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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Angina pectoris

  • Positive stress test for myocardial ischemia, especially exercise ECG or stress myocardial perfusion abnormalities

  • Normal or near-normal epicardial coronary arteries

  • Majority are women

  • No evidence of coronary spasm on ambulatory ECG monitoring or coronary angiography

GENERAL CONSIDERATIONS

  • This syndrome is different from metabolic syndrome X

  • Microvascular endothelial dysfunction is believed to be the cause, but its etiology is unclear

  • Has been reported in 3–20% of patients undergoing coronary angiography for angina symptoms depending on the exclusion criteria employed.

  • Most studies exclude patients with:

    • – Valvular heart disease

    • – Diabetes mellitus

    • – Left ventricular hypertrophy

    • – Systemic hypertension

    • – Cardiomyopathy

    • – Systolic heart failure

    • – Left bundle branch block

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Atypical chest pain in many patients

  • Classic effort angina in a majority

  • Chest pain possibly severe and disabling

  • Angina may occur with exertion or at rest but seldom at night

  • Poor or worsening response to nitrates

PHYSICAL EXAM FINDINGS

  • Positive findings uncommon

  • Evidence of autonomic dysfunction in an occasional patient

DIFFERENTIAL DIAGNOSIS

  • Variant angina pectoris

  • Missed coronary artery lesions because of inadequate angiography

  • Other causes of chest pain with a false-positive stress test, such as esophageal dysmotility

  • Neuropsychiatric disorder

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC to exclude anemia as an etiology for chest pain

  • Metabolic panel

  • Lipid panel

  • Fasting glucose, hemoglobin A1c

ELECTROCARDIOGRAPHY

  • ECG may be abnormal

  • Holter monitoring may show ST depression even if stress test was negative

IMAGING STUDIES

  • Stress echocardiogram and nuclear stress tests may be abnormal

DIAGNOSTIC PROCEDURES

  • Coronary angiogram to exclude epicardial lesions or vasospasm

TREATMENT

CARDIOLOGY REFERRAL

  • Patients with angina are referred to cardiologists on most occasions

HOSPITALIZATION CRITERIA

  • Persistent severe pain

  • Accelerating symptoms

MEDICATIONS

  • Reassurance; prognosis is good

  • Calcium channel blockers

  • Statins even if lipids normal

  • Vasodilatory beta blockers for selected patients

  • Ranolazine for selected patients

  • Omega-3 fatty acids in some patients

  • Spinal cord stimulation in selected cases

  • Estrogen in some cases

MONITORING

  • Reevaluation during exacerbation

DIET AND ACTIVITY

  • Cardiac low-fat diet

  • Physical exercise or cardiac rehabilitation

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • Control of symptoms

  • After angiogram findings are known, patients may be managed as outpatients

FOLLOW-UP

  • Periodic follow-up during exacerbations or every 6 months

COMPLICATIONS
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