ANGINA PECTORIS AND MYOCARDIAL ISCHEMIA IN THE ABSENCE OF OBSTRUCTIVE CORONARY ARTERY DISEASE: CLINICAL CASE

Our clinical case shows patient with worsening clinical signs of angina without obstructive lesions of coronary artery which requires further control. Recommendations for lifestyle modification as well as further treatment tactics are described. 
This case is іnterestіng іn the development of decompensatіon (oedema of the lower extremities, reduced tolerance to stress) in a patient with cardiac syndrome X. 
Management of patents with angina and evidence of myocardial schema on stress testing without obstructive coronary artery disease by angiography (previously referred to as cardiac syndrome X, or CSX) is a challenge. 
Key points for the clіnіcіan include recognition of schema and deployment of guideline-endorsed therapy for angina and reduction of cardiac risk factors. 
Systemic hypertension is often associated with mіcrovascular angіna. Several pathogenic mechanisms have been іdentіfіed which represent suitable targets for treatment. Mіcrovascular dysfunction needs to be іnvestіgated (and treated if present) іn patents with systemic hypertension, angina and angіographically normal coronary arteries.


INTRODUCTION
Cardiac syndrome X (CSX, microvascular angina) is a pathological condition characterized by the presence of signs of myocardial ischemia (typical angina-like chest pain with evidence of myocardial ischemia: ST segment depression ≥ 1.5 mm [0.15 mV] for more than 1 minute, during 48-hour ECG monitoring) in the absence of flow-limiting stenosis on coronary angiography and spasm of the epicardial coronary arteries during coronary angiography. The cost of case management of patients with chest pain and no obstructive CAD is not cheap as a result of challenges in diagnosis and treatment. [1][2]. Most patients with cardiac syndrome X are postmenopausal women [3][4][5]. However, the «female-pattern» terminology may soon be irrelevant [6]. CSX is likely to be multifactorial in these patients and it is conceivable that risk factors such as hypertension, hypercholesterolemia, diabetes mellitus and smoking can contribute to its development. Additional factors such as abnormal pain perception may contribute to the pathogenesis of chest pain in patients with angina pectoris and normal coronary angiograms [7].

CLINICAL CASE
The patient С., a man born in 1959, was admitted to the clinical base of internal medicine department in Railway Clinical Hospital № 1 of «HC» JSC «Ukrzaliznytsia» in December, 11.10.17 with complaints of pressing pain behind the sternum radiating to the back with moderate severity of physical exertion, not relieved by nitro-glycerine, shortness of breath when rising to the 3rd floor, periodic numbness of the extremities, high blood pressure periodically to 150/90 mm Hg.

ANAMNESIS MORBI
In May 2017, patient was admitted at hospital for treatment of arterial hypertension, and from that time the pressing pain behind the sternum began to disturb. In June 2017, patient was hospitalized at The Endocrinology department for treatment of diabetes mellitus. There was performed ECG recording, ischemia was detected in the form of ST-segment depression; treadmill test was positive (ischemia detected). It was recommended a diet and patient received bisoprolol 5 mg 1 time per day, valsartan 40 mg 1 time per day in the morning, which he is taking now. Regarding the treatment of diabetes, patient takes glibenclamide 5 mg in the morning before breakfast. However, after the treatment, there was no positive dynamics in the patient's condition. Currently, general condition of the patient is worsening during the last 3 weeks in the form of aggravation of the above complaints. Skin is pale-pink, without any scars. There is symmetrical oedema of the lower extremities, up to the middle third of the leg, aggravated in the evening, not passing after a night rest. Peripheral lymph nodes are not palpable, on palpation of the thyroid gland painless. Signs of eyelid retraction, periorbital oedema, proptosis are absent.
Cardiovascular system: heart borders extended to the left on 2 cm of midclavicular line, HR =70 bpm, regular. Ps= 70 bpm. No pulse deficiency. Auscultation of the heartheart sounds heart tones are rhythmic, clear. Blood pressure (BP) dextr = 145/88 mm Hg, BP sin = 140/86 mm Hg, (on the background of antihypertensive therapy).
Gastrointestinal system: abdomen is symmetrical, soft, painless, no discrepancies of the abdominal muscles. No visible peristalsis. Liver edge is smooth, painless, palpated 1.5 cm below the costal arch. Spleen and pancreas are not palpable.
Pasternatskiy sign is positive on the right. Urination is free, painless.

LABORATORY AND INSTRUMENTAL TESTS
Tests were conducted according to the Protocol approved by order of the Ministry of Health of Ukraine from 02.03. 16 No. 152: assessment of the pre-test probability of stable coronary artery disease (CAD), complete blood count, urinalysis, biochemical analysis of blood (potassium, sodium, creatinine, GFR, AlAT, AsAT), lipidogram (total cholesterol, TG, lowdensity lipoprotein; HDL, high-density lipoprotein), glucose, HbA1c, 12-lead Electrocardiography, echocardiography, treadmill and/or bicycle ergometer (bike) exercise tests, coronary angiography, abdominal ultrasound (additional), X-Ray (additional).

RESULTS OF LABORATORY AND INSTRUMENTAL DIAGNOSIS
Assessment of the pre-test probability of stable CAD: corresponds to medium to high pretest probability of 66-85 %, non-invasive functional tests with visualization are recommended to confirm the diagnosis.
Complete blood count: normal. Urinalysis: normal. Biochemical analysis: all parameters within the normal range.
Fasting glucose test: 8 mmol/l. Abdominal ultrasound: Diffuse changes in the parenchyma of the liver and pancreas without enlargement of them. Thickening of the gallbladder wall. Congestion bile in gallbladder. Right-sided hydrocalycosis. Cyst of the right kidney. Split of pyramid-shaped lobes the left kidney. Kidney microcalculus.
Angiography: Right type of coronary blood flow. Moderate of coronary tortuosity on the coronary blood flow. The left coronary arterythe trunk is not changed, circumflex and left anterior descending coronary artery and its branches is not visible angiographic signs of atherosclerotic lesion. The right coronary artery no plaque was detected.

CLINICAL DIAGNOSIS
Essential arterial hypertension stage II, 1 grade. Hypertensive heart (LVH). The risk is moderate.

PROGNOSIS
Although prognosis is good regarding survival, patients with cardiac syndrome X have an impaired quality of life.
In a recent survey conducted in four large European countries, women reported more severe angina, a higher number of angina attacks per month, and more frequently accompanying symptoms (dyspnoea, arrhythmias/tachycardia), than men. Atypical symptoms were more common for women as well [8].

PREVENTION
Secondary prevention include lifestyle modification; good blood pressure control, decrease sodium intake, lipid lowering diet, aerobic non strenuous exercises; control of fluid balance and check up for decompensation of heart failure; control of compliance to our medical recommendations.

DISCUSSION
The mechanisms underlying angina pectoris in essential arterial hypertension patents without obstructive coronary artery disease are still largely unknown, but such association doesn't rarely occurs [9][10][11]. Furthermore, hypertensive patents have a higher likelihood of presenting with features of the metabolic syndrome, e.g., hypertension, dyslipidaemia, obesity and іnsulіn resistance, compared with the general population, which makes the diagnosis and treatment of such comorbid cases more complex and multicomponent [12][13]. Insulin resistance, therefore, may represent an important mechanism for vascular dysfunction іn this setting [14][15][16]. Moreover, cardiac syndrome X is now recognized as a condition that can cause a significant morbidity and increases the risk for CV events [1] Evidence-based guidelines for treating CSX are still lacking as well as optimal methods of identification of CMD patients although research in this direction continues [1,[17][18][19][20][21][22][23]. Therefore, the presentation and study of cases of successful management of patients with this pathology remains relevant.
Our clinical case shows patient with worsening clinical signs of angina without obstructive lesions of coronary artery which requires further control with all the necessary diagnostic methods. This article describes the subsequent management of our patient, which includes both non-drug methods of treatment that cannot be neglected, based on the comorbidity of the disease and the material burden on the patient in general, and medication management.
As a result of our research, our patient needed further correction of the treatment of AH and more accurate diagnosis (and treatment) of angina pectoris and first of all, modification of the lifestyle and reconsideration of the regularity of taking medicines.

CONCLUSION
1. This case is іnterestіng іn the development of decompensatіon (oedema of the lower extremities, reduced tolerance to stress) in a patient with cardiac syndrome X.
2. Management of patents with angina and evidence of myocardial schema on stress testing without obstructive coronary artery disease by angiography (previously referred to as cardiac syndrome X, or CSX) is a challenge.
3. Key points for the clіnіcіan include recognition of schema and deployment of guideline-endorsed therapy for angina and reduction of cardiac risk factors.
4. Systemic hypertension is often associated with mіcrovascular angіna. Several pathogenic mechanisms have been іdentіfіed which represent suitable targets for treatment. Mіcrovascular dysfunction needs to be іnvestіgated (and treated if present) іn patents with systemic hypertension, angina and angіographically normal coronary arteries.