potential neuropathic pain in CSX patients is managed by ranolazine’s ability to control neuronal voltage-gated sodium channels. According to the Seattle Angina Questionnaire, Ranolazine was helpful in females with anginal symptoms but no known evidence of coronary artery obstruction.
  • Statins improve the vasodilatory properties of the endothelium and may be helpful for CSX patients.
  • ACE inhibitors have been said to offer advantages. They prevent the breakdown of endothelium bradykinin, which has vasodilatory effects.

These effects may further control the microvascular tone of the coronary arteries.


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