Acute Onset Of Chest Pain Research Articles

Staged Endovascular Intervention of Bilateral Pulmonary Artery Stenosis

A 29-year-old woman with a history of clinically diagnosed sarcoidosis presented with acute onset dyspnea and chest pain. Chest computed tomography showed bilateral pulmonary artery (PA) stenosis, with complete occlusion of the left PA (LPA) ([Figure 1][1]) and 50% stenosis of the right PA (RPA) ([

Pulmonary inflammatory myofibroblastic tumour misdiagnosed as a round pneumonia

A 9-year-old male patient, previously healthy, presented with acute-onset chest pain. The pain was on the right lateral chest, 10/10 in severity and non-reproducible. The patient had 1-week history of...

Palpable thoracoabdominal aortic aneurysm through the chest wall: A late and ominous presentation

Thoracoabdominal/thoracic aortic aneurysm is often diagnosed incidentally while evaluating for dyspnea or atypical chest pain of long duration. Late presentation in various forms such as palpable pulsatile swelling in this patient is quite rare and fatal and foreruns impending rupture. We present a 53-year-old female who presented with acute-onset left-sided chest and back pain with swelling on the left side of the chest wall for 2 weeks. She was evaluated with chest X-ray which showed mediastinal widening and computed tomography scan thorax showed a large thoracic aortic aneurysm protruding out through seventh intercostal space onto the chest wall. She underwent open repair of aneurysm and was doing well at 6 months of follow-up. Thoracic aortic aneurysm mandates early diagnosis and prompt treatment as delay in the same leads to fatal rupture. Open surgical repair is the treatment of choice in large aneurysms causing significant compressive symptoms and imminent rupture.

Value of Myocardial Perfusion Assessment With Coronary Computed Tomography Angiography in Patients With Recent Acute-Onset Chest Pain

ObjectivesThe authors sought to perform a randomized controlled trial to evaluate the clinical efficacy of combined examination with coronary computed tomography angiography (CTA) and computed tomography perfusion imaging (CTP) compared to coronary CTA alone. BackgroundStress myocardial CTP may increase diagnostic specificity when added to coronary CTA in patients suspected of having ischemic heart disease. MethodsPatients recently hospitalized for acute-onset chest pain, who had acute coronary syndrome had been ruled out by normal electrocardiograms, normal troponin levels, and relief of symptoms, and who had a clinical indication for outpatient noninvasive testing, were screened for inclusion in the CATCH-2 (CArdiac cT in the treatment of acute CHest pain 2) trial (NCT02014311). Patients were randomized 1:1 to examination with coronary CTA or coronary CTA+CTP. The primary endpoint was the frequency of coronary revascularization among patients referred for invasive coronary angiography (ICA) based on index computed tomography evaluation. Secondary endpoints were invasive procedural complications at index-related ICA, post-index cardiac death, hospital admittance because of recurrence of chest pain, unstable angina pectoris, or acute myocardial infarction, ICA, and revascularization. ResultsAmong 300 patients allocated to the coronary CTA+CTP group, 41 (14%) were referred for ICA compared with 89 (30%) allocated to coronary CTA (p < 0.0001). The primary endpoint occurred in 50% of coronary CTA+CTP patients versus 48% of invasively examined patients (p = 0.85). The total number of revascularizations was significantly lower in the coronary CTA+CTP group compared to the coronary CTA group (n = 20 [7%] vs. n = 42 [14%]; p = 0.0045). At median follow-up of 1.5 years, the occurrence of secondary endpoints was similar in the 2 groups. ConclusionsA post-discharge diagnostic strategy of coronary CTA+CTP safely reduces the need for invasive examination and treatment in patients suspected of having ischemic heart disease. (CArdiac cT in the treatment of acute CHest pain 2–Myocardial CT Perfusion [CATCH2]; NCT02014311)

Clinics in diagnostic imaging (182)

A 77-year-old man presented with acute-onset severe chest pain radiating to the back and elevated blood pressure. Multiphasic computed tomography of the aorta revealed an intimal tear in the descending thoracic aorta which extended both retrograde to the aortic root and antegrade to the infra-renal abdominal aorta. The initial impression, that the images showed a Stanford type B aortic dissection, was because the portion of the false lumen that extended beyond the aortic arch remained unopacified even on delayed phases, making it challenging to assess the extent of the dissection flap. Bedside transthoracic echocardiography revealed a pericardial effusion. Cardiac tamponade ensued and the patient passed away shortly after presentation. This case highlights the need for early and accurate imaging assessment of acute aortic dissection, including accurate identification of the site of intimal tear and the extent of the dissection flap.

Case 5: Chest Pain and Elevated Troponin in a Teenager

1. Benson S. Hsu, MD, MBA* 2. Mary Guillot, MD* 3. Jennifer Mosher, MD† 4. Theresa Stamato, MD* 1. *Department of Pediatrics, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD 2. †Department of Pediatrics, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND A 16-year-old boy presents to a local emergency department with the acute onset of chest pain. He describes the pain as sharp, stabbing, and directly over his sternum with radiation to his back. Before this presentation, he had 1 week of upper respiratory and gastrointestinal symptoms, including cough, rhinorrhea, and diarrhea. Physical examination reveals a nontoxic-appearing teenager with a temperature of 98.06°F (36.7 ° C), heart rate of 93 beats/min, respiratory rate of 23 breaths/min, blood pressure of 116/65 mm Hg, and oxygen saturation of 96% in room air. His height is 66 in and weight is 66.4 kg for a body mass index of 23.5. His cardiac examination documents regular rate and rhythm and no murmurs, rubs, or gallops. His respiratory examination reveals good air entry throughout without wheezing or crackles. Capillary refill is at 2 seconds, and he has warm and well-perfused extremities. Abdominal examination findings are benign and sternal pain is noted at the xiphoid process. In the emergency department, his chest pain improves with treatment directed at gastroesophageal reflux. …

St-Elevation Acute Myocardial Infarction Due to Arterial Thrombosis in a 29-Year-Old Woman with Normal Coronary Arteries

Acute myocardial infarction (AMI) is rare in young adults. We present a case of a 29-year-old black woman who presented with an acute onset of chest pain while sleeping. Anterior wall ST-elevation AMI was diagnosed based on clinical presentation, electrocardiographic findings, and elevated cardiac biomarkers. Coronary angiography revealed a totally occluded proximal left anterior descending artery. The obstructing lesion, thrombus, was removed. There was no evidence of atherosclerotic disease or dissection. An evaluation for a hypercoagulable state was unrevealing. Echocardiography 1 year later revealed normal left ventricular wall motion and systolic function.

Acute Myocardial Infarction in a 26-Year-Old Man with Normal ST-Segment

Acute myocardial infarction (AMI) is rare in young adults. The management of these patients is considered as a clinical challenge. We report the case of a 26-year-old man who was presented to the Emergency Room of Affiliated Hospital of Guilin Medical University with an acute onset of chest pain. Initially electrocardiogram (ECG) with no evidence of ST-segment abnormalities but QT prolongation a signal of sudden cardiac death, 20 minutes later, it revealed ST-segment elevation myocardial infarction (STEMI). Coronary angiography (CAG) demonstrated left main coronary artery occlusion. AMI was diagnosed based on clinical symptom, elevated cardiac biomarkers, electrocardiographic dynamic monitoring and CAG. The awareness of chest pain as possible underlying AMI symptom—especially in young patients presenting with QT prolongation—is crucial for clinical treatment, as a missed diagnosis can worsen the patient’s further prognosis. In addition, reperfusion arrhythmia is a challenge to short-term outcomes of young patients with AMI, so it is necessary to make preoperative risk stratification.

Aortic Valve Trifecta

Mr SM is an 83-year-old male with severe aortic regurgitation, congestive heart failure, hypertension, ischaemic heart disease s/p CABG in 2008, BPH, GERD, hypothyroidism and carotid artery occlusion. He had severe aortic stenosis and underwent a surgical AVR in 2013 (27 mm St Jude Trifecta valve). This valve was complicated by bioprosthetic valve degeneration for which he had a valve-in-valve TAVR (29 mm CoreValve) 1.5 years later. One year after his repeat TAVR, he developed acute onset dyspnoea and chest pain and was admitted to hospital. He had a NSTEMI (likely secondary to demand ischaemia) and was found to have severe aortic regurgitation. His blood cultures had been negative to date at the time of evaluation. Given his high surgical risk as a 3rd sternotomy and his haemodynamic instability, a repeat valve-in-valve TAVR was thought the best management option for him. This was performed urgently with a 26 mm Edwards XT valve via a right transfemoral approach. Since his procedure, he has had positive antibodies for Chlamydia pneumoniae. It is unclear if this indicates a current infection or just a previous exposure. Infectious disease recommended a repeat antibody test in 3 months time. In the meantime, he has been placed on long-term antibiotics. This case highlights the difficult dilemma of treating patients with degenerative bio-prosthetic valves and raises the question of why he had two early valve failures and what his long term monitoring and treatment plan should be.

Oesophageal fistula-related pneumopericardium secondary to radiochemotherapy

A 53-year-old man presented to the emergency department due to acute onset of chest pain during eating breakfast. Emergent cardiac troponin was negative and electrocardiogram showed low voltage in limb lead with diffuse concave ST-segment elevation and PR-segment depression, which was suggestive of pericarditis ( Panel A ). The …

Prediction of clinical outcome by myocardial CT perfusion in patients with low-risk unstable angina pectoris.

The prognostic implications of myocardial computed tomography perfusion (CTP) analyses are unknown. In this sub-study to the CATCH-trial we evaluate the ability of adenosine stress CTP findings to predict mid-term major adverse cardiac events (MACE). In 240 patients with acute-onset chest pain, yet normal electrocardiograms and troponins, a clinically blinded adenosine stress CTP scan was performed in addition to conventional diagnostic evaluation. A reversible perfusion defect (PD) was found in 38 patients (16 %) and during a median follow-up of 19 months (range 12-22 months) 25 patients (10 %) suffered a MACE (cardiac death, non-fatal myocardial infarction and revascularizations). Accuracy for the prediction of MACE expressed as the area under curve (AUC) on receiver-operating characteristic curves was 0.88 (0.83-0.92) for visual assessment of a PD and 0.80 (0.73-0.85) for stress TPR (transmural perfusion ratio). After adjustment for the pretest probability of obstructive coronary artery disease, both detection of a PD and stress TPR were significantly associated with MACE with an adjusted hazard ratio of 39 (95 % confidence interval 11-134), p < 0.0001, for visual interpretation and 0.99 (0.98-0.99) for stress TPR, p < 0.0001. Patients with a PD volume covering >10 % of the LV myocardium had a worse prognosis compared to patients with a PD covering <10 % of the LV myocardium, p = 0.0002. The optimal cut-off value of the myocardial PD extent to predict MACE was 5.3 % of the left ventricle [sensitivity 84 % (64-96), specificity 95 % (91-97)]. Myocardial CT perfusion parameters predict mid-term clinical outcome in patients with recent acute-onset chest pain.

Typical STEMI: or not? Embolic left anterior descending artery occlusion, fulminant pulmonary embolism, and in-transit thrombus in a patent foramen ovale

A 38-year-old male patient with unremarkable past medical history presented with acute-onset chest pain and ST segment elevation in leads V2–V5, I, and aVL ( Panel A ). Immediate coronary angiography demonstrated embolic occlusion of the mid left anterior descending artery (LAD) ( Panel B ) without further pathological findings. Thrombus aspiration and, due to poor reflow, stenting of the index lesion with a sirolimus-eluting stent was performed. Consecutively, …

Myocardial perfusion 320-row multidetector computed tomography–guided treatment strategy for the clinical management of patients with recent acute-onset chest pain: Design of the CArdiac cT in the treatment of acute CHest pain (CATCH)-2 randomized controlled trial

Patients admitted with chest pain are a diagnostic challenge because the majority does not have coronary artery disease (CAD). Assessment of CAD with coronary computed tomography angiography (CCTA) is safe, cost-effective, and accurate, albeit with a modest specificity. Stress myocardial computed tomography perfusion (CTP) has been shown to increase the specificity when added to CCTA, without lowering the sensitivity. This article describes the design of a randomized controlled trial, CATCH-2, comparing a clinical diagnostic management strategy of CCTA alone against CCTA in combination with CTP. Patients with acute-onset chest pain older than 50 years and with at least one cardiovascular risk factor for CAD are being prospectively enrolled to this study from 6 different clinical sites since October 2013. A total of 600 patients will be included. Patients are randomized 1:1 to clinical management based on CCTA or on CCTA in combination with CTP, determining the need for further testing with invasive coronary angiography including measurement of the fractional flow reserve in vessels with coronary artery lesions. Patients are scanned with a 320-row multidetector computed tomography scanner. Decisions to revascularize the patients are taken by the invasive cardiologist independently of the study allocation. The primary end point is the frequency of revascularization. Secondary end points of clinical outcome are also recorded. The CATCH-2 will determine whether CCTA in combination with CTP is diagnostically superior to CCTA alone in the management of patients with acute-onset chest pain.

Takayasu Arteritis as an Odd Cause of Chest Pain

&lt;p&gt;We describe a case of Takayasu arteritis with unusual presentation, having chest pain as the main symptom and a&lt;strong&gt; &lt;/strong&gt;nasal septal perforation as a rare complication, without upper and lower extremities, abdominal, neck or cerebral compromise. The patient, a 34 year-old male, previously healthy, presented with acute onset of chest pain, dyspnea and severe compromise of his functional status. Severe stenosis of pulmonary arteries and coronaries, as well as signs of aortitis were found in a CT angiography of the thorax, pulmonary angiography and right and left heart catheterization&lt;strong&gt;. &lt;/strong&gt;Anti-neutrophil cytoplasmic antibodies were positive. The patient received 750 mg of Methylprednisolone and monthly bolus of Cyclophosphamide. Six months after the diagnosis, the patient developed a nasal septal perforation. This is the first reported case of Takayasu arteritis with rapidly progressing coronary disease as the only presentation, complicated by a nasal septal perforation. &lt;/p&gt;

TCTAP C-003 Left Main Bifurcation Lesion Treated with Hybrid Stents (Bioresorbable Vascular Scaffold and Drug-eluting Stent)

### Patient initials or identifier number Chang ### Relevant clinical history and physical exam The 54 years old man with chronic hepatitis was admitted for acute onset chest pain. He had chest tightness with throat stuff sensation for one more month which treated as GI problems. One day morning

Rupture of gastrointestinal stromal tumor presenting with sudden onset chest and back pain and accompanied by gastric dilatation

A 72-year-old man with hypertension was admitted with acute-onset chest and back pain followed by epigastralgia. He was transported by helicopter due to suspected acute aortic dissection. Systolic blood pressures were equal in both arms. Physical examination showed epigastric tenderness without rebound. Blood tests showed leukocytosis. Electrocardiogram and echocardiogram were normal. Abdominal radiography showed acute gastric dilatation with an air-outlined large mass-like shadow. Abdominal computed tomography revealed a 6-cm exophytic mass and large intramural hematoma in the lesser curvature of the gastric body. The patient underwent urgent laparotomy with total gastrectomy. The resected tumor showed positivity for CD117 and CD34 but negativity for S100, indicating a gastrointestinal stromal tumor. Fourteen days after the surgery, the patient was uneventfully discharged. Intramural bleeding of submucosal tumors including gastrointestinal stromal tumor should be considered in cases of acute gastric dilatation. Abdominal radiography may be a clue regarding the presence of this condition.

Noninvasive cardiac imaging in suspected acute coronary syndrome.

Noninvasive cardiac imaging has an important role in the assessment of patients with acute-onset chest pain. In patients with suspected acute coronary syndrome (ACS), cardiac imaging offers incremental value over routine clinical assessment, the electrocardiogram, and blood biomarkers of myocardial injury, to confirm or refute the diagnosis of coronary artery disease and to assess future cardiovascular risk. This Review covers the current guidelines and clinical use of the common noninvasive imaging techniques, including echocardiography and stress echocardiography, computed tomography coronary angiography, myocardial perfusion scintigraphy, positron emission tomography, and cardiovascular magnetic resonance imaging, in patients with suspected ACS, and provides an update on the developments in noninvasive imaging techniques in the past 5 years.

Evaluation of Serum Pregnancy Associated Plasma Protein-A & Plasma D-Dimer in Acute Coronary Syndrome.

Acute coronary syndrome (ACS), a spectrum comprising unstable angina pectoris, ST Elevated Myocardial Infarction (STEMI) & Non ST Elevated Myocardial Infarction (NSTEMI) is the major cause of presentation in Emergency Department today. Though ECG and cardiac enzymes are used for diagnosis, they mislead the diagnosis sometimes and delay in treatment initiation. This leads us to search certain new parameters which reflect the pathophysiology of ACS. Markers of plaque stability like Pregnancy Associated Plasma Protein-A and D-Dimer, a marker of ongoing thrombosis are found to be better markers in early diagnosis. To evaluate the diagnostic competence of PAPP-A and D-Dimer in acute coronary syndrome over CK-MB and to compare with the inflammatory marker High Sensitive C-Reactive Protein (hs-CRP) which is associated with atherosclerosis. Fifty patients presenting with acute onset of chest pain to Emergency Department with or without ECG changes served as cases and 50 healthy people served as controls. Serum PAPP-A is measured by Enzyme Linked Immunosorbent Assay (ELISA), D-Dimer and hs-CRP by using Latex Turbidimetry method. A statistical significant difference of PAPP-A and D-Dimer was noted between the ACS and controls (p < 0.001) whereas CK-MB shows no much difference (p 0.09). Statistically significant positive correlation is noted between parameters. PAPP-A marker of plaque instability and D-Dimer marker of ongoing thrombosis are raised in acute coronary syndrome and thus can be considered as one of the marker in ACS for diagnosis.

Thymic Epidermoid Cyst: Clinical and Imaging Manifestations of This Rare Anterior Mediastinal Mass.

Thymic epidermoid cysts are an extremely rare entity. These arise from epidermal cells that migrate to the thymus. The radiologic diagnosis of this rare lesion is challenging. We describe a case of an otherwise healthy 35-year-old woman who presented with an acute onset of chest pain and shortness of breath. She was found to have an anterior mediastinal mass. The imaging findings were, however, not characteristic for any single diagnostic entity. Since the imaging was inconclusive, surgical resection was performed for definitive diagnosis. The mass was found to be a thymic epidermoid cyst. This case underlines the significance for radiologists to be aware that epidermoid cysts can occur in the thymus and should be considered in the differential diagnosis for a heterogeneous anterior mediastinal mass.

Post Balloon Stent Right Coronary Artery Aneurysm: Cardiologist's Nightmare

Coronary artery aneurysm is an uncommon complication after balloon angioplasty and stent insertion but not rare. A sixty three years old male presented with acute onset chest pain after 1 year of stent insertion in RCA (Right coronary artery). Investigations revealed RCA aneurysm with stent thrombosis. This was managed successfully by surgical resection of aneurysmal sac and removal of the occluded stent with ligation of RCA followed by distal RCA anastomosis under femoro- femoral bypass during meticulous dissection of the aneurismal sac followed by CABG under cardiopulmonary bypass.