Cardial syndrome of X

Description:

The cardial syndrome of X  is the morbid condition which is characterized by existence of symptoms of ischemia of a myocardium against the background of absence of atherosclerosis of coronary arteries and a spasm of epicardial coronal arteries on coronary angiography (symptoms of ischemia of a myocardium: typical attacks of stenocardia and depression of a segment of ST ≥ 1,5 mm (0,15 mV) of the lasting more than 1 minute, established at 48-hour monitoring ECG).

Thus, the cardial syndrome of X is diagnosed for patients:
• with typical retrosternal pains;
• with positive loading tests;
• with angiographically normal epicardial coronary arteries and lack of clinical or angiographic proofs of existence of a spasm of coronary arteries;
• with absence of a system arterial hypertension with a hypertrophy of a left ventricle and without it, and also with lack of disturbances of systolic function of a left ventricle at rest.

In rare instances patients with a syndrome of X have a blockade of the left leg of a ventriculonector with the subsequent development of a dilatatsionny cardiomyopathy. It is necessary to pay attention that in the absence of changes in coronary arteries at an angiography often there is occlusal pathology of distal vessels (microvascular stenocardia).

Reasons of a cardial syndrome of X:

The etiology of a cardial syndrome of X remains until the end of not found out and only some pathophysiological mechanisms leading to development of typical kliniko-tool displays of a disease are installed:
• the increased sympathetic activation;
• endothelium dysfunction;
• structural changes at the level of microcirculation;
• metabolism changes (hyperpotassemia, giperinsulinemiya, "an oxidizing stress", etc.);
• hypersensitivity to endocardiac pain;
• chronic inflammation;
• the increased rigidity of arteries, etc.

Symptoms of a cardial syndrome of X:

Among patients with a cardial syndrome of X middle-aged persons, generally women prevail. Less than at 50% of patients with a cardial syndrome of X the typical angina of exertion is observed, at the most part – the pain syndrome in a breast is atypical.

Episodes of the pains behind a breast of anginal character arising during an exercise stress or which are provoked cold, emotional pressure appear as the main complaint; with typical irradiation in some cases pains more long, than at an ischemic heart disease, are also not always stopped by nitroglycerine reception (at most of patients drug worsens a state).

The X symptoms accompanying a cardial syndrome remind vegeto-vascular dystonia. Quite often cardial syndrome of X is found in people hypochondriac, with the high level of uneasiness, against the background of depressive and phobic frustration. Suspicion on these states demands consultation from the psychiatrist.

As diagnostic criteria of a cardial syndrome of X are allocated:
• typical thorax pain and a considerable depression of a segment of ST at an exercise stress (including on the tredmil and the stationary bicycle);
• a passing ischemic depression of a segment of ST ≥ 1,5 mm (0,15 mV) lasting more than 1 minute at 48-hour monitoring of an ECG;
positive dipiridamolovy test;
• positive ergometrinovy (ergotavinovy) test, decrease in cordial emission on its background;
• absence of atherosclerosis of coronary arteries at a koronaroangiografiya;
• the increased maintenance of a lactate in the period of ischemia at blood test from a zone of a coronary sine;
• ischemic disturbances at a load stsintigrafiya of a myocardium with 201 Tl.

(!) The syndrome of X reminds stable stenocardia. However clinical manifestations at patients with a syndrome the X very variable, and in addition to an angina of exertion can be observed also attacks of stenocardia of rest.

At diagnosis of a cardial syndrome of X also have to be excluded:
• patients with a spasm of coronary arteries (vasospastic stenocardia),
• patients at whom objective methods documented the extracardiac reasons of pains in a thorax, for example:
- muscular and bone reasons (osteochondrosis of cervical department of a backbone, etc.);
- psychological reasons (alarming and depressive syndrome, etc.);
- gastrointestinal reasons (esophagospasm, gastroesophagal reflux, stomach ulcer or duodenum, cholecystitis, pancreatitis, etc.);
- the pulmonary reasons (pneumonia, tubercular process in lungs, pleural imposings, etc.);
- latentno the proceeding infections (syphilis) and rheumatological diseases.

Treatment of a cardial syndrome of X:

Treatment of group of patients with a syndrome of X remains up to the end not developed. The choice of treatment is often complicated both for attending physicians, and for patients. Success of treatment usually depends on identification of the pathological mechanism of a disease and finally is defined by participation of the patient. An integrated approach to treatment of patients with a cardial syndrome of X is often necessary.

There are various approaches to drug treatment: anti-anginal drugs, APF inhibitors, antagonists of receptors of angiotensin II, statines, psychotropic drugs, etc.

Anti-anginal drugs, such as antagonists of calcium (nifedipine, diltiazem, verapamil, амлодипин) and β-adrenergic blockers (атенолол, метопролол, бисопролол, небиволол, etc.) are necessary for patients with documentary ischemia of a myocardium or with the broken myocardial perfusion. Sublingual nitrates are effective at 50% of patients with a cardial syndrome H. Imeyutsya of the proof concerning efficiency of the nikorandil having bradikardichesky effect, α1–адреноблокатора Prazozinum, L-arginine, APF inhibitors (a perindopril and enalapril), cytoprotectors (trimetazidin).

The general councils for change of quality of life and treatment of risk factors, especially performing aggressive lipidsnizhayushchy therapy by statines (decrease in the general cholesterol to 4,5 mmol/l, LPNP cholesterol less than 2,5 mmol/l), have to be considered as vital components at any chosen strategy of treatment.