Cause Of Acute Chest Pain Research Articles

Epipericardial Fat Necrosis and Covid-19.

Epipericardial fat necrosis (EFN) is a rare and self-limiting cause of acute chest pain. We describe a case of EFN in a patient with a recent coronavirus disease (COVID-19). A 55-year-old male presented with a sudden onset of left-sided pleuritic chest pain for the past two days. The patient was diaphoretic, tachypneic, and tachycardic. Acute coronary syndrome was ruled out. A computed tomography (CT) pulmonary angiogram revealed an ovoid encapsulated fatty mass surrounded by dense appearing tissue. Patient symptoms improved remarkably with a short course of non-steroidal anti-inflammatory drugs (NSAIDs). EFN typically presents with a sudden onset of excruciating chest pain. Misdiagnosis, under-diagnosis, and mismanagement are unavoidable. EFN is incidentally diagnosed on CT scan. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infects visceral adipose tissue and appears to increase the risk of EFN by promoting inflammatory cytokine production and death of adipocytes. EFN is a rare cause of acute chest pain. SARS-CoV-2 is likely to induce EFN. This rare clinical entity should be considered in the differential of acute chest pain especially in patients with active or recent COVID-19. Epipericardial fat necrosis (EFN) is a rare cause of acute pleuritic chest pain that is often misdiagnosed and mismanaged.SARS-CoV-2 can possibly increase the risk of EFN and this entity should be considered in the differential of chest pain, especially in patients with active or recent coronavirus disease (COVID-19).Clinician awareness of EFN and its potential association with COVID-19, can reduce unnecessary testing and emotional distress.

Chest pain in patients with cancer: prevalence of myocardial infarction and diagnostic performance of high-sensitivity cardiac troponin T/I

Abstract Background Among patients with active or past cancer presenting with acute chest discomfort to the emergency department (ED), multiple uncertainties remain regarding the prevalence of acute myocardial infarction (AMI), outcomes, and the diagnostic utility of recommended diagnostic tools. Purpose We aimed to evaluate 1) the prevalence of AMI among consecutive patients with a history of cancer presenting with acute chest pain to the ED; 2) time to discharge from the ED and hospitalization rate; 3) the diagnostic accuracy of 34 predefined chest pain characteristics (CPCs) and ECG signatures; 4) the diagnostic accuracy of hs-cTnT and hs-cTnI concentrations; and 5) the performance of the European Society of Cardiology (ESC) 0/1h-hs-cTnT/I algorithms. Methods Patients presenting with chest pain to the ED were prospectively enrolled in an international multicenter diagnostic study. Cancer status was prospectively assessed. Final diagnosis was centrally adjudicated by two independent cardiologists, applying the 4th universal definition of AMI. Findings were externally validated in an independent, multicenter cohort. Results Among 8267 patients, 711 (8.6%) had cancer. Cancer patients had a higher burden of cardiovascular risk factors and preexisting cardiac disease, and more often a final diagnosis of AMI (184 [26%] patients with cancer vs 1562 [21%, P<0.001] without cancer). This difference was largely due to a significantly higher proportion of NSTEMIs in cancer patients (23% vs 17%; p<0.001). Total length of stay in the ED was significantly longer in patients with cancer versus those without (5.2h versus 4.3h, p<0.001). The hospitalization rate was higher in cancer patients (49.8%) than in non-cancer patients (34.3%, P<0.001), driven by non-AMI diagnoses (36.3% vs 21.3%, P<0.001). All-cause mortality at 5-years was 34.4% in patients with cancer versus 8.9% in patients without cancer (P<0.001). In cancer patients, high-sensitivity cardiac troponin (hs-cTn) T, but not hs-cTnI, concentrations had lower diagnostic accuracy for NSTEMI versus those without cancer (hs-cTnT area under the receiver-operating characteristics curve 0.89 [95%CI 0.86-0.92] vs 0.94 [95%CI 0.93-0.94], p<0.001). In cancer patients, the ESC 0/1h-hs-cTnT/I-algorithms maintained a very high safety but had lower efficacy with significantly more patients remaining in the observe zone (with hs-cTnT: 39.0% vs 20.0%, P<0.001). Similar findings were obtained in the external validation cohort. Conclusions Patients with current or past cancer have a substantially higher prevalence of AMI as the cause of acute chest pain. Time to discharge from the ED and the rate of hospitalization are increased, mainly due to non-AMI causes. The diagnostic performance of hs-cTnT/I and the efficacy of the ESC 0/1-h-hs-cTnT/I-algorithms is reduced.

Long-term follow-up of patients with myocardial infarction and myocardial injury

Abstract Introduction Patients with symptoms indicative of acute myocardial infarction (MI) frequently present to the emergency department (ED) and undergo a structured diagnostic assessment. Apart from MI, other diagnoses are frequently identified, including myocardial injury. In these patients estimation of long-term risk is crucial to guide preventive strategies. Purpose To assess and compare the long-term incidence of all-cause death and cardiovascular events in patients with MI, myocardial injury and other causes of acute chest pain. Methods We conducted a prospective, observational cohort study enrolling consecutive patients presenting with suspected MI to the ED of a tertiary hospital. The final diagnoses were adjudicated by two independent cardiologists according to the 4th Universal Definition of MI using high-sensitivity cardiac troponin T (hs-cTnT). Patients were followed to assess incidental all-cause death and a composite endpoint (cardiovascular death, MI, or myocardial revascularization). We used Kaplan-Meier plots for crude and Cox regression models (providing hazard ratios [95% confidence intervals]) for adjusted (sex, age, cardiovascular risk factors, heart failure, renal function) time-to-event analyses, respectively, using patients with other causes of chest pain as reference. Results Overall, we prospectively included 2,714 patients with a median age of 64 (25th, 75th: 51, 75) years, of whom 1,745 (64.3%) were male. In total, 143 (5.3%) had ST-elevation MI (STEMI), 128 (4.7%) Type 1 Non-ST-elevation MI (NSTEMI), 236 (8.7%) Type 2 NSTEMI, 86 (3.2%) acute myocardial injury, 677 (24.9%) chronic myocardial injury, and 1,444 (53.2%) other diagnoses of chest pain not involving hs-cTn elevation. The median follow-up time was 4.6 (4.5, 7.3) years. The highest rates of all-cause death were observed in patients with myocardial injury (81.6 [71.7, 92.3] events/1000 patient-years) and infarction (55.9 [46.3, 66.7]), compared to other diagnoses (12.2 (9.8, 15.1). Figure 1 provides the Kaplain-Meier estimates for the final diagnoses. In adjusted Cox regression analyses, all patients with MI or myocardial injury were at significantly higher risk for all-cause death, compared to patients with other causes of chest pain (Figure 2A). Additionally, the risk for the secondary composite endpoint (cardiovascular death, MI, revascularization) was significantly increased in those with acute or chronic myocardial injury, and patients with Type 1 NSTEMI or STEMI, but not Type 2 NSTEMI (Figure 2B). Conclusion Patients with acute myocardial infarction and acute or chronic myocardial injury are at high long-term risk for death and incident cardiovascular events. Importantly, those patients with acute myocardial injury showed the highest mortality rate. Further studies need to determine appropriate management strategies for patients with myocardial injury.Kaplan-Meier plot for final diagnosesForest plot of adjusted outcome analysis

Epipericardial fat necrosis: a case report of an underdiagnosed disease.

Epipericardial fat necrosis: a case report of an underdiagnosed disease.

Epipericardial Fat Necrosis: A Retrospective Analysis in Japan.

Objective Epipericardial fat necrosis (EFN) has been considered to be a rare cause of acute chest pain, and especially important for emergency physicians. Chest computed tomography (CT) is often used for the diagnosis of EFN after excluding life-threatening states, such as acute coronary syndrome and pulmonary embolism. While the proportion of EFN patients who underwent chest CT in emergency departments is being clarified, little is still known about other departments in Japan. To investigate the proportion of EFN patients who underwent chest CT for acute chest pain in various departments. Methods Chest CT performed from January 2015 to July 2020 in Asahikawa Medical University Hospital in Japan was retrospectively analyzed in this study. All images were reviewed by two radiologists. Results There were 373 outpatients identified by a search using the word ‘chest pain’ who underwent chest CT. Eight patients satisfying the imaging criteria were diagnosed with EFN. The proportions of patients diagnosed with EFN were 10.7%, 4.8%, 2.8%, 0.9% and 0% in the departments of general medicine, cardiovascular surgery, emergency medicine, cardiovascular internal medicine and respiratory medicine, respectively. Only 12.5% of the patients were correctly diagnosed with EFN, and the other patients were treated for musculoskeletal symptoms, acute pericarditis or hypochondriasis. Conclusion EFN is not rare and is often overlooked in various departments. All physicians as well as emergency physicians should consider the possibility of EFN as the cause of pleuritic chest pain.

Imaging Paradigms in Nontraumatic Aortic Emergencies.

Aortic cause of acute chest pain or abdominal pain can be easily overlooked. Unceasing wariness is required for timely diagnosis and prompt treatment. In such cases, cross-sectional imaging can detect the type of aortic involvement, its site, extent, complications, and could help clinicians decide on a management method and prognosticate the condition. This pictorial illustration represents a spectrum of life-threatening conditions involving the aorta in a non-traumatic setting.

Epicardial Fat Necrosis After COVID-19 Infection: A Case Report

Epipericardial or epicardial fat necrosis (EFN) is a self-limited inflammatory process occurring in the mediastinal fat surrounding the heart. It is an uncommon cause of acute chest pain and mimics more critical clinical disorders such as acute coronary syndrome, aortic dissection, and pulmonary embolism. However, EFN is frequently overlooked and under-recognized in emergency departments (EDs) owing to the unfamiliarity of this condition among physicians and radiologists. Herein, we present the case of a previously healthy young male patient, with a recent history of mild COVID-19 infection (two weeks before presentation), who presented to the ED for acute chest pain. Paraclinical evaluation including computed tomography (CT) of the chest revealed fat stranding along with the left epicardial fat pad in favor of EFN.

Fish bone ingestion mimicking acute coronary syndrome

Fish bone as a foreign body is the most common food-associated foreign body in Asians as compared to meat impaction in the Western population, and the most common site is upper esophagus. The impaction of fish bones in the gastrointestinal tract during ingestion is a common complaint and can mimic acute coronary syndrome (ACS). A 45-year-old man presented to our emergency department with acute-onset retrosternal pain. Electrocardiogram, Troponin I, and two-dimensional-echocardiography were normal. Computed tomography of the chest showed a lodged fish bone tenting the upper esophagus, which was removed endoscopically. He was discharged on the 3rd day of the procedure. This case showed an unusual cause of acute chest pain which was initially suspected as ACS based on American College of Cardiology/American Heart Association guidelines. This case highlights the importance of thorough history taking and a need for high level of alertness in reaching the correct diagnosis.

Novel biomarkers in diagnostic workup of acute aortic dissection

Background and Aims: Acute aortic dissection (AAD) is a rare condition, but together with acute myocardial infarction (AMI) and pulmonary embolism (PE) it belongs to the most relevant and life-threatening causes of acute chest pain. Until now, there is no widely accessible and accepted blood test for AAD diagnosis.

Novel Blood Biomarkers for a Diagnostic Workup of Acute Aortic Dissection.

Acute aortic dissection (AAD) is a rare condition, but together with acute myocardial infarction (AMI) and pulmonary embolism (PE) it belongs to the most relevant and life-threatening causes of acute chest pain. Until now, there has been no specific blood test in the diagnostic workup of AAD. To identify clinically relevant biomarkers for AAD, we applied Proseek® Multiplex assays to plasma samples from patients with AAD, AMI, PE, thoracic aortic aneurysm (TAA), and non-cardiovascular chest pain (nonCVD). Subsequently, we validated top hits using conventional immunoassays and examined their expression in the aortic tissue. Interleukin 10 (IL-10) alone showed the best performance with a sensitivity of 55% and a specificity of 98% for AAD diagnosis. The combination of D-dimers, high-sensitive troponin T (hs-TnT), interleukin 6 (IL-6), and plasminogen activator inhibitor 1 (PAI1) correctly classified 75% of AAD cases, delivering a sensitivity of 83% and specificity of 95% for its diagnosis. Moreover, this model provided the correct classification of 77% of all analyzed cases. Our data suggest that IL-10 shows potential to be a rule-in biomarker for AAD. Moreover, the addition of PAI1 and IL-6 to hs-TnT and D-dimers may improve the discrimination of suspected AAD, AMI, and PE in patients presenting with acute chest pain.

Diagnostic Value of Multislice Spiral CT Cardiothoracic Combined with Angiography in Acute Chest Pain.

Acute chest pain is a common clinical emergency condition with a variety of causes, including acute coronary syndrome, pulmonary embolism, aortic coarctation, and pneumothorax. It is essential for emergency physicians to quickly and accurately understand the cause of acute chest pain. 64-slice spiral CT combined cardiothoracic angiography is an accurate and rapid way to diagnose and differentiate the cause of acute chest pain. 64-slice combined cardiothoracic angiography can accurately and rapidly display the thoracic aorta, both pulmonary arteries, the main trunk of the coronary artery and its major branches, and also provide a comprehensive view of both lungs and mediastinum, which is an effective test for the diagnosis and differential diagnosis of acute chest pain. Based on this, this study further investigated the value of 64-slice spiral CT triplex examination in the diagnosis of acute chest pain. The results showed that 64-slice spiral CT has the advantages of fast scanning speed, high resolution, and advanced postprocessing technology, and combined cardiothoracic angiography can quickly and accurately help emergency physicians analyze the cause of acute chest pain, which plays a very important role in formulating the correct treatment plan in a timely manner. At the same time, with the continuous development of CT technology, the temporal and spatial resolution has improved the quality of CT images, giving us more options to reduce the effective radiation dose and reduce the total amount of contrast, making the 64-row spiral CT cardiothoracic imaging more perfect.

Epipericardial Fat Necrosis: A Concise Review of Literature

Epipericardial fat necrosis (EFN) is an inflammatory process that occurs in the mediastinal fat surrounding the heart. It is a rare cause of acute chest pain and mimics more ominous clinical conditions such as acute coronary syndrome, aortic dissection, and pulmonary embolism. Clinicians are often not familiar with this condition due to its infrequent occurrence, and traditional textbooks of medicine and cardiology have not covered this topic adequately. In the past, EFN had been managed primarily with thoracotomy and surgical excision. This has changed with advances in imaging techniques and their more frequent utilization. Computed tomography (CT) of the chest is essential for the diagnosis of EFN as it allows for the evaluation of the nature and precise location of the lesion. Magnetic resonance imaging helps to differentiate EFN from other mediastinal fatty lesions such as lipomas or liposarcomas. The clinical presentation of acute chest pain along with CT findings of the encapsulated fatty pericardial lesion is adequate for diagnosis. Our review describes the emerging role of imaging in diagnosis and change in management over the last few years.

An unusual cause of acute pericarditis: a case report.

BackgroundInflammation of the pericardium, or pericarditis, is a frequent cause of acute chest pain in young patients. Pericarditis is typically associated with viral infections, but other potential causes may have distinct prognostic and therapeutic implications.Case summaryA 26-year-old man presented with typical signs and symptoms of acute pericarditis. However, imaging disclosed an anterior mediastinal mass that compressed the right ventricular outflow tract. The coarse outflow murmur convincingly mimicked a pericardial friction rub on auscultation.ConclusionClinicians should be aware of alternative aetiologies to pericarditis in patients who present with prolonged or refractory symptoms.

Cardiac MRI in Patients with Acute Chest Pain.

Acute chest pain is a common reason for visits to the emergency department. It is important to distinguish among the various causes of acute chest pain, because treatment and prognosis are substantially different among the various conditions. It is critical to exclude acute coronary syndrome (ACS), which is a major cause of hospitalization, death, and health care costs worldwide. Myocardial ischemia is defined as potential myocyte death secondary to an imbalance between oxygen supply and demand due to obstruction of an epicardial coronary artery. Unobstructed coronary artery disease can have cardiac causes (eg, myocarditis, myocardial infarction with nonobstructed coronary arteries, and Takotsubo cardiomyopathy), and noncardiac diseases can manifest with acute chest pain and increased serum cardiac biomarker levels. In the emergency department, cardiac MRI may aid in the identification of patients with non-ST-segment elevation myocardial infarction or unstable angina or ACS with unobstructed coronary artery disease, if the patient's clinical history is known to be atypical. Also, cardiac MRI is excellent for risk stratification of patients for adverse left ventricular remodeling or major adverse cardiac events. Cardiac MRI should be performed early in the course of the disease (<2 weeks after onset of symptoms). Steady-state free-precession T2-weighted MRI with late gadolinium enhancement is the mainstay of the cardiac MRI protocol. Further sequences can be used to analyze the different pathophysiologic subjacent mechanisms of the disease, such as microvascular obstruction or intramyocardial hemorrhage. Finally, cardiac MRI may provide several prognostic biomarkers that help in follow-up of these patients. Online supplemental material is available for this article. ©RSNA, 2020.

Early diagnosis of acute myocardial infarction in patients with a history of percutaneous coronary intervention

Abstract Background Recurrence of acute chest pain after percutaneous coronary intervention (PCI) is common. The early detection of acute myocardial infarction (AMI) as a possible cause of acute chest pain can be challenging in patients with a history of PCI due to e.g. pre-existing electrocardiographic abnormalities. It is unknown, whether high-sensitivity cardiac troponin T (hs-cTnT) concentrations and hs-cTnT-based rapid algorithms perform equally well in patients with a history of PCI. Purpose To investigate the impact of prior PCI on the diagnostic performance of hs-cTnT concentrations for early rule-out and rule-in of AMI. Methods In an ongoing multicentre international study, we prospectively enrolled unselected patients presenting to the emergency department (ED) with symptoms suggestive of AMI. Final diagnoses were centrally adjudicated by two independent cardiologists using all available medical records obtained during clinical care including 90 day follow-up information and cardiac imaging. High-sensitivity cTnT concentrations at presentation and after 1h were compared against the adjudicated final diagnosis. Patients were stratified according to the presence or absence of previous PCI. Results Among 5536 patients (1313 with and 4223 without previous PCI), incidence of AMI was significantly higher in patients with previous PCI (26.3% versus 21.4%; p&amp;lt;0.001). Patients with prior PCI and a final diagnoses other than AMI had significantly higher concentrations of hs-cTnT at presentation to the ED (median 9ng/l [IQR 6 to 15.8] vs 5.5ng/l [IQR 3 to 10]; p&amp;lt;0.001). However, in patients with final adjudicated diagnosis of AMI, hs-TnT concentrations at presentation were lower in patients with previous PCI (median 46ng/l [IQR 23 to 94] vs 55ng/l [IQR 25 to 175]; p=0.003). The diagnostic accuracy of hs-cTnT was high in patients with history of PCI, but significantly lower compared to patients without PCI (AUC 0.91 [95% CI 0.89–0.92] versus AUC 0.94 [95% CI 0.94–0.95]; p&amp;lt;0.001, respectively). When applying the ESC 0/1-algorithm among patients with previous history of PCI, the rule out pathway showed also very high safety in patients with a history of PCI (sensitivity 99.2 [95% CI 97.2–99.8] and negative predictive value 99.6 [95% CI 98.5–99.9]). However, the efficacy of the ESC 0/1h-algorithm for early rule out of NSTEMI was lower in the PCI group compared to no PCI (45.2% vs 65.1%; P&amp;lt;0.001, respectively), triaging more patients to the observe zone (36.8% versus 18.8%; p&amp;lt;0.001). Time to discharge from the ED was significantly longer in patients with prior PCI (334 min vs 290 min; p&amp;lt;0.001). When stratified for index AMI, patients with history of PCI waited longer for a final diagnoses of AMI (285 vs 217 min; p&amp;lt;0.001). Conclusions History of PCI impacts on the diagnostic performance of hs-cTnT. Although the ESC 0/1h-algorithm still performs very safe when applied to patients with a history of PCI, its efficacy is significantly reduced. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation, the KTI, the Stiftung für kardiovaskuläre Forschung Basel the University of Basel and the University Hospital Basel

PERICARDIAL FAT NECROSIS: A RARE CAUSE OF ACUTE CHEST PAIN

Pericardial fat necrosis is a rare and benign cause of acute chest pain that mimics more severe clinical entities including acute coronary syndrome, pulmonary embolism and pericarditis. 55-year-old female with history of acid reflux disease presented to the hospital with acute chest pain that began

An unusual phenotype of acute aortic syndrome: A case report.

Acute Aortic Syndromes are a major cause of acute chest pain. We report a case of a woman which presented mixed features from acute aortic syndromes phenotypes in angiotomography.

Feasibility of applying post-processing techniques in triple-rule-out computed tomography angiography

Triple-rule-out CTA technique can evaluate the thoracic aorta, pulmonary artery and coronary artery at the same time. Some diseases of above arteries are life threatening causes of acute chest pain (ACP), which belong to most frequently symptoms of patient in the emergency departments. Triple-rule-out CTA can not only reduce radiation dose, but also contrast volume. Furthermore, it reduces the cost and time of examinations. Post-processing techniques include multi-planar reconstruction, curved-planar reconstruction and volume rendering technique. Post-processing techniques are effective methods to evaluate thoracic aorta, pulmonary artery and coronary artery in triple-rule-out CTA.

Spontaneous pneumomediastinum: a rare cause of dyspnea

In this report, we present the case of an 18-year-old male with dyspnea and thoracic pain since 1 day. Investigation revealed the presence of a pneumomediastinum without apparent aetiology. He had an uneventful recovery after a short observation. Spontaneous pneumomediastinum (SPM) is defined as presence of air in the mediastinum in the absence of traumatic, infectious or iatrogenic cause. It is a rare cause of acute chest pain and dyspnea, yet it is a benign condition with an excellent prognosis and low recurrence rates.

Imaging of acute pulmonary embolism: an update.

Imaging plays an important role in the evaluation and management of acute pulmonary embolism (PE). Computed tomography (CT) pulmonary angiography (CTPA) is the current standard of care and provides accurate diagnosis with rapid turnaround time. CT also provides information on other potential causes of acute chest pain. With dual-energy CT, lung perfusion abnormalities can also be detected and quantified. Chest radiograph has limited utility, occasionally showing findings of PE or infarction, but is useful in evaluating other potential causes of chest pain. Ventilation-perfusion (VQ) scan demonstrates ventilation-perfusion mismatches in these patients, with several classification schemes, typically ranging from normal to high. Magnetic resonance imaging (MRI) also provides accurate diagnosis, but is available in only specialized centers and requires higher levels of expertise. Catheter pulmonary angiography is no longer used for diagnosis and is used only for interventional management. Echocardiography is used for risk stratification of these patients. In this article, we review the role of imaging in the evaluation of acute PE.