Most patients who present with angina pectoris without an obvious haemodynamic cause such as aortic stenosis have atheromatous coronary artery disease. The pathophysiology of this condition is well understood; management is generally straightforward and the response to treatment usually satisfactory. We use the term 'angina' to imply that the cause is myocardial ischaemia , while recognizing that it is not always easy to demonstrate this in practice so that where it is not confirmed there often remains room for doubt. Between 10 and 30 per cent of patients referred to a cardiac unit for the assessment of chest pain are found on diagnostic cardiac catheterization to have no angiographic evidence of significant disease in the coronary arteries [2, 3]. This heterogeneous and large group of patients can pose considerable problems in management. The great majority of these patients do not have a cardiac cause for their symptoms, which are attributable after careful assessment and appropriate investigation either to musculoskeletal or oesophageal causes in most cases , and it is important that the diagnosis be established firmly at the outset for their successful management. In a small minority, however, the clinical suspicion remains that the symptoms are due to myocardial ischaemia, though without obvious cause even after extensive investigation - these are the patients with what has been called 'Syndrome X'.
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