Anginal Chest Pain Research Articles

Syndrome X (angina pectoris with normal coronary arteries) and myocardial infarction in patients with anti-phospholipid (Hughes) syndrome

Patients with clinical features of angina pectoris in the absence of coronary artery pathology have remained an enigma to clinicians. Previous data has suggested that almost 20% of women with symptoms suggestive of angina had abnormal stress induced ischaemia. This phenomenon is more commonly observed in women than in men. 1 Anti-phospholipid (Hughes) syndrome (APS) is an autoimmune disease of unknown aetiology characterized by arterial and/or venous thromboses, pregnancy losses and the presence of anti-phospholipid antibodies (aPL). 2 Although thrombosis and pregnancy loss are the cardinal features of APS, heterogeneous clinical features such as cardiac valve involvement, livedo reticularis and low platelets are also described. 3 There is accumulating evidence to suggest that there is an increased risk of accelerated atherosclerosis in patients with primary APS as well as APS associated with SLE. 4 Since the description of the APS (Hughes) syndrome in 1983, a number of cardiac manifestations have been described in association with APS, 5,6 including cardiac valvular abnormalities (Libman‐Sacks endocarditis). The syndrome has been implicated in coronary artery disease in young adults and coronary artery bypass graft occlusions. 7 Vaarala 8 described an increased prevalence of myocardial infarction (MI) in patients with aPL. Hamsten et al. 9 found an association between the presence of aPL and recurrent cardiovascular events in young survivors of MIs. Although typical MI with occluded coronary arteries is well described in patients with APS, there are a number of reports describing anginal chest pain and MI with normal coronary arteries in patients. In 2002, we described a patient with syndrome X and Hughes syndrome, suggesting that MI in APS may be associated with normal coronary arteries. 10 Further anecdotal

Síndrome de Tako-Tsubo (discinesia apical transitoria): Un síndrome que simula un infarto de miocardio

Tako-Tsubo syndrome or transient apical dyskinesia, is an entity that can mimic an acute coronary event. It is characterized by anginal chest pain with ST-T changes in precordial leads, no coronary obstruction on angiography and a characteristic left ventricular antero-apical dyskinesia that recovers to normal in a few days. This syndrome has been described in Japan, but few cases have been reported in Western countries. We report a case of Tako-Tsubo syndrome after thyroid surgery.

Inflammatory Changes in Small Blood Vessels in the Endomyocardium of Cardiac Syndrome X in Female Patients with Increased C-Reactive Protein

The pathogenesis and pathohistological changes of CSX, a syndrome characterized by anginal chest pain and normal coronary arteries on coronary angiography, is poorly understood. The purpose of this study was to analyse morphological changes in small blood vessels of the CSX patients with increased CRP levels (above 5 mg/l). EMB was performed for diagnostic purposes in 31 female patients with CSX, and EMB specimens were histologically and immunohistochemically analysed. Increased CRP was found in 18 (58.1%) female patients with CSX. Signs of inflammation in the walls of small blood vessels were demonstrated in 13 (76%) and TUNEL-positive endothelial cells in 3 (17%) women with increased CRP. Morphological analysis of small blood vessels in EMB in CSX female patients with increased CRP levels revealed signs of inflammation and apoptosis of endothelial cells, indicating the role of inflammation in the pathogenesis of CSX.

Apical hypertrophic cardiomyopathy in encephalomyopathy

Apical hypertrophic cardiomyopathy (AHC) is associated with neurological abnormalities such as transient ischemic attack, stroke, limb-girdle muscular dystrophy, or eosinophilic myositis in single cases. The association of AHC and metabolic myopathy has not been reported. In an 84-year-old woman with long-standing gait disturbance, dementia, Parkinson syndrome, ptosis, ophthalmoparesis, tetraparesis, polyneuropathy, lactacidosis, polyarthralgia, dorsalgia, and osteoporosis, cardiac examination for long-standing anginal chest pain and palpitations, revealed supraventricular and monomorphic ventricular ectopic beats, hypertrophic signs, ST-depression and negative T waves on electrocardiogram (ECG), diastolic dysfunction with impaired relaxation, and AHC on transthoracic echocardiography. AHC was confirmed by cardiac magnetic resonance imaging, which additionally showed a small left ventricular apical aneurysm with a wall-thickness of only 3 mm. The patient was suspected to additionally have a multisystem disease, most likely due to impaired oxidative metabolism. This case shows that AHC may take a mild course and be associated with a number of extracardiac abnormalities.

An unusual complication of coronary angiography: Bidirectional dissection of the right coronary artery and the ascending aorta

Iatrogenic aortocoronary dissection is a rare but devastating complication of percutaneous coronary interventions.The authors present the case of a 45 years old woman admitted for anginal chest pain. She underwent coronary angiography and developed complete anterograde dissection of the right coronary artery simultaneously with retrograde extensive propagation to the ascending aorta. Failure to attempt stenting because of altered hemodynamics and intractable chest pain prompted an emergent bypass surgery with treatment of the aortic dissection. Causes and modalities of treatment of iatrogenic aortocoronary dissections are discussed.

Apical Ballooning Syndrome or Takotsubo Syndrome: A Novel Cardiac Syndrome

Apical Ballooning Syndrome or Takotsubo Syndrome: A Novel Cardiac Syndrome

Congenital absence of left circumflex coronary artery presented with vasospastic angina and myocardial bridge in single left coronary artery

Congenital absence of left circumflex coronary artery (LCX) is a very rare congenital anomaly of the coronary circulation, and few cases have been reported in the literature. We report a case of a 48-year-old male who had congenital absence of LCX presented with vasospastic angina. Routine coronary angiography showed congenital absence of the LCX, typical myocardial bridge in the mid left anterior descending coronary artery (LAD) and super-dominant right coronary artery (RCA). The dominant LAD showed a spastic appearance at the baseline coronary angiography and significant spasm was induced by incremental intracoronary acetylcholine (ACh) provocation test at mid LAD where the myocardial bridge site was observed and was extended to the distal LAD. Typical anginal chest pain was documented during the Ach provocation test and the patient was stabilized with conventional anti-anginal medication. Precise morphological and functional evaluation of the anomalous coronary artery is important for selecting the best treatment modality and better prognosis.

Coronary Slow Flow Phenomenon and Risk for Sudden Cardiac Death Due to Ventricular Arrhythmias: A Case Report and Review of Literature

We report a case of coronary slow flow phenomenon (CSFP) in a patient who underwent coronary angiography due to anginal chest pain and recurrent syncope with complete normalization of flow after intracoronary adenosine. He was noted to have multiple episodes of nonsustained ventricular tachycardia on holter monitor and increased QTc dispersion on surface electrocardiogram (EKG). He responded very well to oral dipyridamole therapy with complete resolution of his symptoms and no episodes of ventricular tachycardia on the event recorder at 3 months. We review the diagnosis and clinical features of CSFP and its association with increased QTc dispersion and the role of oral dipyridamole therapy in this condition.

Relationship of epicardial adipose tissue by echocardiography to coronary artery disease

Objective:To study the relationship of echocardiographic epicardial adipose tissue (EAT) with coronary artery disease (CAD) risk factors and the extent of coronary atherosclerosis.Methods:EAT thickness was measured in 527 patients undergoing...

Myocardial Infarction in Healthy Adolescents

Chest pain in children and adolescents is a frequent cause for office or emergency department visits. However, it is unclear whether myocardial infarction occurs in children with no anatomic abnormality presenting with chest pain. Clinical history, electrocardiography, echocardiography, and cardiac enzyme levels were evaluated in patients presenting to the emergency department over a period of 11 years (June 1995 to May 2006). Patients in whom findings were suggestive of acute myocardial infarction, in addition, underwent drug screening, serum lipid profile, and hypercoagulability workup and, when myocardial infarction was diagnosed, heart catheterization with coronary angiography. Nine patients (8 boys; age range: 12-20 years; mean: 15.5 years) met established criteria for myocardial infarction. Abnormal electrocardiograms were found in 8 patients (6 with ST elevation and 2 with nonspecific ST-T abnormalities), abnormal cardiac enzyme levels in all, and echocardiographic abnormalities in 3. Cardiac dysrhythmias were found in 4 patients, 3 with nonsustained ventricular tachycardia. Drug abuse, lipid profile, and hypercoagulability studies were negative in all. Left ventricular focal hypokinesia was seen by echocardiogram or angiography in 5 patients and abnormal coronary anatomy in none. Cardiac function normalized in 8 patients. One patient had a persistent focal inferior hypokinesis. Calcium channel blocker therapy was initiated in all of the patients with no recurrence of anginal chest pain on follow-up. One patient complained of chest pain distinct from anginal pain. Myocardial infarction can occur in adolescents with normal coronary arterial anatomy. Adolescents who present for emergency care with typical chest pain need electrocardiographic and cardiac enzyme workups. Those with results that are suggestive of acute infarction require additional workup. Coronary vasodilation therapy seems helpful, but given the lack of coronary thrombosis in these patients, thrombolytic therapy seems unwarranted. Long-term follow-up is necessary, and adjustments in therapy may be required with time.

Diagnostic Accuracy of Myocardial Hypoenhancement on Multidetector Computed Tomography in Identifying Myocardial Infarction in Patients Admitted With Acute Chest Pain Syndrome

To evaluate prevalence and diagnostic accuracy of myocardial hypoenhancement (MH) using multidetector computed tomography (MDCT) in patients admitted for acute chest pain syndromes. Sixty-nine patients underwent first-pass MDCT, coronary angiography, and echocardiography. Using a standardized analysis protocol, left ventricular short-axis reformations were evaluated for presence, size, and density of MH in 16 myocardial segments. These were correlated with the presence and location of myocardial infarction (MI), regional myocardial dysfunction, and coronary artery disease. Myocardial hypoenhancement was found in acute MI (27/35), healed MI (6/14), unstable angina (3/9), and atypical chest pain (0/11). Sensitivity, specificity, and positive and negative predictive values of MH for diagnosing any MI were 67%, 85%, 92% and 52%, respectively. The presence of MH on MDCT in acute chest pain patients has high positive predictive value and specificity but only moderate sensitivity for presence of acute or healed MI using the strict criteria proposed in this study.

The effect of double dose of omeprazole on the course of angina pectoris and treadmill stress test in patients with coronary artery disease — A randomised, double-blind, placebo controlled, crossover trial

Background Gastroesophageal reflux (GER) and coronary artery disease (CAD) frequently overlap, making the proper diagnosis of chest pain more difficult. GER symptoms may mistake anginal chest pain, and oesophageal acidification may induce myocardial ischaemia both in the rest and in the effort. Increase of oesophageal pH should prevent these conditions. Aim To estimate the effect of double omeprazole dose on the course of angina pectoris and treadmill stress test in patients with coronary artery disease (CAD), using double-blind, crossover randomised, placebo-controlled study design. Methods We studied 48 patients with angina pectoris symptoms and significant narrowing of coronary vessels in angiography. After baseline examination and treadmill stress test all subjects were randomised to treat either with omeprazole (20 mg b.i.d.) or placebo for 14 days, using a double-blind, crossover placebo controlled design. Results Seventeen (35%) subjects reported more than by half decrease in symptoms severity after omeprazole and 6 (12%) after placebo ( p = 0,01). Omeprazole significantly decreased the number of chest pain episodes and number of nitroglycerin doses taken in the second week of both study phases, as well as the percentage of subjects with significant decrease of ST interval during the stress test (64% vs. 73%, p < 0,05). However majority of other stress test parameters (i.e. test duration, DUKE index) have improved both after omeprazole and placebo administration (by 9–38%). Conclusion Double dose of omeprazole significantly decreased symptoms severity in 35% of patients with CAD, as well as frequency of some electrocardiographic signs of myocardial ischaemia during stress test.

Coronary blood flow in patients with cardiac syndrome X

Epicardial coronary arteries are normal in patients with cardiac syndrome X. It is, however, unclear whether there is an abnormality at the level of microvascular circulation. In this study, our aim was to evaluate the epicardial coronary blood flow and myocardial perfusion in patients with cardiac syndrome X. Two hundred and three patients (mean age 53+/-10 years, 85 men) were included in the study. The diagnosis of cardiac syndrome X was made in patients who had a complaint of typical anginal chest pain and had ischemic findings on either myocardial perfusion scintigraphy or a treadmill exercise test, and whose coronary angiograms did not reveal any pathology. Fifty patients (mean age 54+/-11 years, 24 men) who had a complaint of typical anginal chest pain and had a normal myocardial perfusion test and normal coronary arteries were recruited as the control group. Epicardial coronary blood flow was evaluated with the thrombolysis in myocardial infarction frame count method and myocardial perfusion was evaluated with the myocardial blush grade method. A myocardial blush grade of < or =2 in any vessel was considered abnormal. Although the right coronary thrombolysis in myocardial infarction frame count was higher in patients with syndrome X (14.9+/-7.6 vs. 11.7+/-4.4 in controls; P=0.014), there were no statistically significant differences between the groups in terms of mean thrombolysis in myocardial infarction frame count in the coronary arteries. Abnormal myocardial blush grade was present in 85 patients (42.3%) with syndrome X, and in 17 patients (34.7%) in the control group (P>0.05). We found that the epicardial coronary blood flow, as assessed by thrombolysis in myocardial infarction frame count, and myocardial perfusion, as assessed by myocardial blush grade, were normal in patients with cardiac syndrome X.

Thyrotoxicosis with Coronary Spasm that Required Coronary Artery Bypass Surgery

We describe a 47-year-old woman with severe coronary vasospasm induced by hyperthyroidism. The patient complained of anginal chest pain without specific characteristics of thyrotoxicosis. Coronary arteriography was performed and revealed 90% stenosis of both the left and right coronary os. She was treated with emergent coronary artery bypass graft surgery. Postoperatively, she exhibited a comatose mentality. Severe thyrotoxicosis was indicated on thyroid function tests and thyrotoxic storm was diagnosed. Nineteen days after the surgery and following the initiation of propylthiouracil treatment, coronary arteriography revealed entirely normal coronary arteries.

Left ventricular free wall rupture in a Caucasian female with takotsubo syndrome: a case report and a brief literature review

The takotsubo syndrome is a clinical entity that can mimic an acute myocardial infarction. It is characterised by anginal chest pain with ST-T elevation in precordial leads, without coronary obstruction at angiography; its distinctive feature is a peculiar pattern of left ventricular contraction, with expansion of the apical segments and basal hyperkinesis, also known as 'apical ballooning'. This syndrome usually has a good prognosis, with normalisation of the left ventricular contraction impairment within several days, although Japanese authors have described two cases of free left ventricular wall rupture in these patients.We describe a case of apical ballooning syndrome complicated by left ventricular rupture in a Caucasian old female. To our knowledge, this is the first-ever case of a fatal outcome in the Caucasian population, due to free wall ventricular rupture, and confirms that the takotsubo syndrome may lead to a fatal cardiac event.

Coronary Collaterals in Full Effect

A 59-year-old man with no relevant medical history was referred to our clinic for analysis of exertional chest pain. He had noticed slowly progressive symptoms approximately 6 months before referral, although they did not prohibit his daily 12-mile cycling exercise routine. During diagnostic 99m-technetium-sestamibi single photon emission computed tomography treadmill stress testing, the ECG showed pathological ST-segment depression, and the patient had anginal chest pain. Three-dimensional reconstructed scintigraphic perfusion images (Figure 1) displayed a substantial reversible defect in the anterolateral myocardium with only a mild resting perfusion defect in the distal segment of the anterior wall, which coincided with a small area of subendocardial fibrosis visualized …

Myocardic extended ischemia after scombroid syndrome

We describe a case of a healthy woman, presenting to the emergency department because of sudden onset of diffuse pruriginous erythema, profound arterial hypotension and anginal chest pain, just after consuing a meal with cooked fresh tuna fish. She developed progressive ECG signs of myocardial ischemia suggesting subendocardial infarction and increased serum level of troponin I. After vigourous fluid resuscitation with iv fluids and treatment with anti-hystamine drugs, corticosteroids, beta-blockers and calcium-channell blockers she progressively recovered. A clinical diagnosis of sgombroid syndrome was established: it is a syndrome which may follow the ingestion of some spoiled fish, characterized by urticara, headhache, gastrointestinal upset and rarely bronchospasm, shock, coronary ischemia and arrythmias. A sample of the consumed fish could be analysed, finding a very high level of hystamine concentration, conferming the diagnosis of sgombroid syndrome. A coronary angiography was performed and confermed the patient had a normal coronary tree, devoid of atherosclerotic lesions. Her anginal symptoms and ECG signs were probably due to functional ischemia determined by hystamine mediated vasoconstriction and hypotension. This not so rare but not well known syndrome is further discussed and addressed to the emergency physicians’ attention, because of its importance in the differential diagnoses of suspected food allergies

Talking about…

Talking about…

Myocardial perfusion SPECT with dipyridamole stress test in cardiac syndrome X

Cardiac syndrome X defines patients with typical anginal chest pain, a positive exercise ECG stress test and angiographically normal coronary arteries. AIM of this study was to evaluate the role of myocardial perfusion SPECT with dipyridamole stress in the diagnosis of cardiac syndrome X. 68 patients with syndrome X aged 32 to 60 years were subjected to myocardial imaging using (99m)Tc-MIBI according to the two-days protocol: at rest and after dipyridamole infusion. Semiquantitative evaluation of the images was based on the assessment of (99m)Tc-MIBI uptake in 17 myocardial segments using a 5-points scale (0 point -- normal uptake, 4 points -- no uptake). Scores obtained in each segment were summed up, constituting the summed rest score (SRS) and summed stress score (SSS). Mean SRS was 7.9 +/- 4.8 and mean SSS was 7.2 +/- 4.4 (non-significant difference). Individual comparison of SRS and SSS values revealed three patterns of scintigraphic images: 1) in 25 patients (36.8%), a paradoxical improvement of perfusion at stress images was found, 2) in 23 patients (33.8%), the myocardial perfusion deteriorated after dipyridamole, 3) in 20 patients (29.4%), no significant change of the myocardial perfusion between rest and stress images occurred. In cardiac syndrome X, myocardial SPECT with dipyridamole stress shows different patterns of myocardial perfusion that reflects heterogeneity of this pathology.

Hypertrophic Cardiomyopathy

Hypertrophic Cardiomyopathy