title: Cardiac Syndrome X: update 2014.
abstract: Cardiac Syndrome X (CSX), characterized by angina-like chest discomfort, ST segment depression during exercise, and normal epicardial coronary arteries at angiography, is highly prevalent in women. CSX is not benign, and linked to adverse cardiovascular outcomes and a poor quality of life. Coronary microvascular and endothelial dysfunction and abnormal cardiac nociception have been implicated in the pathogenesis of CSX. Treatment includes life-style modification, anti-anginal, anti-atherosclerotic, and anti-ischemic medications. Non-pharmacological options include cognitive behavioral therapy, enhanced external counterpulsation, neurostimulation, and stellate ganglionectomy. Studies have shown the efficacy of individual treatments but guidelines outlining the best course of therapy are lacking.
authors.affiliation: David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA.
authors.forename: Shilpa
authors.initials: S
authors.lastname: Agrawal
authors.affiliation: Department of Medicine, Cedars-Sinai Medical Center, Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, 127 South San Vicente Boulevard, Los Angeles, CA 90048, USA. Electronic address: puja.mehta@cshs.org.
authors.forename: Puja K
authors.initials: PK
authors.lastname: Mehta
authors.affiliation: Department of Medicine, Cedars-Sinai Medical Center, Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, 127 South San Vicente Boulevard, Los Angeles, CA 90048, USA.
authors.forename: C Noel
authors.initials: CN
authors.lastname: Bairey Merz
mesh_terms: D003952:Diagnostic Imaging / Q000379:methods*; D014943:Global Health; D006801:Humans; D017566:Microvascular Angina / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D009017:Morbidity / Q000639:trends; D009204:Myocardial Revascularization / Q000379:methods*; D011379:Prognosis; D014665:Vasodilator Agents / Q000627:therapeutic use*
chemical_list: D014665:Vasodilator Agents
keywords: Angina; Cardiac syndrome X; Ischemia; Microvascular endothelial dysfunction; Myocardial hypersensitivity
references.citation: Heart Lung Circ. 2009 Feb;18(1):19-27
references.pmid: 19119077
references.citation: Rev Port Cardiol. 2010 Feb;29(2):193-203
references.pmid: 20545247
references.citation: J Pain Symptom Manage. 2005 Aug;30(2):183-91
references.pmid: 16125034
references.citation: J Cardiothorac Vasc Anesth. 2014 Feb;28(1):69-75
references.pmid: 24290748
references.citation: Eur Heart J. 2014 May;35(17):1101-11
references.pmid: 24366916
references.citation: Physiother Res Int. 2002;7(1):35-43
references.pmid: 11992983
references.citation: Br Heart J. 1992 Sep;68(3):282-5
references.pmid: 1389759
references.citation: Curr Probl Cardiol. 2011 Aug;36(8):291-318
references.pmid: 21723447
references.citation: Pain. 1999 Dec;83(3):389-400
references.pmid: 10568846
references.citation: J Am Coll Cardiol. 1999 Jun;33(7):1833-40
references.pmid: 10362181
references.citation: J Am Coll Cardiol. 1991 Jun;17(7):1461-70
references.pmid: 2033177
references.citation: Am Fam Physician. 2013 Feb 1;87(3):177-82
references.pmid: 23418761
references.citation: Am J Cardiol. 1986 Dec 1;58(13):1181-7
references.pmid: 3788805
references.citation: JAMA. 2009 Apr 8;301(14):1468-74
references.pmid: 19351944
references.citation: Circulation. 1992 Jul;86(1):179-86
references.pmid: 1617771
references.citation: Cardiol Rev. 2010 Jul-Aug;18(4):190-7
references.pmid: 20539102
references.citation: Anadolu Kardiyol Derg. 2009 Oct;9(5):371-9
references.pmid: 19819787
references.citation: Cardiologia. 1999 Dec;44(12):1065-9
references.pmid: 10687257
references.citation: N Engl J Med. 1971 Oct 14;285(16):903-4
references.pmid: 5112730
references.citation: J Am Coll Cardiol. 2004 Apr 21;43(8):1375-82
references.pmid: 15093870
references.citation: Eur Heart J. 2003 Nov;24(22):1999-2005
references.pmid: 14613735
references.citation: Am J Cardiol. 1973 Sep 7;32(3):375-6
references.pmid: 4725594
references.citation: Arch Intern Med. 2009 May 11;169(9):843-50
references.pmid: 19433695
references.citation: Am J Cardiol. 2006 Jun 15;97(12):1727-31
references.pmid: 16765122
references.citation: Am J Cardiol. 1999 Oct 1;84(7):854-6, A8
references.pmid: 10513787
references.citation: N Engl J Med. 1995 Feb 23;332(8):488-93
references.pmid: 7830729
references.citation: Can J Cardiol. 2012 Mar-Apr;28(2 Suppl):S70-80
references.pmid: 22424287
references.citation: Menopause. 2008 May-Jun;15(3):454-60
references.pmid: 18188136
references.citation: Clin Cardiol. 2007 Feb;30(2):69-74
references.pmid: 17326061
references.citation: J Am Coll Cardiol. 1990 Nov;16(6):1359-66
references.pmid: 2229787
references.citation: Am Heart J. 2013 Jul;166(1):38-44
references.pmid: 23816019
references.citation: JAMA. 2004 Jan 21;291(3):309-16
references.pmid: 14734593
references.citation: J Am Coll Cardiol. 2001 Mar 1;37(3):780-5
references.pmid: 11693752
references.citation: BMJ. 1994 Apr 2;308(6933):883-6
references.pmid: 8173366
references.citation: Cardiovasc Drugs Ther. 2010 Aug;24(4):331-9
references.pmid: 20577898
references.citation: J Am Coll Cardiol. 1999 May;33(6):1442-52
references.pmid: 10334407
references.citation: J Am Coll Cardiol. 1995 Jun;25(7):1547-51
references.pmid: 7759705
references.citation: S D Med. 2013 Sep;66(9):366-9
references.pmid: 24279112
references.citation: Cardiovasc Diagn Ther. 2013 Sep;3(3):153-60
references.pmid: 24282764
references.citation: Eur J Pain. 2007 Apr;11(3):360-5
references.pmid: 16762572
references.citation: Br Heart J. 1992 Jul;68(1):48-50
references.pmid: 1515291
references.citation: Ann Intern Med. 1999 Apr 6;130(7):578-81
references.pmid: 10189327
references.citation: J Am Coll Cardiol. 2000 Nov 1;36(5):1619-25
references.pmid: 11079667
references.citation: Int J Cardiol. 2010 Jul 9;142(2):113-9
references.pmid: 20138677
references.citation: Circulation. 1999 Apr 13;99(14):1795-801
references.pmid: 10199874
references.citation: JACC Cardiovasc Imaging. 2011 May;4(5):514-22
references.pmid: 21565740
references.citation: Am J Cardiol. 2005 Jan 15;95(2):266-8
references.pmid: 15642566
references.citation: J Am Coll Cardiol. 2014 Jan 21;63(2):103-9
references.pmid: 24201078
references.citation: J Am Coll Cardiol. 2008 Jan 22;51(3):249-55
references.pmid: 18206731
references.citation: Circulation. 1994 Jul;90(1):50-60
references.pmid: 8026038
references.citation: Eur Heart J. 1996 Aug;17(8):1175-80
references.pmid: 8869858
references.citation: Am J Cardiol. 2002 Nov 1;90(9):974-82
references.pmid: 12398965
references.citation: Eur Heart J. 1995 Nov;16(11):1571-7
references.pmid: 8881850
references.citation: J Am Coll Cardiol. 1986 Mar;7(3):479-83
references.pmid: 3512658
references.citation: QJM. 1999 Feb;92(2):81-6
references.pmid: 10209659
references.citation: J Am Coll Cardiol. 1991 Feb;17(2):499-506
references.pmid: 1991909
references.citation: J Cardiovasc Pharmacol Ther. 2013 Jul;18(4):310-9
references.pmid: 23637119
references.citation: Am Heart J. 2008 Feb;155(2):375-81
references.pmid: 18215611
references.citation: Am J Cardiol. 1986 Dec 1;58(13):1242-7
references.pmid: 3788814
references.citation: N Engl J Med. 2007 Feb 22;356(8):830-40
references.pmid: 17314342
references.citation: Heart. 1997 Jun;77(6):523-6
references.pmid: 9227295
references.citation: Am J Cardiol. 2004 Sep 1;94(5):652-5
references.pmid: 15342302
references.citation: Am J Cardiol. 1993 Jul 15;72(2):134-9
references.pmid: 8328372
references.citation: Heart. 2004 Apr;90(4):457-63
references.pmid: 15020531
references.citation: Am J Cardiol. 1985 Jul 1;56(1):35-40
references.pmid: 2861738
references.citation: Dis Esophagus. 2012 Feb;25(2):89-101
references.pmid: 21777340
references.citation: N Engl J Med. 1994 May 19;330(20):1411-7
references.pmid: 8159194
references.citation: Clin Auton Res. 2003 Dec;13 Suppl 1:I26-30
references.pmid: 14673669
references.citation: Eur Heart J. 2008 Apr;29(7):932-40
references.pmid: 18334475
references.citation: Circulation. 2004 Feb 17;109(6):722-5
references.pmid: 14970106
references.citation: Eur Heart J. 2012 Mar;33(6):734-44
references.pmid: 21911339
references.citation: Ital Heart J. 2001 Jan;2(1):25-30
references.pmid: 11214698
references.citation: N Engl J Med. 2000 Mar 23;342(12):829-35
references.pmid: 10727587
references.citation: J Am Coll Cardiol. 1997 Feb;29(2):293-301
references.pmid: 9014980
references.citation: Circ J. 2012;76(4):818-20
references.pmid: 22374148
references.citation: J Am Acad Nurse Pract. 2009 Jul;21(7):371-6
references.pmid: 19594655
references.citation: N Engl J Med. 2010 Mar 11;362(10):886-95
references.pmid: 20220183
references.citation: Am Heart J. 2011 Oct;162(4):678-84
references.pmid: 21982660
references.citation: Med Clin North Am. 2010 Mar;94(2):259-73
references.pmid: 20380955
references.citation: J Am Coll Cardiol. 2008 Jan 29;51(4):466-72
references.pmid: 18222358
references.citation: Am J Cardiol. 1989 Feb 1;63(5):286-90
references.pmid: 2643845
references.citation: Int J Cardiol. 2009 Jun 26;135(2):256-7
references.pmid: 18590931
references.citation: J Am Coll Cardiol. 1989 Nov 15;14(6):1450-3
references.pmid: 2809002
references.citation: Cardiovasc Ther. 2009 Spring;27(1):49-58
references.pmid: 19207480
references.citation: Cardiovasc Drugs Ther. 2013 Jun;27(3):229-34
references.pmid: 23338814
references.citation: Br Med J (Clin Res Ed). 1988 Jan 16;296(6616):170-1
references.pmid: 3122985
references.citation: Prog Cardiovasc Dis. 2008 Jan-Feb;50(4):294-310
references.pmid: 18156008
references.citation: J Am Coll Cardiol. 1998 Jan;31(1):62-6
references.pmid: 9426019
references.citation: Eur Heart J. 1998 Feb;19(2):250-4
references.pmid: 9519318
references.citation: Am Heart J. 1984 Jul;108(1):67-72
references.pmid: 6731285
references.citation: Eur Heart J. 1997 Jan;18(1):60-8
references.pmid: 9049516
references.citation: Int J Evid Based Healthc. 2013 Mar;11(1):56-68
references.pmid: 23448331
references.citation: Cardiology. 1998;89(2):130-3
references.pmid: 9524014
references.citation: Can J Cardiol. 2012 Mar-Apr;28(2 Suppl):S3-6
references.pmid: 22424282
references.citation: G Ital Cardiol. 1997 Jan;27(1):50-4
references.pmid: 9199943
references.citation: Am J Cardiol. 1997 Jan 1;79(1):1-6
references.pmid: 9024726
references.citation: Am Heart J. 1996 Nov;132(5):1060-3
references.pmid: 8892788
references.citation: J Pain Symptom Manage. 2007 Mar;33(3):310-6
references.pmid: 17349500
references.citation: Cardiovasc Res. 2001 Nov;52(2):208-16
references.pmid: 11684068
references.citation: Circulation. 2010 Jun 1;121(21):2317-25
references.pmid: 20516386
references.citation: Eur Heart J. 1995 Oct;16(10):1356-60
references.pmid: 8746903
references.citation: Behav Pharmacol. 2009 Dec;20(8):755-8
references.pmid: 19773645
references.citation: Am J Physiol Heart Circ Physiol. 2000 Dec;279(6):H2627-33
references.pmid: 11087214
references.citation: Int J Cardiol. 1995 Nov 24;52(2):135-43
references.pmid: 8749873
references.citation: Coron Artery Dis. 2014 Jan;25(1):40-4
references.pmid: 24256699
references.citation: J Am Coll Cardiol. 1995 Mar 15;25(4):807-14
references.pmid: 7884081
references.citation: J Am Coll Cardiol. 1994 Mar 1;23(3):652-7
references.pmid: 8113548
references.citation: N Engl J Med. 2002 Jun 20;346(25):1948-53
references.pmid: 12075055
references.citation: Circulation. 2003 Jun 3;107(21):2747-52
references.pmid: 12742996
references.citation: J Am Coll Cardiol. 1991 Nov 15;18(6):1463-70
references.pmid: 1939947
references.citation: Am J Med. 1992 May 27;92(5A):33S-40S
references.pmid: 1595762
references.citation: Am J Cardiol. 1985 Aug 1;56(4):242-6
references.pmid: 4025160