CARDIOVASCULAR MEDICINE

Central neural contribution to the perception of chest pain in cardiac syndrome X

S D Rosen¹, E Paulesu², R J S Wise¹, P G Camici¹

¹ MRC Clinical Sciences Centre, Faculty of Medicine, Imperial College, London, UK
² Psychology Department, University of Milan–Bicocca, INB-CNR, IRCCS H San Raffaele, Milan, Italy

Correspondence to:
Correspondence to:
Dr S D Rosen, MRC Cyclotron Unit, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK;
stuart.rosen{at}ic.ac.uk

Objective: To investigate the central neural contribution to chest pain perception in cardiac syndrome X (angina-like pain, ECG changes during stress, angiographically normal coronary arteriogram).

Subjects: Eight syndrome X patients and eight healthy volunteers.

Methods: Dobutamine stress using echocardiography to assess myocardial function, and positron emission tomography to measure changes in regional cerebral blood flow, as an index of neuronal activity.

Results: During similar doses of dobutamine, syndrome X patients and controls showed comparable regional cerebral blood flow changes in the hypothalamus, thalami, right orbito-frontal cortex, and anterior temporal poles, associated with the sensation of a fast or powerful heart beat. In patients, but not controls, the stress also generated severe chest pain associated with increased activity in the right anterior insula/frontal operculum junction. There were ischaemia-like ECG changes in the syndrome X patients, but no left ventricular dysfunction on echocardiography. Activation of the right insula during chest pain clearly distinguished the syndrome X patients from a group of patients with known coronary disease.

Conclusions: Chest pain and ECG changes were not accompanied by demonstrable myocardial dysfunction in syndrome X patients, but altered central neural handling of afferent signals may contribute to the abnormal pain perception in these patients.

Keywords: syndrome X; chest pain; regional cerebral blood flow

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