YOUNG VS OLD: MENOPAUSE-INDUCED CARDIAC SYNDROME X

Abstract

TOPIC: Cardiovascular Disease TYPE: Original Investigations PURPOSE: A 53-year-old post-menopausal female with no past medical history presented with typical chest pain, dyspnea and dizziness. METHODS: Patient was found to have elevated troponin and ST depression and she was taken for angiography when repeat troponin had tripled. RESULTS: Her cardiac workup included a normal echo as well as a clean cath excluding atherosclerotic disease. Hours after angiography, she had sudden angina, hypotension and diffuse inferior ST elevation which immediately resolved with Imdur and Cardizem. CONCLUSIONS: Microvascular angina is typically seen in younger females with risk factors such as cocaine, nicotine or triptan use. However, recent studies have demonstrated a lack of estrogen and progesterone modulating endothelial dysfunction predisposing to coronary vasospasms. This case demonstrates endothelial hyperreactivity due to low post-menopausal hormone levels resulting in vasospastic angina. Estrogen receptors are expressed in cardiac vasculature and mediate vasodilation, hence the immediate effect on vasomotion within minutes of administration of transdermal estrogen. Reduced levels of estrogen result in vasomotor instability and the cardinal symptoms seen in Cardiac Syndrome X. CLINICAL IMPLICATIONS: Understanding the role of estrogen receptors in coronary vasomotion is crucial as microvascular angina is commonly associated with young females but based on the aforementioned physiology can disproportionately affect post-menopausal women and result in misdiagnosis and improper treatment. Furthermore, consideration should be given to the pharmacological choice in this subgroup as certain patients may benefit from hormone replacement therapy in addition to the standard nitrate and calcium channel blocker cocktail. DISCLOSURE: No significant relationships.