Atypical Chest Pain Research Articles

Transient Brugada Like after Scorpion Sting: An Unexpected Connection

Introduction: Brugada syndrome was described in 1992 as a new clinical and electrocardiographic syndrome involving susceptibility to ventricular arrhythmias and sudden cardiac death in patients without obvious structural heart disease. Brugada phenocopy (BrP) is an evolving term for Brugada-like ECG patterns due to reversible causes. In this article, we will illustrate the case of a patient presenting with a transient Brugada pattern following a scorpion sting. Case Report: A 65-year-old woman with age and menopause as cardiovascular risk factors, but no notable medical history, presented to the emergency department with atypical chest pain five hours after a scorpion sting. She had no associated symptoms such as dyspnoea, syncope, or palpitations, nor a personal or family history of sudden death. On admission, she was conscious, hemodynamically stable, normotensive, and tachycardic, with no signs of heart failure. Her ECG showed a 2 mm elevation at the J point and an inverted T wave in V1 and V2, indicating a Brugada pattern. She was admitted to the ICU for close monitoring. An echocardiogram revealed normal left and right ventricular function. Lab tests showed negative troponins, a normal blood ionogram, and normal renal and hepatic function. The Brugada pattern resolved within a few hours, and the patient remained stable. Discussion and Conclusion: Our case highlights the importance of conducting a thorough medical history to rule out the presence of arrhythmia, syncope, or a family history of sudden cardiac death in similar situations. If the history raises concerns, cardiological follow-up is essential to investigate the possibility of Brugada syndrome. Performing a follow-up ECG at discharge is beneficial to confirm the reversibility of the findings. This distinction is crucial as it helps differentiate between Brugada syndrome and the Brugada pattern, the latter being a condition that may occur in patients with scorpion stings or other triggers.

Score-2 in heavy smokers: are we underestimating the risk?

Abstract Background The shared diagnostic decision-making process in patients with atypical chest pain is challenging, especially when functional tests are negative. SCORE2 (1) can help in making decisions. In this score, the risk is assessed based on geographical origin, age, sex, current smoking, systolic blood pressure, cholesterol values. However, it does not take into account the quantity of cigarettes smoked but only the current binary value, yes or no. In our study we wanted to evaluate the impact of smoking on prognosis, considering the number of cigarettes smoked and in particular focusing on heavy smokers. Methods In the last 15 years we evaluated 3,588 outpatients aged >35 years (average 64±9, women 55%) for the presence of stable chest pain. We excluded 290 patients who had ECG changes compatible with recent ischemia, history of myocardial infarction or any other major cardiovascular event, evidence of heart failure, left ventricular dysfunction, or cardiomyopathies. In the other 3,298 cases we applied the traditional classification of typical, atypical angina and non-anginal pain. A functional test was performed in all patients. In 2,774 patients with atypical chest pain and negative functional test we evaluated the extent of cardiovascular risk based on SCORE2 and the number of cigarettes currently smoked. One year follow-up was carried out to evaluate vital status and any fatal and non-fatal cardiovascular events. Results Table 1 shows the events in patients classified according to the degree of cardiovascular risk of SCORE2 and in heavy smokers (≥ 20 cigarettes per day) aged <70 years as a cathegory in itself. In moderate smokers (<20 cigarettes/day) of any age, the risk was considered binary as in the conventional assessment. Tables 2 and 3 show the risk stratification in male and female patients. SCORE2 is unable to intercept the extremely high risk of heavy smokers aged <70 years. This happens both in males, considered at moderate risk in 76% of cases but with a rate of fatal events of 2.4% and as many non-fatal events, both in women with a risk considered moderate in 80% of cases but with a 12% rate of fatal events (as seen in Table 1). Conclusions SCORE2 does not consider the quantity of cigarettes smoked per day, so if we rely on it heavy smokers seem to have a moderate risk. On the contrary, based on our analysis, they all have an extremely high risk, regardless of other risk factors, and in any case higher than non-smoking or moderately smoking patients. Especially heavy smoking women aged <70 years with atypical chest pain and negative functional tests have an extreme risk of fatal cardiac events (12% at one year). Probably these patients (male and female), regardless of the outcome of functional tests, should be sent for an anatomical evaluation for the detection of high-risk stenosis, as well as firmly urged to improve lifestyles and treat risk factors .

The prognostic value of contrast stress echocardiography in a real-world population of symptomatic patients without known coronary artery disease

Abstract Background Coronary artery disease (CAD) is the leading cause of mortality and morbidity worldwide. In addition to diagnosis, non-invasive tests may also provide prognostic information useful in the risk stratification and management of CAD patients. Stress echocardiography (SE) is an accurate, non-invasive method for the detection of obstructive CAD. However, in real-world clinical practice the test performance may vary among different centres, depending on availability, local protocols, and operator expertise. Purpose To evaluate the prognostic value of contrast SE in a real-world population of symptomatic patients without known CAD. Methods This was a cohort follow-up study of patients without known CAD and symptoms of atypical chest pain, unexplained dyspnoea or palpitations who were referred to the echocardiography lab of a tertiary hospital for SE between January 2020 and December 2021. Patients with resting regional wall motion abnormalities were excluded. All patients underwent treadmill exercise stress echocardiography (ESE) or dobutamine stress echocardiography (DSE) if unable to exercise. Contrast agents were used in almost all patients (99%). The study population was followed-up for at least 2 years after SE by phone and/or electronic hospital records. Cardiac outcome was defined as anatomically or functionally significant stenosis on angiography, revascularization, acute coronary syndrome (ACS), or cardiac-related death. Results The study comprised 266 patients (mean age 58±12 years, 63% male) who underwent either ESE (58%) or DSE (42%). The patients' details are reported in Table 1. The most common indication for the exam was atypical chest pain, with a prevalence of 73%. SE exams were positive for inducible ischaemia in 14 (5%) patients. Symptoms during the exam were present in 3 (21%) patients with positive SE and 4 patients (2%) with negative SE (p=0.004). No serious complications (sustained ventricular tachycardia, myocardial infarction, or death) were recorded. During the follow-up (median 30, IQR 23–38 months), 264 patients (99%) were successfully contacted. Cardiac outcome occurred in 10 patients. Among 14 patients with positive SE, 8 underwent revascularization due to significant coronary artery stenosis. Among 250 patients with negative SE, 1 underwent revascularization due to significant coronary artery stenosis and 1 presented with ACS 13 months after the test (both patients underwent DSE). Negative predictive value was 99% over a median follow-up of 30 months, corresponding to an annualized event rate of 0.32% per year. A positive SE was significantly associated with cardiac outcome (log-rank test p<0.0001, Figure 1). Conclusion Contrast SE carries significant prognostic implications in symptomatic patients without known CAD. A positive test is strongly associated with the need for revascularization, while a normal test result has an excellent negative predictive value regarding cardiovascular morbidity and mortality.Figure 1

NICE guidance in the rapid access chest pain clinic: does it work?

Abstract Background Rapid Access Chest Pain Clinics (RACPC) were developed following the publication of the National Service Framework for Coronary Heart Disease in 2000(1). The National Institute for Health and Care Excellence (NICE) produces guidelines for the management of patients with recent onset chest pain of suspected cardiac origin(2). In 2016 the guidance was updated and recommended the use of CT coronary angiography (CTCA) as the initial investigation for patients with chest pain which was typical or atypical of angina. Adherence to the guideline may be dependent upon factors such as local availability of CT scanners and clinician preference. The RACPC in this tertiary centre is nurse-run with no medical involvement. There is good engagement with the CT department and in July 2017 the NICE guidance was adopted in the clinic. Purpose To evaluate the use of CTCA as the first line investigation for patients with typical or atypical chest pain. Methods Data from all patients reviewed in the clinic between 01/07/2017 and 31/12/2023 were prospectively collected, entered into a database, and then retrospectively analysed. The data were organised into 3 groups: patients with typical chest pain; atypical pain and those with non-cardiac sounding chest pain. The number of patients in each group who underwent a CTCA, and the outcome of the scan were evaluated. The CT scans were categorised as showing significant coronary artery disease (CAD), non-obstructive CAD, no CAD, or as inconclusive. The outcome of patients who had a positive CTCA was also recorded. Results 2986 patients were reviewed in the RACPC in the above period. 14.2% of patients presented with typical pain, 47.4% with atypical pain, and 30.6% had non-cardiac pain. The remaining patients presented with other symptoms such as breathlessness. CTCA was used as the first investigation in the majority of patients with typical or atypical pain, unless alternative investigations or management were deemed to be more clinically appropriate. In 59.5% of typical and 78.5% of atypical presentations, the CT scan showed no CAD, or non-significant CAD. There was a low incidence of positive scans in both groups, however patients with typical pain were more likely to have significant CAD (Table). All patients who had a CTCA indicating significant CAD, were referred for invasive angiography. 88.0% of typical presentations, and 64.0% of those with atypical pain, underwent revascularisation. No patient who underwent invasive angiography was found to have normal coronary arteries. Conclusion Atypical pain is the most frequent presentation in the RACPC, however the majority of these patients, and most of those with typical pain, do not have significant CAD. Careful assessment and the use of CTCA as the initial investigation, enable the identification of those patients who need invasive angiography. This is a cost-effective strategy which also reduces risk and radiation exposure for patients.

Association between dyspnea, chest pain, nt-probnp and cardiac impairment in people with cystic fibrosis

Abstract Background Cystic fibrosis (CF) is an autosomal recessive disease affecting multiple organs. Emerging evidence indicates an elevated risk of cardiovascular complications in people with CF (pwCF), with some studies implicating CF-related cardiomyopathy as an underlying mechanism. Whether screening for cardiac symptoms and N-terminal pro B-type natriuretic peptide (NT-proBNP) levels may aid in identifying cardiac impairment in pwCF remains unknown. Purpose To assess prevalence of dyspnea and chest pain in pwCF and investigate whether symptoms and NT-pro-BNP are predictive of cardiac impairment. Methods We interviewed 104 adult pwCF and 104 age- and sex-matched controls from the general population about symptoms of dyspnea and chest pain. All participants were examined with transthoracic echocardiography and NT-proBNP. Cardiac impairment was defined as left ventricular (LV) ejection fraction (LVEF) <50%, LV global longitudinal strain (GLS) < 16% or presence of diastolic dysfunction. Results Chest pain was more frequent in pwCF than in controls: (29% vs. 1%, p<0.001), although primarily characterized as atypical and non-exertional chest pain (27%). PwCF also suffered more from dyspnea than controls (89% vs. 18%, p<0.001) (Figure 1) and more pwCF had abnormal cardiac function compared to controls (44% versus 22%, p<0.001). Median NT-proBNP in pwCF was 50.0 pg/ml (40.7; 100.8) and increasing NT-proBNP level was associated with decreasing FEV1 (L) (estimate: -0.008, p<0.001). NT-proBNP level was not associated with neither dyspnea nor chest pain (p=0.60 and p=0.15, respectively). PwCF with dyspnea did not differ from those without on clinical or echocardiographic parameters. However, pwCF with chest pain had lower absolute GLS compared to pwCF without (17.4% vs.18.5%, p=0.026). Neither dyspnea nor chest pain was more frequent in pwCF with cardiac impairment versus normal cardiac function (54% vs. 39%, p=0.17 and 29% vs. 28%, p=0.91, respectively). Decreasing absolute GLS was associated with increased odds of chest pain (OR 1.25, 95% CI 1.02; 1.53, p=0.030) (Figure 2). Neither dyspnea or chest pain alone, nor in combination with NT-proBNP were able to predict abnormal cardiac function. While dyspnea and chest pain combined showed a slight improvement in sensitivity and positive predictive value for diagnosing cardiac impairment, the combination of symptoms and increased NT-proBNP did not enhance diagnostic accuracy. Conclusions In this cross-sectional study, dyspnea and atypical, non-exertional chest pain were common symptoms in adult pwCF. While abnormal cardiac function was prevalent in pwCF, neither symptoms, NT-proBNP nor a combination of these were associated with increased odds of cardiac impairment. Dyspnea and chest pain, though prevalent, are multifactorial in pwCF and do not seem to serve as sensitive markers of cardiac impairment, even when combined with NT-proBNP level.

High Altitude Polycythemia Presenting as Atypical Chest Pain with TMT Positive and Normal Coronaries

High-altitude polycythemia (HAP), also known as chronic mountain sickness (CMS), is a condition in which individuals residing at high altitudes develop increased red blood cell mass in response to chronic hypoxia. This leads to increased hemoglobin and hematocrit levels, which can result in complications such as blood hyperviscosity, thrombotic events, and rarely, cardiovascular symptoms like chest pain. This case report illustrates a patient presenting with atypical chest pain, a positive treadmill test (TMT), and normal coronary angiography, whose symptoms were ultimately attributed to HAP.

The pericoronary adipose tissue attenuation in CT strongly depends on kernels and iterative reconstructions.

To investigate the influence of kernels and iterative reconstructions on pericoronary adipose tissue (PCAT) attenuation in coronary CT angiography (CCTA). Twenty otherwise healthy subjects (16 females; median age 52 years) with atypical chest pain, low risk of coronary artery disease (CAD), and without CAD in photon-counting detector CCTA were included. Images were reconstructed with a quantitative smooth (Qr36) and three vascular kernels of increasing sharpness levels (Bv36, Bv44, Bv56). Quantum iterative reconstruction (QIR) was either switched-off (QIRoff) or was used with strength levels 2 and 4. The fat-attenuation-index (FAI) of the PCAT surrounding the right coronary artery was calculated in each dataset. Histograms of FAI measurements were created. Intra- and inter-reader agreements were determined. A CT edge phantom was used to determine the edge spread function (ESF) for the same datasets. Intra- and inter-reader agreement of FAI was excellent (intra-class correlation coefficient = 0.99 and 0.98, respectively). Significant differences in FAI were observed depending on the kernel and iterative reconstruction strength level (each, p < 0.001), with considerable inter-individual variation up to 34 HU and intra-individual variation up to 33 HU, depending on kernels and iterative reconstruction levels. The ESFs showed a reduced range of edge-smoothing with increasing kernel sharpness, causing an FAI decrease. Histogram analyses revealed a narrower peak of PCAT values with increasing iterative reconstruction levels, causing aFAI increase. PCAT attenuation determined with CCTA heavily depends on kernels and iterative reconstruction levels both within and across subjects. Standardization of CT reconstruction parameters is mandatory for FAI studies to enable meaningful interpretations. Question Do kernels and iterative reconstructions influence pericoronary adipose tissue (PCAT) attenuation in coronary CT angiography (CCTA)? Findings Significant differences in fat-attenuation-index (FAI) were observed depending on the kernel and iterative reconstruction strength level with considerable inter- and intra-individual variation. Clinical relevance PCAT attenuation heavily depends on kernels and iterative reconstructions requiring CT reconstruction parameter standardization to enable meaningful interpretations of fat-attenuation differences across subjects.

Utility of the AngelMed Guardian System in myocardial bridging: a case report

BackgroundMyocardial bridging (MB) is a known congenital anomaly in which a segment of the coronary artery transverses from the epicardium through the myocardium. MB may clinically manifest as recurrent angina, acute coronary syndrome, ventricular dysrhythmia, and even sudden cardiac death. On electrocardiogram (EKG), MB can present with findings consistent with significant ST-segment changes. The AngelMed Guardian System (the Guardian device) was developed in an effort to optimize the time from the onset of myocardial ischemia to intervention. The device analyzes myocardial electrical changes and alerts the patient to seek emergent medical evaluation if an acute ST-segment deviation is detected. We describe the first documented case of the Guardian device detecting acute ST-segment changes secondary to myocardial bridging.Case PresentationA 50-year-old male, with a history of percutaneous coronary intervention of the proximal left anterior descending (LAD) artery, presented to his cardiologist’s office with reports of recurrent, atypical chest pain. The Guardian device was implanted. One month after implantation, the patient experienced chest pain and was alerted by the Guardian device to seek emergent medical evaluation. Initial EKG and high-sensitivity troponins were negative for acute ischemia. Guardian device interrogation revealed significant ST depressions, encouraging further ischemic evaluation. The exercise myocardial perfusion imaging revealed an apical reversible defect. Left heart catheterization revealed a large segment of mid-LAD MB with the patient’s previous LAD stent noted to be widely patent along with no evidence of new obstructive coronary disease. Following the identification of the MB, medication regimen adjusted and the patient denied recurrence of chest pain or Guardian alerts.ConclusionsWe describe the first documented case of the Guardian device detecting acute ST-segment changes that were secondary to myocardial bridging. The Guardian device appropriately documented an ischemic event not appreciated with initial EKG or troponin testing. With the assistance of the Guardian device, we were able to rapidly identify MB as the cause for the ischemic EKG changes and subsequent abnormal stress test, optimize medical management, and prevent recurrent atypical chest pain along with office and hospital visits.

DO TEACHING HOSPITALS HAVE COMPARABLE OUTCOMES TO NON-TEACHING HOSPITALS FOR PERCUTANEOUS CORONARY INTERVENTIONS?

Objectives: Teaching hospitals may have comparable surgical outcomes as compare to non-teaching hospitals from major surgical conditions. However, limited data are available regarding percutaneous coronary interventions performed in teaching hospitals involving trainées. Methods: In this observational study, 103 patients who had percutaneous coronary intervention (PCI) in a hospital attached to a medical college were retrospectively evaluated. The indications for PCI were ST-elevation myocardial infarction (STEMI), improvement in quality of life in patients with atypical chest pain, angina (stable and unstable, a positive stress test, or non-STEMI, and patients without any documented angina, chest pain, or positive stress test. Teaching hospital status was as defined by the National Medical Commission-based number of teaching faculty/trainees to-bed ratio. Trainee participation in at least 50% PCI procedures in the teaching hospital was a pre-requisite for inclusion in the study. Results: The mean age of participants was 60.4±9.8 years; there was a male preponderance (84.4%). Prior PCI was done in 11.3% patients and 7.5% had history of stroke previously. About 20.6% were diabetics, 33.9% had dyslipidemia, and 50.9% had systemic hypertension, respectively. Left anterior descending with the left coronary circumflex artery was the most affected vessels in both sexes combined and 84.4% patients had double-vessel disease. Thirty-one (31.9%) underwent PCI by femoral route and 72 (68%) by radial route, respectively. PCI was successful in 74 (71.8%) and 10 (9.7%) had vascular complication. The mortality rate was 6 (5.8%). Twenty-five (24.3%) patients had reinfarction. Conclusion: Although vascular complications may occur at the hands of trainees, the overall mortality rates are low for PCI in teaching hospitals.

7071 Cushing disease presenting with Dilated Cardiomyopathy

Abstract Disclosure: H. Majeed: None. C. Nguyen: None. R. Galagan: None. D. Lovre: None. Background: Hypercortisolism manifests with numerous ways due to the wide distribution of glucocorticoid receptors. Here we describe a case of Cushing’s disease presenting with reversible non-ischemic cardiomyopathy. Case Presentation: A 30-year-old male presented to ER with palpitations, dyspnea, and atypical chest pain. His exam was notable for a BMI of 30.26 kg/m2, HR 76 bpm and BP of 200/110 mm Hg. His EKG revealed Left ventricular hypertrophy. Echocardiogram (ECHO) showed an EF of 25-30% with diffuse hypokinesis. An angiogram demonstrated normal coronary anatomy. He was started on Lisinopril, Carvedilol, and Spironolactone for non-ischemic cardiomyopathy. He also complained of a 40 lb weight gain, loss of libido, hot flashes and breast tenderness. He was referred to endocrinology. Initial evaluation demonstrated total testosterone (TT) of 171 ng/dl (286-1511 ng/dl), FSH 3.8 IU/L (2-12 IU/L), LH 5.6 IU/L (2-9 IU/L) consistent with secondary hypogonadism. Further pituitary workup revealed AM cortisol level 31.22 mcg/dl (4.3-22.4mcg/dl), ACTH 79 pg/ml (7.2 - 63.3pg/ml), IGF-1 257 ng/mL (88-246 ng/mL), Prolactin 23.7 ng/dl (2.1- 17.7ng/dl), TSH 0.54 mIU/l (0.35-3.74mIU/l) and FT4 0.6 ng/dl (0.76-1.46 ng/dl). A 24hr urine cortisol was 167 ug(0-50ug/24h) and midnight salivary cortisol 0.160 ug/dl (&amp;lt;0.010-0.090 ug/dl). An overnight 1mg dexamethasone suppression test (DST) resulted in AM cortisol of 20.95 mcg/dl (&amp;lt;1.8mcg/dl) and 8mg DST cortisol fell from 34 mcg/dl to 4.16 mcg/dl. A pituitary MRI revealed a left 6 mm x 4 mm microadenoma. He was treated with levothyroxine pre-op for central hypothyroidism. He underwent transsphenoidal resection of the pituitary adenoma. Post-op AM cortisol was 1.1 mcg/dl. His steroid withdrawal syndrome was treated with a prolonged course of tapered hydrocortisone. Two months post-op ECHO showed EF of 55-60%. His BP normalized on carvedilol alone. Eighteen months post-op he no longer required any hormone replacement. Repeat ACTH 24.4 pg/ml, Total Testosterone 584ng/dl, TSH 0.57 mIU/l and FT4 0.93 and 24hr urine cortisol was 24ug/dl, MN salivary cortisol &amp;lt;0.10 ug/dl confirming remission of his cushing's disease and resolution of secondary hypogonadism and hypothyroidism. Conclusion: Prolonged hypercortisolism can cause abnormal cardiac remodeling resulting in cardiomyopathy. Surgical remission of Cushing’s disease reverses hypercortisolism which may restore normal cardiac function. Presentation: 6/2/2024

A penetrating aortic ulcer rapidly evolving into aortic dissection in a patient presenting with respiratory tract infection to the emergency department: an acute aortic syndrome case report

BackgroundPenetrating aortic ulcers (PAU) are life-threatening conditions which derive from severely advanced atherosclerotic lesions of the aorta. The clinical course is unpredictable; thus clinical vigilance should be maintained. It is very challenging to separate PAU from co-existing AAS as predisposing factors and findings overlap.Case presentationCase of 58-year-old gentleman, who presented for atypical chest pain in the setting of respiratory tract infection. Computed Tomographic angiography (CTA) of the chest showed a large PAU and intramural hematoma which rapidly progressed into an acute aortic dissection in the emergency department. Close follow up with cardiac point of care ultrasound one hour later detected an intimal flap which was not initially present on CTA. Patient underwent surgical aortic graft replacement and had an uneventful in-hospital stay.DiscussionThis case underlines the importance of broadening differential diagnoses in atypical presentations in patients with risk factors. Prompt intervention and careful management are imperative to optimize patient outcomes and prevent complications of aortic lesions. Cardiac point of care ultrasound can help in detecting progression of dynamic atherosclerotic diseases such as acute aortic syndrome.

Safety and Usefulness of Intracoronary Acetylcholine 200 μg Into the Left Coronary Artery as Vasoreactivity Testing: Comparisons With Intracoronary Acetylcholine Maximum 100 μg.

We retrospectively analyzed the usefulness and safety of intracoronary acetylcholine (ACh) 200 μg into the left coronary artery (LCA) as vasoreactivity testing compared with intracoronary ACh 100 μg. We recruited 1433 patients who had angina-like chest pain and intracoronary ACh testing in the LCA, including 1234 patients with a maximum ACh 100 μg and 199 patients with a maximum ACh 200 μg. ACh was injected in incremental doses of 20/50/100/200 μg into the LCA. Positive spasm was defined as ≥ 90% stenosis, usual chest pain, and ischemic electrocardiogram (ECG) changes. The incidence of coronary constriction ≥ 90%, usual chest pain, and ischemic ECG changes with a maximum ACh of 100 μg was markedly higher than that with a maximum ACh of 200 μg. The frequency of unusual chest pain in patients with a maximum ACh of 200 μg was higher than that in those with a maximum ACh of 100 μg (13% vs. 3%, p < 0.001). In patients with rest angina, positive spasm of maximum ACh 100 μg was significantly higher than that of maximum ACh 200 μg, whereas there was no difference regarding positive spasm in patients with atypical chest pain between the two ACh doses. Major complications (1.38% vs. 1.51%, p = 0.8565) and the occurrence of paroxysmal atrial fibrillation (1.81% vs. 2.63%, p = 0.6307) during ACh testing in the LCA were not different between the two maximum ACH doses. Intracoronary ACh 200 μg into the LCA is clinically useful and safe for vasoreactivity testing when intracoronary ACh 100 μg dose not provoke spasms.

REVERSIBILITY OF COMPLETE HEART BLOCK AFTER ACUTE ANTERIOR WALL MI

Acute myocardial infarction (MI) can result in varying degrees of heart block, most commonly in inferior wall MI. Identifying the reversibility of complete heart block (CHB) is crucial for guiding clinical management, particularly in determining the need for temporary or permanent pacemaker implantation. Objective: To determine the frequency of reversibility of complete heart block in patients presenting with acute myocardial infarction at Bolan Medical Complex, Quetta. Methods: This cross-sectional study was conducted at Bolan Medical Complex, Quetta, from March 2022 to June 2023. A total of 100 patients aged 18–65 years presenting with syncope and atypical chest pain were included. All patients underwent coronary angiography to identify ischemic causes of bradyarrhythmias. Temporary pacemaker dependency was monitored for two weeks, and permanent pacemaker implantation was performed if necessary. Data on demographic and clinical characteristics were collected and analyzed using SPSS version 22.0. Descriptive statistics were calculated, and the association between heart block reversibility and clinical variables was assessed using the Chi-square test, with p ≤ 0.05 considered significant. Results: The mean age of the patients was 52.5 ± 14.8 years, with 60% male and 40% female patients. The prevalence of diabetes, hypertension, and smoking was 40%, 55%, and 43%, respectively. CHB occurred in 7% of patients aged 16-35 years and 8% in those aged 36-65 years. The overall reversibility rate of CHB was 48%. A statistically significant association (p &lt; 0.05) was found between second-degree atrioventricular (AV) block and CHB in relation to reversibility. Conclusion: Complete heart block in patients with acute myocardial infarction is often reversible, particularly in those with mild coronary artery disease. Temporary pacemaker use should be considered before deciding on permanent pacemaker implantation to allow time for potential spontaneous recovery.

Peak Procedural ACT Is Associated With All-Cause Mortality After Femoral Access PCI

BackgroundA minimum threshold activated clotting time (ACT) to guide heparin dosing during percutaneous coronary intervention (PCI) is associated with lower ischemic complications. However, data are variable regarding the risk of high ACT levels. The aim of this study was to assess the impact of peak procedural ACT on complications and mortality for transfemoral and transradial access PCI. MethodsThe UC San Diego Health National Cardiovascular Data Registry CathPCI Registry was used to obtain data on patients who underwent native vessel PCI from January 2007 to September 2022. Coronary artery bypass graft patients and those who received bivalirudin were excluded. Complications and all-cause mortality at 30 days and 1-year post-PCI were assessed by ACT tertile. ResultsA total of 2473 patients (age 65 ± 12 years; 74% male) undergoing PCI with 53% femoral and 47% radial access were included. The majority (82%) had 1-vessel coronary artery disease with heterogeneous clinical presentations (21.8% ST-elevation myocardial infarction, 25.4% non–ST-elevation myocardial infarction, 4.9% unstable angina, 33.8% stable angina, 3.4% atypical chest pain, 10.7% other indication for PCI). With femoral access, patients in the third tertile (ACT ≥ 275) had significantly higher all-cause mortality at 30 days (5.3% vs 2.7% vs 0.9%; P < .001), 6 months (6.3% vs 4.0% vs 2.0%; P = .007), and 1 year (9.0% vs 6.0% vs 2.7%; P < .001) compared to the second (ACT 228-275) and first tertile (ACT ≤ 228), respectively. A 30-day landmark analysis revealed that there was no difference in all-cause mortality beyond 30 days (3.9% vs 3.4% vs 1.8%; P = .176). There were increased bleeding complications in the highest tertile (12.8% vs 9.8% vs 7.5%; P = .034) and a higher need for blood products (10.4% vs 6.7% vs 5.4%; P = .014). There was no difference in ischemic major adverse cardiovascular events specifically periprocedural myocardial infarction or stroke between tertiles. There was no difference in clinical outcomes by peak ACT for patients who had radial access. ConclusionsHigher ACT with transfemoral access PCI was associated with increased 30-day mortality, bleeding complications, and need for blood products post-PCI.

Predicting cardiovascular events in out-of-hospital patients presenting with atypical chest pain and complete left bundle branch block: role of CTA and echocardiographic Global Longitudinal Strain.

Out-of-hospital patients presenting with atypical chest pain and complete left bundle branch block (LBBB) have to be stratified for the presence of coronary artery disease and the risk of developing heart failure (HF). We investigated the prognostic role of coronary CT-angiography (CTA) and echocardiographic global longitudinal strain (GLS) in those patients in a mid-term follow-up. Out-of-hospital patients with LBBB underwent echocardiography and a 64-slice CT angiography were evaluated retrospectively. Development of HF or a cardiovascular death were the events scheduled. Seventy-eight patients (32 female; mean age: 66.0 ± 10.4 years were enrolled. During a follow-up of 33 months (IQR: 17-77), one patient (1.5%) experienced a cardiovascular death, 14 patients (17.9%) required urgent outpatient visits due to acute decompensated HF (12 hospitalizations). Echocardiography showed a slightly reduced left ventricular ejection fraction (LVEF) (50.0% ± 9.8%) and GLS within the normal range (-16.2% ± 4.1%). CTA analysis showed coronary stenosis > 50% in 28 patients (35.9%). A high Agatston score (> 100) was observed in 29.5%. Notably, 25 patients (32.1%) were diagnosed with left main coronary artery disease and 15 patients (16.7%) underwent revascularization during the follow up. Significant associations were observed between events and LVEF (P = 0.001), diastolic dysfunction grade ≥ 2 (P = 0.02), GLS (P < 0.001), multiple coronary stenosis (P = 0.04) and Agatston score (P = 0.05). Multivariate analysis confirmed the relationships with LVEF (R2 = 0.89, P < 0.001), diastolic dysfunction (R2 = 3.30, P = 0.04), GLS (R2 = 1.43, P < 0.001), and Agatston score (R2 = 1.01, P = 0.05). In patients with complete LBBB, CTA and GLS identified those at a high risk of development HF.

Chest pain.

Chest pain is a common symptom in the community, with underlying causes ranging from benign musculoskeletal pain to life-threatening cardiac events. It is a challenging presentation for healthcare providers, because the aetiology is not always immediately apparent. Chest pain can also cause significant anxiety for patients, leading to increased healthcare utilisation and costs. The objective of this discussion is to emphasise the importance of accurately describing the nature of chest discomfort and using appropriate terminology to facilitate an appropriate diagnostic work-up. The discussion also highlights the differences between typical and atypical chest pain and provides information about the aetiology of chest pain and management in the community. Accurately describing the nature of chest discomfort by using appropriate terminology is crucial in identifying the underlying cause of the symptom. Healthcare providers should be aware of the different terms patients might use to describe their chest discomfort and use precise and informative terms to describe the potential underlying cause of the chest pain. Atypical chest pain is often used to describe non-cardiac chest pain, but it lacks specificity. Using the terms 'cardiac,' 'possibly cardiac' or 'non-cardiac' is the preferred terminology.

Symptomology, Outcomes and Risk Factors of Acute Coronary Syndrome Presentations without Cardiac Chest Pain: A Scoping Review.

For patients experiencing acute coronary syndrome, early symptom recognition is paramount; this is challenging without chest pain presentation. The aims of this scoping review were to collate definitions, proportions, symptoms, risk factors and outcomes for presentations without cardiac chest pain. Full-text peer reviewed articles covering acute coronary syndrome symptoms without cardiac chest pain were included. MEDLINE, CINAHL, Scopus and Embase were systematically searched from 2000 to April 2023 with adult and English limiters; 41 articles were selected from 2,954. Dyspnoea was the most reported (n=39) and most prevalent symptom (11.6-72%). Neurological symptoms, fatigue/weakness, nausea/ vomiting, atypical chest pain and diaphoresis were also common. Advancing age appeared independently associated with presentations without cardiac chest pain; however, findings were mixed regarding other risk factors (sex and diabetes). Patients without cardiac chest pain had worse outcomes: increased mortality, morbidity, greater prehospital and intervention delays and suboptimal use of guideline driven care. There is a need for structured data collection, analysis and interpretation.

An Unusual ECG Finding during Adenosine Stress Myocardial Perfusion Imaging

Adenosine is extensively utilized in myocardial stress perfusion imaging for the detection and risk stratification of coronary artery disease. It has a well-established safety profile. The majority of the undesirable effects experienced during adenosine infusion are transient (owing to its brief half-life of ~10 s) and arise from the stimulation of receptors in the atrio-ventricular (AV) node (AV block) and bronchial smooth muscles (bronchospasm). We hereby report an unusual electrocardiographic finding during adenosine stress perfusion imaging, in a patient who had previously undergone single chamber pacemaker insertion and was referred for the assessment of atypical chest pain.

Analysis of patient data to explore cardiovascular risk factors

According to the World Health Organisation, cardiovascular diseases claim over 17.9 million lives yearly on a global scale. Hence, cardiovascular diseases are responsible for 32 percent of global deaths yearly. Furthermore, it is estimated that more than 50 percent of heart disease cases are only discovered after they have reached the critical stage of heart failure and stroke. However, early detection of these heart diseases can reduce the mortality rates of cardiovascular diseases. Scientists have suggested using machine learning algorithms to identify the risk factors. However, the unavailability of data has hindered the significant success of this approach. In this study, machine learning algorithms are used to identify the important features that should be monitored to prevent heart diseases by considering a dataset obtained from 1000 patients. The six machine learning algorithms used for this study are Logistic Regression, Support Vector Machine, k-nearest Neighbour, Decision Tree, Random Forest and Multi-layer Perception Classifier. The dataset consists of twelve features that are considered to be associated with heart disease and a target variable. The results from this study show that patients suffering from typical and atypical angina chest pain are prone to heart disease. Patients who exercise up the slope have a higher likelihood of living without heart disease. Among the six algorithms used, the MLP Multi-layer Perception Classifier outperforms all others by achieving a 99 percent accuracy. Moreover, the Random Forest algorithm follows with an accuracy of 98 percent.

Hospital Outcome of Hypertensive Non-ST elevation Myocardial Infarction Patients in Diabetic and Non-Diabetic Groups

Objective: Acute myocardial infarction is one of the leading causes of all acute emergencies and is becoming an important public health problem in developing countries. Non-ST elevation myocardial infarction (NSTEMI) is more heterogeneous in its presentation and may be poorly characterized in clinical practice, leading to greater variation in diagnosis and treatment. Patients with diabetes and hypertension who develop an NSTEMI are at increased risk for poor hospital outcomes. This study aims to assess the differences between hypertensive diabetic and hypertensive non-diabetic patients with NSTEMI and to evaluate the prognostic impact of selected clinical and laboratory parameters on the occurrence of hospital complications. Methods: This was a cross-sectional analytical study. All the adult hypertensive patients of newly diagnosed NSTEMI with or without diabetes mellitus admitted to Ibrahim Cardiac Hospital &amp; Research Institute, Dhaka who fulfilled the inclusion and exclusion criteria were enrolled. The study population comprised 100 hypertensive patients with their first NSTEMI and were divided into two groups according to the presence of type 2 diabetes mellitus. Group I (n = 40) patients were diabetic and Group II (n = 60) were non-diabetic. The hospital outcome of the study population was recorded. The incidence of in-hospital adverse clinical events in the two groups was compared by using the odds ratio of the two binomial proportion analyses. Results: Among 100 hypertensive NSTEMI patients, 40% were diabetic (Group I) and 60% were non-diabetic (Group II). The mean age was 58.1±10.2 years in the case of the diabetic group (Group I) and 56.3±10.5 years in the non-diabetic group (Group II) ranging from 30-70 years. Male patients (66%) were predominant in the study. The most common clinical presentation was chest pain which was 77.5% in Group I and 83.3 % in Group II followed by sweating (12.5% and 16.7%), dyspnea (10.0% and 11.7%), syncope (5.0% and 6.7%) and atypical chest pain (2.5% and 3.3%) respectively. Smoking was the commonest risk factor which was 62.5% in Group I and 75% in Group II followed by dyslipidemia (32.5% and 36.7%), family history of IHD (30% and 23.3%) and obesity (22.5% and 13.3%) respectively. Diabetic hypertensive patients had significantly higher heart rates, hypertensive peaks, and more episodes of asymptomatic ST segment depression. The most common in-hospital complications were heart failure (30% and 16.7%), arrhythmias (22.5% and 6.7%), renal failure (10% and 5.0%), cerebral ischemia (7.5% and 1.7%), death (7.5% and 3.3%) and cardiogenic shock (5.0% and 3.3%) in Group I and Group II respectively. Conclusion: In-hospital adverse clinical events were more frequent in diabetic hypertensive individuals compared to non-diabetics.