Long-term follow-up in patients with positive exercise test and angiographically normal coronary arteries (syndrome X)

doi:10.1016/S0002-9149(99)80630-4

The American Journal of Cardiology

Volume 75, Issue 8, 15 March 1995, Pages 620-621

https://doi.org/10.1016/S0002-9149(99)80630-4 Get rights and content

Abstract

Our results confirm that patients with carefully diagnosed syndrome X have a good prognosis. We observed no major coronary event or signs and symptoms of impaired cardiac function in any patient. However, in about one third of patients, despite medical treatment, there is residual morbidity with relevant medical and social consequences.

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Cited by (31)

Angina pectoris in women: Focus on microvascular disease
2013, International Journal of Cardiology
Citation Excerpt :
The common belief that women suffering of angina in the absence of significant coronary artery stenosis are characterized by good prognosis may not always hold true. Earlier studies reported very few cardiac events in these patients [23,50,51]. However, more recently it has been shown that prognosis in such patients may be less benign.
Ischemic heart disease (IHD) is the leading cause of death among women in Western countries, and it is associated with higher morbidity and mortality than in men. Nevertheless, IHD in women remains underdiagnosed and undertreated, and the misperception that females are “protected” against cardiovascular disease leads to underestimation of their cardiovascular risk; instead, women with chest pain have a high risk of cardiovascular events. Women suffering from angina pectoris tend to have different characteristics compared to men, with a high prevalence of non-significant coronary artery disease. Angina in women is more commonly microvascular in origin than in men, and therefore standard diagnostic algorithms may be suboptimal for women. This different pathophysiology impacts clinical management of IHD in women. While response to medical therapy may differ in women, they are scarcely represented in clinical trials. Therefore, solid data in terms of gender efficacy of antianginal drugs are lacking, and particularly when angina is microvascular in origin women often continue to be symptomatic despite maximal therapy with classical antianginal drugs. Recently, new molecules have shown promising results in women.
In conclusion, women with angina are a group of patients in whom it seems appropriate to concentrate efforts aimed at reducing morbidity and improving quality of life.
Long-term prognosis of patients with cardiac syndrome X
2010, International Journal of Cardiology
Citation Excerpt :
Yet, as patients undergoing repeat coronary angiography were those with the highest probability of some evolution towards obstructive CAD, due to recurrence or worsening of symptoms, it is unlikely that a higher prevalence of CAD lesions might have been found in the whole population. While clinical prognosis was excellent, a significant number of our CSX patients continued to present angina symptoms at follow-up, which is also in agreement with previous studies [1–4]. Chest pain episodes remained unchanged in one third of patients and worsened significantly in 14% of them, despite multiple drug therapy.
Previous follow-up studies of patients with cardiac syndrome X (CSX) reported good prognosis. However, some recent reports challenged this finding by showing appreciable mortality rates in patients with angina and normal coronary arteries admitted for acute coronary syndromes.
We performed clinical follow-up of 155 patients (mean age 58.9 ± 10 years, 40 men) with typical CSX. The occurrence of major cardiac events (cardiac death, acute myocardial infarction), readmission for chest pain, revascularization procedures, angina status, and non cardiac events during follow-up were collected for each patient.
At a mean follow-up time of 137 ± 78 months (range 24–372) from the onset of symptoms, 4 patients died, 3 for cancers and 1 for acute pancreatitis. No patient died from cardiovascular causes or had any major cardiovascular event. Hospital readmission for recurrent chest pain was reported by 89 patients (58%), and 33 (22%) underwent at least one more coronary angiography. During follow-up, chest pain had remained unchanged in 33% of patients and had worsened in 14% of patients.
Our data show that patients with CSX have excellent long-term clinical prognosis. A significant number of patients, however, shows persistence or worsening of symptoms, as well as further recurrence to medical evaluation.
Cardiac Syndrome X and Endothelial Dysfunction: New Concepts in Prognosis and Treatment
2006, American Journal of Medicine
Cardiac syndrome X (CSX), or angina with no flow-limiting stenosis on coronary angiogram, has been regarded as a condition with an excellent prognosis despite variable symptomatic improvement. Newer data show that patients with CSX with endothelial dysfunction have an increased risk for future adverse cardiac events. Current hypotheses of CSX pathophysiology emphasize a dysfunctional vascular endothelium that leads to microvascular ischemia. Treatments that target improving endothelial function, such as statins, angiotensin-converting enzyme inhibitors, estrogen, and lifestyle modification, are promising additions to treatment regimens for CSX. The goal of this article is to provide information for improved diagnosis, risk stratification, and therapy for the population with CSX.
Approach to the patient with chest pain and nonobstructive coronary artery disease
2004, Progress in Cardiovascular Diseases
Differential coronary calcification on electron-beam CT between syndrome X and coronary artery disease in patients with chronic stable angina pectoris
2001, Chest
Citation Excerpt :
Syndrome X comprises a heterogeneous group of patients with clinical presentation of anginal chest pain, ischemia-like ECG findings, and normal coronary angiographic results. It is generally considered to be a relatively benign clinical entity associated with a good prognosis, and only limited treatment is necessary.2526 However, patients with angiographic evidence of CAD require aggressive lifestyle modifications, appropriate and adequate medical therapy, and even revascularization procedures if indicated.
The differential diagnosis of syndrome X and coronary artery disease (CAD) in patients with evidence of myocardial ischemia may be difficult. The possible difference in coronary calcium detected by electron-beam CT (EBCT) between syndrome X and CAD is rarely evaluated, especially in aged patients with chronic, stable angina.
Prospective, controlled study at a tertiary referral medical center.
Forty patients with syndrome X (85% male) and 53 patients with CAD (89% male) were enrolled. Ten control subjects (90% male) with negative exercise treadmill test results and normal coronary angiographic findings served as control subjects. EBCT determined the coronary calcium scores (CCSs), and standard cardiovascular risk factors of all study subjects were analyzed.
The 93 study patients had CCSs that ranged from 0 to 1,857. Coronary calcification was seen in 2 of the 10 control subjects (20%), 21 of the 40 syndrome X patients (52.5%), and 51 of the 53 CAD patients (96.2%) [p < 0.01]. The CCS (median [range]) was significantly lower in syndrome X patients than in CAD patients: 1 (0 to 117) vs 202 (0 to 1,857)[p < 0.001]. Receiver operating characteristic curve analyses also demonstrated that coronary calcification differentiated syndrome X from CAD (area under curve, 0.891; 95% confidence interval, 0.806 to 0.947). Of the CAD patients whose CCSs were < 117 and overlapped with CCSs of syndrome X, multivariate analyses determined CCS > 5 (odds ratio, 13.1; 95% confidence interval, 2.86 to 59.7), hypertension (odds ratio, 6.4; 95% confidence interval, 1.5 to 27.4), and hypercholesterolemia (odds ratio, 6.7; 95% confidence interval, 1.5 to 30.5) to be independent discriminators to differentiate CAD from syndrome X. Patients with CAD had more frequent hypertension than patients with syndrome X.
The coronary calcium detected noninvasively by EBCT was different, though with some overlapping, between patients with syndrome X and CAD. In addition to standard cardiovascular risk factors, CCS determined by EBCT (especially > 117 or = 0) could differentiate between syndrome X and CAD in patients with chronic, stable angina with evidence of myocardial ischemia. Larger trials would be useful to validate CCS on EBCT as a predictor of clinical outcome in these patients.
Three-year follow-up of the Japanese patients with microvascular angina attributable to coronary microvascular spasm
2001, International Journal of Cardiology
Background: We recently reported that coronary microvascular spasm could cause angina in patients with chest pain and normal coronary arteriograms. However, the long-term prognosis of these patients or the effect of calcium channel blockers is not known. Methods: Of consecutive 283 patients who underwent acetylcholine testing for the evaluation of chest pain, we identified 68 patients with microvascular angina attributable to coronary microvascular spasm. All patients were discharged on calcium channel blockers and followed up for an average period of 3.3 years. Results: As compared with those having epicardial spasm (n=169), there was a female predominance in the microvascular spasm group (P<0.01), and 81% of the female patients were postmenopausal. During the follow-up, no patient died and one patient (1%) developed non-Q wave myocardial infarction. The frequency of chest pain was unchanged or increased in 24 patients (36%) and decreased or disappeared in 42 patients (64%). The angina status was improved only in 16 of 33 patients treated with calcium channel blockers alone. By contrast, it was improved in 18 of 21 patients on the combination of calcium channel blockers and angiotensin converting enzyme inhibitors (P<0.05). Conclusions: Patients with microvascular angina in the present study were more women and had a different risk factor profile as compared with those having epicardial spasm. Long-term prognosis was excellent with regard to mortality, but angina persisted in many patients even on calcium channel blockers. The result warrants prospective studies to evaluate the efficacy of angiotensin converting enzyme inhibitors as adjunct to calcium channel blockers in this population.

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¹: Dr. Radice's current address is: Via Muratori 29, 20100, Milano, Italy.

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Brief reportLong-term follow-up in patients with positive exercise test and angiographically normal coronary arteries (syndrome X)

Abstract

J Am Coll Cardiol

Lancet

Am J Cardiol

Brief report
Long-term follow-up in patients with positive exercise test and angiographically normal coronary arteries (syndrome X)