Search

Cardiac syndrome X (CSX), defined as typical exertional chest pain, a positive response to stress testing, and normal coronary arteriograms, encompasses different pathogenic subgroups. Both cardiac and non-cardiac mechanisms have been suggested to play a pathogenic role, and it has been shown that the syndrome is associated with myocardial ischaemia in at least a proportion of patients. Radionuclide myocardial perfusion defects, coronary sinus oxygen saturation abnormalities and pH changes, myocardial lactate production and stress-induced alterations of cardiac high energy phosphate have been reported in CSX patients, suggesting an ischaemic origin for their symptoms. Microvascular abnormalities often caused by endothelial dysfunction appear to be responsible for myocardial ischaemia in these patients. CSX is more prevalent in women than in men, and the majority of women with CSX are peri- or post-menopausal. Thus oestrogen deficiency has been suggested to have a pathogenic role in CSX. Additional factors such as abnormal pain perception may also contribute to the genesis of chest pain in patients with angina and normal coronary angiograms. The management of this syndrome is difficult because of the heterogeneity of pathogenic mechanisms and uncertainties as to its origin. This article discusses the problem of CSX in women, the potential pathogenic role of oestrogen deficiency, and practical clinical management.

Myocardial infarction occurring in young people with angiographically normal coronary arteries is well described but the pathophysiology of this condition remains unknown. Coronary artery spasm in association with thrombus formation and minimal atheromatous disease or spontaneous coronary artery dissection are possible causes. Two young men presented with severe chest pain after acute alcohol intoxication and each sustained an extensive anterior myocardial infarction. Investigations including intravascular ultrasound showed no evidence of atherosclerotic coronary artery disease. Coronary artery spasm associated with acute alcohol intoxication as well as prothrombotic state and endothelial damage related to cigarette smoking may be mechanisms leading to acute myocardial infarction in these cases. Acute myocardial infarction occurs in young persons with normal coronary arteries and the diagnosis should be considered in young patients presenting with severe chest pain, particularly those abusing cocaine or alcohol, so that reperfusion therapy can be initiated promptly.