Microvascular angina

Introduction Microvascular angina, or "X" syndrome, refers to a typical labor-type angina symptom or ECG exercise test, coronary angiography is normal, and the need to exclude coronary artery fistula. "X syndrome" is also known as "microvascular angina", and its possible pathogenesis is due to abnormalities in the structure and function of microvessels and microcirculations of coronary arteries less than 200 microns. In the process of understanding and diagnosing the above concepts, it is necessary to avoid speculation, subjective reasoning, and partiality; it should emphasize objective evidence and comprehensive evaluation; the diagnosis should be strict and the treatment should be wide. That is, do not wear a coronary heart disease hat without sufficient evidence, and use appropriate preventive treatment to reduce the risk. Symptoms of exertional angina or angina-like discomfort, active plate ECG exercise tests have evidence of myocardial ischemia such as ST-segment depression, and coronary angiography (CAG) shows a group of clinical syndromes with normal or non-obstructive coronary changes. Likoff first reported in 1967 that Kenp called it X syndrome in 1973. Recently, Cannon et al suggested that it be called microvascular angina pectoris (CMSA). As for the reasons for physical weakness, shortness of breath and other symptoms, you should go to a hospital with a conditional hospital. First diagnose clearly, and then standardize prevention and treatment.

Cause

Causes of microvascular angina:

Studies have found that 10%-20% of patients undergoing coronary angiography due to angina have no organic coronary stenosis or spasm. Some people with angina with normal coronary angiography and positive exercise test and no other evidence of heart disease are called X syndrome. Some people also recommend it as "microvascular angina pectoris". There are many problems with X syndrome that are still unclear. So far, the etiology and pathogenesis of syndrome X are not fully understood, and the comprehensive literature report may be related to the following factors:

1, coronary blood flow reserve capacity is reduced

2, abnormal endothelial function

3, abnormal autonomic regulation

4, estrogen

5, other reasons, there is abnormal pain perception

In recent years, with the popularization of CAG technology, it has been found that X syndrome is not uncommon. It is reported that this disease accounts for about 15% of the registered cases of coronary anatomy (CASS), especially in menopausal women.

an examination

Related inspection

Phosphocreatine kinase phosphocreatine isoenzyme protein electrophoresis serum immunoprotein electrophoresis dynamic electrocardiogram (Holter monitoring)

Examination and diagnosis of microvascular angina:

Cardiac X syndrome refers to typical angina symptoms, especially angina pectoris. The exercise stress test has ischemic ST-segment depression, but the coronary angiography before and after the ergometrine test is normal, and exclusion can lead to ECG deficiency. Other heart diseases with blood changes. X syndrome is more common in patients around the age of 50, more common in women, especially in premenopausal women, mainly in the development of paroxysmal retrosternal pain, most patients with chest pain and increased myocardial oxygen consumption, such as fatigue, emotional arousal, etc.; The threshold of physical exertion of chest pain in some patients is not constant, and it can also occur at rest; some patients often have chest pain for a long time (>30 minutes), and the effect of nitroglycerin is poor, and the symptoms of chest pain are repeated. In exercise, atrial pacing, and the use of vasodilators (such as dipyridamole, nitroglycerin, or papaverine), coronary blood flow in normal subjects increases, while patients with syndrome X have coronary artery blood, although there is no stenosis in the subepicardial coronary artery. The flow rate was not found to increase, indicating that the coronary blood flow reserve (ie, the ratio of the largest blood flow to the basal blood flow in the coronary arteries) decreased, which is an important feature of the X syndrome.

X syndrome - disease check

The commonly used diagnostic criteria for disease examination are: 1 have angina symptoms; 2 electrocardiogram exercise test (ST segment ischemic down 0.1 mm); or dynamic electrocardiogram test at least once ST segment ischemic down 0.1 mm 3 Coronary angiography is normal, no spontaneous or induced (intracoronary ergometrine challenge test) coronary artery spasm.

1, special examination

Endocrine special examination, special examination of stomatology, special examination of obstetrics and gynecology, cardiovascular examination, special examination of digestive system, special examination of dermatology, special examination of ophthalmology, special examination of otolaryngology, examination of pulmonary function.

2, clinical blood test

Bleeding and coagulation tests, white blood cells, red blood cells

3. Clinical hemorheology examination

4. Immunological examination of infectious diseases

Gonorrhea, syphilis immunological test, immunological detection of severe infectious diseases, immunological detection of rickettsial infectious diseases, immunological detection of bacterial infectious diseases, immunological detection of spirochete infectious diseases.

5, body fluids and excreta inspection

Saliva and tear examination, urine examination sweat electrolyte examination, serous cavity puncture examination, synovial fluid examination sputum examination, stool examination semen and prostatic fluid examination, amniotic fluid examination renal function test, gastric juice and duodenal drainage fluid examination , cerebrospinal fluid examination, vaginal secretion examination

6, immunological examination

Cellular immunoassay, autoantibody assay, serum immunoglobulin assay, serum complement assay

7, imaging examination

B-mode ultrasonography CT examination PET imaging X-ray examination isotope examination magnetic resonance examination

8, hormone determination

Pituitary hormone determination, gonadal hormone determination, digestive tract hormone determination, parathyroid hormone determination, thyroid hormone determination, adrenal hormone determination, pancreatic endocrine function test, other hormone determination

9, electrophysiological examination

10, blood biochemical examination

Determination of Amino Acids, Nitrides, and Organic Acids, Measurement of Lipids, Measurement of Pigments, Determination of Proteins, Analysis of Blood and Blood, Determination of Blood and Inorganic Materials, and Measurement of Serum and Vitamins.

11. Serological examination, agglutination test precipitation, serological examination of test virus, tumor immunoassay, complement fixation test, other

12, blood cell chemical staining

13, bone marrow cytology examination

Differential diagnosis

Differential diagnosis of microvascular angina:

Esophageal disease

(1) reflux esophagitis: due to the lower esophageal sphincter relaxation, acidic gastric reflux, causing esophageal inflammation, paralysis, manifested as burning pain in the posterior sternum or mid-upper abdomen, sometimes can be radiated to the back and suspected angina. However, the disease usually occurs when the patient is lying down on the meal, and the antacid can relieve it.

(2) esophageal hiatus hernia: often accompanied by acid reflux, the symptoms are similar to esophagitis, often after bending or lying down after a meal, gastrointestinal angiography can be clearly diagnosed.

(3) diffuse esophageal fistula: can also be associated with reflux esophagitis, which can cause a variety of chest pain, taking nitroglycerin is effective, ergometrine can be induced, it is easy to suspect angina pectoris, is atypical angina A common cause of chest pain. According to the patient's history of acid reflux and anorexia, the symptoms often occur when eating or especially cold drinks or after meals, and are not related to fatigue, and dysphagia at the time of onset may be distinguished from angina pectoris. Esophagoscopy and esophageal manometry can confirm the diagnosis. Clinically, angina and esophageal diseases often coexist, esophageal reflux can reduce the threshold of angina pectoris, esophageal fistula can be induced by ergometrine and relieved by nitroglycerin, so the identification of the two is often difficult. Chest pain is characterized by "burning heart" and is associated with changes in body position and eating. At the same time, dysphagia is a characteristic of esophageal pain; esophageal pain is more often radiated to the back than angina. Accurate diagnosis requires not only careful medical history and physical examination, but sometimes laboratory testing.

2. Lung, mediastinal disease

(1) Pulmonary embolism: The pain suddenly occurs and occurs at rest. Patients with high risk factors (such as heart failure, venous disease, postoperative surgery, etc.) are often accompanied by hemoptysis and shortness of breath. The nature of the pain is typically described as a chest tightness accompanied by or subsequent pleural inflammatory chest pain, ie sharp pain in the side of the chest, which is exacerbated by breathing or coughing. X-ray chest radiograph, pulmonary angiography, and pulmonary radionuclide scan can confirm the diagnosis.

(2) Spontaneous pneumothorax and mediastinal emphysema: Both chest pains occur suddenly. The former is located on the side of the chest and the latter is located in the center of the chest, all accompanied by acute dyspnea. X-ray chest radiographs can be clearly diagnosed.

3. biliary colic This disease often occurs suddenly, the pain is severe and often fixed, lasting 2 to 4 hours, and then can disappear by itself, without any symptoms during the interictal period. It is usually the heaviest in the right upper abdomen, but it can also be located in the upper abdomen or in the anterior region. This discomfort often radiates to the scapula and can travel along the costal ribs to the back, occasionally radiating to the shoulders, suggesting that the diaphragm is stimulated. Often nausea and vomiting, but the relationship between pain and meals is uncertain; the disease often has a history of indigestion, abdominal flatulence, can not tolerate fatty foods, but these symptoms are also common in the general population, the specificity is not strong. Ultrasound imaging is accurate for the diagnosis of gallstones, and can understand the size of the gallbladder, the thickness of the gallbladder wall, and whether there is bile duct dilatation. Oral cholecystography failed to show gallbladder filling, suggesting that the gallbladder is not functional.

4. Causes of nerves, muscles and bones

(1) Cervical radiculitis: It can manifest as persistent pain and sometimes causes sensory disturbances. Pain may be related to neck activity, as is the painful episode of bursitis caused by shoulder joint activity. The finger is pressed along the back, there is a skin allergic area, suspicious and thoracic radiculitis. Sometimes, the cervical rib compression of the arm and shoulder plexus can produce angina-like pain. Physical examination can also be found in the shoulder joint inflammation and / or shoulder ligament calcification, cervical spondylosis, musculoskeletal diseases similar to angina, bursitis under the shoulder and costal cartilage.

(2) chest rib syndrome: also known as Tietze syndrome. The pain is limited to the swelling of the costal cartilage and rib cage joints, and there is tenderness. The typical clinical manifestations of Tietze syndrome are uncommon, and the costal pain (without swelling) at the junction of the ribs and costal cartilage is relatively common. At the time of examination, tenderness at the junction of the costal cartilage is a common clinical sign. Treatment of costal cartilage is usually done with anti-inflammatory and anti-inflammatory drugs.

(3) Herpes zoster: chest pain may occur in the early stage of rash, and may even resemble myocardial infarction in severe cases. The diagnosis of this disease can be made based on the persistence of pain, the limitation of the distribution of sensory nerve fibers in the skin, the extreme sensitivity of the skin to touch, and the appearance of specific herpes.

(4) Unexplained chest wall pain and tenderness: palpation and chest activity (such as bending, turning or swinging the arm while walking) can cause chest pain. In contrast to angina pectoris, which can last for a few seconds or hours, nitroglycerin does not relieve it immediately. Generally no treatment is needed, and even salicylate is needed.

5. Functional or psychiatric chest pain It is a manifestation of anxiety in neurological circulatory disorders. Pain can be located at the apex of the heart, which is a pain that lasts for several hours. It often aggravates or changes to a sharp scalp-like pain in the breast for 1 to 2 s. It occurs mostly in emotional stress and fatigue, and has little to do with exercise. There is tenderness in the anterior area. Attacks may be accompanied by signs of palpitations, hyperventilation, numbness and tingling of the limbs, sighs, dizziness, difficulty breathing, general weakness, and emotional instability or depression. Other drugs other than analgesics do not relieve it, but can be alleviated by various forms of intervention such as rest, labor, tranquilizers, and placebo. In contrast to myocardial ischemic pain, functional pain is more likely to show different responses to different interventions. Since functional pain often occurs after hyperventilation, the latter can cause increased muscle tone and a diffuse chest tightness. Some so-called functional chest pains may actually have a basis for organic diseases. This is common in chest pain in patients with mitral valve prolapse. The nature of chest pain varies greatly between patients, and it can be similar to typical angina pectoris and chest pain similar to the aforementioned neurological circulatory weakness.

6. Non-coronary atherosclerotic heart and vascular disease

(1) acute pericarditis: the age of onset is mild, often with a history of viral upper respiratory tract infection. The pain caused by inflammation is sudden onset, sharper than angina, and the position is leftward rather than in the middle of the chest, often radiating to the neck. The pain is persistent and unrelated to fatigue. Breathing, swallowing, and twisting the body can make it worse, and the pain is relieved when the patient sits up and leans forward. Auscultation has a pericardial friction sound. The diagnosis can be confirmed with the aid of an electrocardiogram.

(2) Aortic disease: When there is sudden and severe pain in patients with high blood pressure, and the radiation to the back and waist, the possibility of aortic dissection is revealed; the continuous expansion of the thoracic aortic aneurysm can erode the limitation of the vertebral body. Severe drilling-like pain, especially at night; severe aortic stenosis due to insufficient coronary blood supply, angina can occur, systolic murmur in the aortic valve area and echocardiography can be identified.

(3) severe right ventricular hypertension: mitral stenosis, primary pulmonary hypertension and pulmonary heart disease can cause pain. This pain can also occur when the pulmonary artery is depressed, such as severe pulmonary stenosis with right ventricular hypertension. It is currently believed that this type of pain is due to limited cardiac output. In the systolic phase, coronary blood flow is reduced due to right ventricular hypertension, and right ventricular oxygen consumption is increased, resulting in poor myocardial perfusion. Therefore, chest discomfort can be caused by cardiac ischemia. Since this pain can be relieved by itself and lasts for several minutes, the reaction to nitroglycerin is difficult to evaluate. If the pain is caused by activity and can be prevented by nitroglycerin, the pain is most likely due to coronary heart disease. Many patients with pulmonary hypertension have ST-segment shifts on the electrocardiogram during or after exercise.

(4) Chest angiography results of normal chest pain: angina pectoris or chest pain similar to angina with normal coronary angiography syndrome is often called X syndrome, which needs to be distinguished from typical ischemic heart disease caused by coronary heart disease. The etiology is still unclear. Some of these patients have true myocardial ischemia, which is characterized by increased lactate production in the heart during exercise or rapid pacing. Studies have shown that many patients with syndrome X have microvascular and/or endothelial dysfunction, and clinical chest pain can coexist with myocardial ischemia. However, some patients have no evidence of any myocardial ischemia in the clinic. These patients often have behavioral, mental disorders or esophageal dysfunction (expressed by the injection of hydrochloric acid in their esophagus, which can cause pain to recur), indicating chest pain. Symptoms can be completely non-cardiac. It is now believed that chest pain in patients with normal coronary angiography can be caused by a variety of abnormalities: chest pain caused by ischemia due to microvascular dysfunction, called microvascular angina; chest discomfort without ischemia can be hyperalgesia; chest pain Feeling is caused by changes in arterial stretching, heart rate, heart rate, or changes in cardiac contractility. The sympathetic predominance of sympathetic astigmatism can cause X syndrome. When performing a cardiac catheterization, some patients with X syndrome are usually sensitive to the operation of the intracardiac device. Direct stimulation of the right atrium and infusion of normal saline can cause typical chest pain. Some patients may also have microvascular dysfunction and hyperalgesia. The pathological changes of coronary vessels in patients with X syndrome are inconsistent: in some patients, the small coronary arteries have intimal thickening or atherosclerotic plaque, while in some patients the coronary arteries are completely normal. Patients with chest pain and normal coronary angiography are more common in premenopausal women. Most of the symptoms of chest pain are not typical. Chest pain can be induced by fatigue, but the threshold for pain is very variable, sometimes the pain is very severe. The disease can affect the quality of work and quality of the patient. Some patients may have clinical manifestations such as panic, anxiety or mental disorders. Some patients have insulin resistance and hyperinsulinemia. There were no abnormal findings in clinical examinations. Some patients may have non-specific ST-T wave abnormalities on the electrocardiogram during chest pain. Nearly 20% of patients have a positive exercise test. Exercise nuclide myocardial imaging can be found in some patients with myocardial perfusion abnormalities, but it has no consistent correlation with the extent of the defect, the positive degree of exercise test and exercise tolerance. Compared with patients with angina pectoris caused by coronary atherosclerosis, the prognosis of X syndrome is usually very good, and there is no significant difference from the normal population. Patients with clinical evidence of ischemia can be treated with nitrates and beta-blockers, but the actual treatment is often unsatisfactory. Nitrate does not improve exercise tolerance in patients with syndrome X, and may even reduce exercise tolerance in some patients. Calcium antagonists can reduce the frequency and severity of chest pain in some patients and increase their exercise tolerance. Try to find non-cardiac causes of chest pain during the treatment. For those with gastric-esophageal reflux and esophageal dysfunction, treating these diseases is effective in relieving symptoms. For those who have no evidence of ischemia and/or those who are not responding to ischemic therapy, in addition to providing general supportive care, patiently explaining the patient's good prognosis to the patient, it is also an important part of the treatment.

Cardiac X syndrome refers to typical angina symptoms, especially angina pectoris. The exercise stress test has ischemic ST-segment depression, but the coronary angiography before and after the ergometrine test is normal, and exclusion can lead to ECG deficiency. Other heart diseases with blood changes. X syndrome is more common in patients around the age of 50, more common in women, especially in premenopausal women, mainly in the development of paroxysmal retrosternal pain, most patients with chest pain and increased myocardial oxygen consumption, such as fatigue, emotional arousal, etc.; The threshold of physical exertion of chest pain in some patients is not constant, and it can also occur at rest; some patients often have chest pain for a long time (>30 minutes), and the effect of nitroglycerin is poor, and the symptoms of chest pain are repeated. After exercise, atrial pacing, and the use of vasodilators (such as dipyridamole, nitroglycerin, or papaverine), coronary blood flow in normal people increases, while patients with syndrome X have coronary artery blood, although there is no stenosis in the subepicardial coronary artery. The flow rate was not found to increase, indicating that the coronary blood flow reserve (ie, the ratio of the largest blood flow to the basal blood flow in the coronary arteries) decreased, which is an important feature of the X syndrome.

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