The Y factor in the cardiac syndrome X

What is interesting in a patient with chest pain and normal coronary arteries on the angiogram? Not much for the Y factor, especially as there is not much we can see, investigate, measure or treat. The publication by Vermeltfoort et al. in this issue is very reassuring [1]. The group in Tilburg in collaboration with the VU University Medical Center in Amsterdam did an excellent job in highlighting the recent data on the prognosis of patients with cardiac syndrome X. The term cardiac syndrome X was first used in 1973 to describe a condition that to this day still remains a bit of a mystery [2]. Defining cardiac syndrome X is difficult as there is still no real agreement on a definition. The diagnosis is generally made when angina-like chest pain, a positive response to stress testing and angiographically normal coronary arteries are present. Over the years, many theories have been discussed [3]. Syndrome X is currently accepted to be a heterogeneous clinical diagnosis which includes genetic, coronary mi-crovascular, metabolic, hormonal and cardiovascular risk factors. Vermeltfoort et al. observed and reported in this Journal that there is no markedly increased mortality within 5 years after making the diagnosis, only 1.5 % [1]. Yet the average age of the population is around 55 years and in the largest study included in the analysis (Women's Ischemia Syndrome Evaluation: WISE study, n0318)) there was a 2.5 fold increase in mortality in cardiac syndrome X patients, compared with a control population [4]. Also the number of cardiovascular events reported is considered to be small in the meta analysis, but that is partly related to disregarding left ventricular dysfunction as a relevant endpoint. In the WISE cohort there was a tenfold increase in women admitted for cardiac failure compared with controls in 5 years. A significant increase in events has also been found in other studies, as reflected by the 5 % cardiovascular event rate reported in the meta analysis. What is very striking is the high rate of ongoing and recurrent symptoms in syndrome X patients. Apparently they are hard or impossible to treat and it seems difficult to make them symptom free. There is always room for improvement. It is crucial to know in how many patients ischaemia has been really proven prior to the coronary angiogram procedure. Was ischaemia detection only based on ECG changes, complaints or METS score during the stress …