Impaired coronary flow reserve (CFR) is associated with increased mortality in patients with
chest pain despite normal coronary arteries (chest pain and normal coronary angiograms
(CPNCA)) , . Furthermore, impaired CFR without any concomitant impairment of regional or
global left ventricular function have additional prognostic significance . In patients with
hypertension both microvascular dysfunction and increased left ventricular mass (LVM) are
described sequels . LVM has also been associated with endothelial dysfunction and coronary
artery remodelling . In addition, patients with hypertrophic obstructive cardiomyopathy
(HOCM) and an impaired micro vascular cardiac circulation assessed with PET, have been
documented to have a poor prognosis . Also diastolic dysfunction as measured by Em/Am ratio
during stress dobutamine echocardiography is related to CFR . Patients with Diabetes Mellitus
have an impaired prognosis and longstanding disease influence microvascular physiology .
Several methods have been utilized to assess micro vascular function including intracoronary
Doppler measurements. CRF can now be assessed with transthoracic Doppler registration .
Several patients with angina and normal coronary arteries show persistence and even worsening
of angina symptoms over time. . These patients constitute a therapeutic problem with
considerable residual morbidity associated with functional limitation and reduced quality of
life . The primary end point in the treatment of these patients is symptom control .
Reduced physical activity is one of the major avoidance behaviours in patients with coronary
heart disease . On the other hand several studies have documented the positive effect of ET
in this population . Psychological morbidity with great impact on daily living is well known
in both patients with cardiovascular disease and in patients with chest pain with no obvious
physical disease. This includes patients with CPNCA. These patients constitute a relatively
large proportion of patients taken care of by the health authority system indicating that
this issue has economic consequences for the society that is not neglectable2.
Exercise training (ET) has been shown to improve endothelial function in patients with
coronary artery disease (CAD) and to reduce LVM in hypertension.. ET also improves
endothelial dysfunction and reverse inflammation in CAD. It is also associated with improved
outcome in the general population and in patients with CAD and heart failure. It has been
documented that hs-CRP correlates with symptoms and ECG markers of myocardial ischemia in
CPNCA patients . Whether hs-CRP is related to the pathogenesis of angina in these patients
deserves further investigation. Whether ET may influence on pathological reduced CFR is
currently not known.
Interventions proposed in CPNCA patients are directed at either improving microvascular
function or decreasing chest pain perception, in an attempt to counteract the accepted
pathophysiological mechanisms of the syndrome. A multidisciplinary approach and a genuine,
sympathetic appreciation by the health staff of the devastating effect of cardiac syndrome X
on the patients' quality of life usually have a positive therapeutic impact . Unfortunately,
most treatments have been evaluated in small numbers of patients and/or in uncontrolled
trials, thus making it difficult to establish their real degree of effectiveness. Tynni Lee
11 investigated the effects of physical training and relaxation therapy on exercise capacity
and quality of life in patients with syndrome X. It is the first trial reported to assess the
effect of physiotherapy intervention in terms of quality of life in patients with coronary
syndrome X. Female patients with this syndrome benefit from physical training in terms of
exercise capacity and quality of life, and from relaxation therapy in terms of quality of
life. However a limitation is the small sample size and therefore non-significant findings
may be due to an inability to detect a difference among groups. Further studies with larger
number of patients are recommended. Different modes of physiotherapy could have the potential
to break the vicious circle of effort-induced chest pain, functional limitations and poor
quality of life in the patients with coronary syndrome.