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Cardiac Syndrome X

When it comes to cardiac health, one of the most mysterious illnesses is cardiac syndrome X. This disease causes a great deal of suffering to those who are diagnosed with it. And yet, it has relatively little effect on their lifespan. Although there’s much that has been discovered about cardiac syndrome X, there’s still a lot that needs to be learned to bring greater relief to patients.

For those who suffer from syndrome X, it can be a source of constant frustration. They know that something isn’t right, and yet many display a clean bill of health. Test results show no abnormality in the function of the heart.

But by understanding the symptoms and treatments, we can develop a clear and effective approach to its diagnosis and prevention.

What is Cardiac Syndrome X?

Cardiac syndrome X is comprised of chest pain with signs of decreased blood flow to the heart. In testing, the coronary arteries show no signs of abnormalities. The syndrome is also referred to as microvascular angina in cases of dysfunction of the smaller blood vessels.

Although there are still no formal defining criteria for cardiac syndrome X, it generally manifests as chest pain, an abnormal cardiac stress test, and the exclusion of the presence of similar sources of chest pain including Prinzmetal’s angina and spasm of the esophagus. In about 30% of cases, abnormal myocardial perfusion imaging test results can be present.

What are the Symptoms of Cardiac Syndrome X?

The primary symptoms of syndrome X include pain that lasts longer when compared to that experienced in other conditions. In addition, nitroglycerin has been shown to be ineffective in cases of syndrome X, whereas it generally provides relief in other cases of chest pain.

What are the Causes of Cardiac Syndrome X?

Syndrome X consists of multiple combined risk factors as opposed to a specific known cause. Some have proposed the idea that individuals with syndrome X have greater pain perception than those without it.

The abnormalities that can occur in the very small blood vessels of the heart lead to a decrease in oxygen to the tissues. This leads to the chest pain that many experience.

Some potential risk factors include the following:
  • High blood pressure
  • Atherogenic dyslipidemia
  • Insulin resistance
  • Glucose intolerance
  • Obesity
  • Chronic low-grade inflammation
  • Prothrombotic state
  • High cholesterol
Syndrome X has also been shown to be genetically linked, and occurs more prevalently in women and individuals with a family history of heart disease.

No physiological mechanisms have been proven in syndrome X, but there are findings of microvascular abnormalities in a large number of patients.

Women and Cardiac Syndrome X

The reasons why more women are likely to develop syndrome X than men are still unknown. However, hormones and risk factors that are specific to females have been considered. The constant changes in the hormone estrogen and changes that result from childbirth have been cited as possible influencers. In addition, the incidence rate has been observed to be higher in black and Hispanic women.

How is Cardiac Syndrome X diagnosed?

Diagnosing syndrome X comes as a result of excluding all other possibilities. These include musculoskeletal, gastrointestinal, psychiatric, and pulmonary dysfunctions. A cardiac MRI can be a valuable diagnostic tool as well.

Secondary testing - This includes glucose, blood lipids, and blood pressure monitoring for sedentary and overweight individuals. Those with a history of type-2 diabetes within their families should be especially proactive in preventative screening.

Exercise stress test - This test helps uncover any cardiac dysfunction related to adequate blood flow during physical exertion. This test is commonly performed on individuals with elevated risk of heart dysfunction. Stress testing is recommended for those who experience angina-like pain and inconsistent response to nitrates.

Angiograms – This procedure can give doctors a detailed image of the heart. This makes them useful for a conclusive diagnosis of cardiac syndrome X. But angiograms are unable to identify abnormalities in the smaller arteries and therefore would require further testing to exclude other cardiac issues. Prinzmetal’s angina, for example, is a condition with similar symptoms to cardiac syndrome X.

What is the Treatment for Cardiac Syndrome X?

Treatment usually begins with nitrates for the relief of pain. These help relax the muscles of the heart and blood vessels. However, nitrates have been found to be inefficient in about half of the patient population.

Alternatives include calcium channel blockers and beta-blockers. These work to reduce pain by improving the flow of blood to the heart and lowering blood pressure.

Aminophylline inhibits the adenosine receptors, making them an effective method of treatment. For women, the use of estrogen has been shown to be a reliable treatment for the disease as well.

L-arginine can produce a dilating effect on blood vessels, while Ranolazine improves angina and ischemia in the heart muscle. Because the arteries are so small, there is little likelihood for reconstructive surgery as a means treatment.

Cardiac syndrome X is a curable disease. It does not put patients at risk of death and seldom leads to heart attacks. The typical treatments include drugs whose primary purpose is to relieve chest pain. It is recommended that patients maintain regular visits with their doctor and repeat tests to make sure that the condition is being maintained.

Lifestyle Factors

Diet and lifestyle factors should be taken into consideration. Eating a healthy diet and increasing physical activity are general recommendations that prove beneficial for many illnesses. Smoking can be a major factor as well. Longtime smokers should therefore consider quitting if experiencing any chest discomfort that might indicate potential cardiac issues.

It has also been noted that cardiac syndrome X patients have a tendency to be less fit than others of the same age and gender.


Cardiac syndrome X adversely affects the quality of life for many people. Although symptoms can improve, about 10-20% of patients experience more severe symptoms with time.

Conversely, life expectancy is unaffected. This low mortality rate has led many to investigate the psychological component of patients suffering from the disease.

The prognosis of syndrome X is negatively affected when associated with microvascular dysfunction in the heart. This increases the changes of developing coronary artery disease or of a cardiovascular event. Those with myocardial ischemia will also have a higher risk of cardiovascular events in the future.

The Art of Healing

Dr. Roya Golshani, a board certified primary care physician, has been practicing general internal medicine since 2002. She is a passionate internist who not only practices internal medicine, but specializes in Women’s Health as well. With her additional training in medical, developmental, and psychological issues, she is fully capable of working with you to solve your problems. Talk with her today to learn more about cardiac syndrome X and how you can successfully treat it.

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