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Background: Cardiac syndrome X (CSX) is typical angina pectoris with objective signs of myocardial ischaemia despite a normal coronary angiogram and may be due to microvascular dysfunction. The incidence of CSX has not been greatly investigated worldwide and its incidence in Ireland is unknown., Aims: We aimed to determine the incidence of CSX in Cork University Hospital (CUH) and to establish the phenotype of the typical Irish CSX patient., Methods: All patients undergoing coronary angiography in CUH during regular working hours over a 3-month period were investigated. CSX was diagnosed using standard criteria. An extended recruitment period of 14 months allowed enrolment of a sufficient number of CSX patients to enable phenotyping., Results: Only 5 of 372 (1.3 %) patients undergoing angiography to investigate chest pain met the diagnostic criteria for CSX. None were given a discharge diagnosis of CSX or received cardiology follow-up. Irish CSX patients were predominantly female (88 %) with a mean age of 59.2 ± 6.6 years. Although they were significantly less functionally limited than patients with obstructive CAD, they had an equally substantial impairment in quality of life., Conclusions: CSX is relatively uncommon in Ireland and is most frequently seen in middle-aged women with hyperlipidaemia. It has significant impacts on patients' quality of life. None of the CSX patients were diagnosed as such, highlighting the lack of awareness or acceptance of this condition in Ireland. These patients require diagnosis and active cardiology follow-up to effectively manage their symptoms.

Gender differences play an important role in coronary heart disease (CHD). Not only in the presentation of symptoms, but also in their underlying pathophysiology. Women with persistent angina without obstructive coronary artery disease (CAD) pose a diagnostic and therapeutic challenge. Half of these women have microvascular coronary dysfunction (MCD). The 2013 guidelines on management of stable angina now acknowledge this condition, but our understanding of MCD is still limited. In this clinical case presentation we elaborate on contemporary methods of diagnosing and managing microvascular angina based on the cases of two women who attended our outpatient clinic. The availability of non-invasive tools to diagnose MCD is still limited. Current treatment is based on reduction of cardiovascular risk factors but physicians and patients should be aware that although therapy usually reduces symptoms, they do not completely disappear. More research on diagnostic methods and effective therapy for MCD is eagerly awaited.

It is clear that angina pectoris with normal coronary arteries is a heterogeneous and ill-defined syndrome that encompasses different pathogenic entities. Differences in patient selection and in definition of 'syndrome X' has made comparison between different study groups rather difficult. Two decades of investigations have not revealed a specific cause of this syndrome. There is now a general belief that syndrome X probably encompasses several pathophysiological disease entities and the mechanisms involved in syndrome X remain to be fully elucidated.

A follow-up over a 7-year period demonstrated that 8.6% of all patients subjected to coronary arteriography because of angina pectoris had normal coronary arteries (NCA). The somatic and social prognosis of these patients were evaluated and these were compared to that of an age- and sex-matched group of patients with arteriographically verified coronary atherosclerosis (CAD). On average 44 months after coronary arteriography, 2.4% with NCA had died versus 20.5% with CAD (P < 0.001). Myocardial infarction occurred in 0% (NCA) versus 12.8% (CAD) among survivors (P < 0.001). Coronary revascularization was carried out in 0% (NCA) versus 76.9% (CAD). Chest pain was unchanged or had worsened in 58.2% (NCA) versus 21.1% (CAD) (P < 0.001) and this in the NCA patients was correlated to the occurrence of minimal lesions of the coronary arteries. Of the NCA patients, 33.3% had ischaemia during exercise-ECG. Normalization was seen in 12 patients and newly developed ischaemia in seven patients. Three patients developed ischaemia during hyperventilation test. Eighty percent (NCA) versus 63.9% (CAD) gave up work due to chest pain (P < 0.001). Further, 55.7% (NCA) versus 34.6% (CAD) had reduced daily activities (P < 0.001); similarly, the frequency of divorce was higher in the NCA group (10.2%) than in the CAD group (1.3%) (P < 0.05).