The Central Nervous System and Psychosocial Factors in Primary Microvascular Angina

Figures

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  Figure 1. Proposed pathophysiology of primary microvascular angina and potential role of psychosocial factors and the central nervous system. Primary microvascular angina (MVA), formerly known as coronary syndrome X, is defined as the clinical manifestation of myocardial ischemia caused by coronary microvascular dysfunction (CMD) in the absence of obstructive CAD, epicardial vasospasm, and structural heart disease. Structural and functional coronary microcirculation alteration results in CMD. The clinical manifestation of MVA, psychosocial factors, and the central nervous system autonomic/afferent pathways may have reciprocal multifaceted activities (see text for details). CMD, coronary microvascular dysfunction; CPS, chronic psychosocial stress; MVA, primary microvascular angina.

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  Figure 2. The neuro–immune–arterial axis. It is the multisystem pathophysiological processes linking chronic psychological stress (CPS) and cardiovascular disease. CPS triggers dysregulation of the autonomic nervous system, the hypothalamic pituitary–adrenal axis, the local and systemic inflammation, and the coagulation system (see text for details). CAN, central autonomic network.

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  Figure 3. Cardiac pain transmission and modulation pathways from the heart to pain matrix in the central nervous system. This figure shows the complex and multilevel genesis and processing of cardiac pain and the associated symptoms triggered by ischemia. Myocardial-visceral pain perception (red box) is transmitted to and modulated by the pain matrix (yellow box) in an extremely broad range of conscious pain sensations that convoy a large spectrum of subject's negative experiences: dyspnea, fatigue, dyspepsia, fear, and sense of imminent death (see text for details). Backwards, the central autonomic network in the CNS exerts both local and systemic effects on the inotropic and chronotropic activity of the heart as well as coronary macro- and microcirculation (green box, see Figure 2 for details). A2 receptors, adenosine 2 receptors; BK, bradykinin; CAN, central autonomic network; CNS, central nervous system.