Chest Pain Symptoms Research Articles

Symptoms and ASCVD score fail to identify majority of the patients at risk of first myocardial infarction

Abstract Background Cardiovascular disease screening has long relied on the presence of symptoms like chest pain or on the Atherosclerotic Cardiovascular Disease (ASCVD) risk score, which is typically initiated at age 40. However, current research suggests that the ASCVD risk score may not incorporate a comprehensive range of factors and should be started earlier. Furthermore, the absence of symptoms such as angina in some patients prior to acute coronary syndrome (ACS) casts doubt on the reliability of symptom-based screening methods. Purpose This study aimed to evaluate the effectiveness of the ASCVD risk score and chest pain as predictors for ACS. Methods We retrospectively analyzed the data of all patients of 65 or younger who presented with their first ACS event in a single US center from January 2020 to January 2024. We collected the demographic and clinical data, including age, sex, lipid panel, blood pressure, medical history, onset of symptoms, and calculated their individual ASCVD risk score. We explored whether these patients, if assessed one week before their ACS event, would have been identified as at risk and thus prescribed lipid lowering or recommended for further diagnostic tests. Results Among 166 patients presenting with ACS, 64 (39%) were considered low risk with an ASCVD risk score of <5 or too low to calculate. 20 (12%) patients were assessed as borderline risk with an estimated risk score of 5-7.5%. In the intermediate risk category, 20 patients (12%) had a score of 7.5% -10% and 42 patients (25%) were estimated to have a score of >10 to <20%. 14 patients (8%) fell in the high-risk category, and lastly 6 patients had an LDL that was above 190 mg/dl. Regarding symptoms of chest pain or shortness of breath, 14 patients (8%) did not experience any symptoms prior to their presentation, 98 (59%) patients experienced their first episode of symptoms within 48 hours, 19 patients (11%) within 2 days to a week, 10 patients (6%) had CP leading up to their event from a week to a month, 6 patients (4%) in the range of a month to 3 months and 19 patients (11%) had symptoms longer than 3 months prior to their presentation. To summarize if there were seen 1 week prior to their first ACS events, 51% of them were not recommended for statin therapy based on their ASCVD risk score and 67% of patients either had no chest pain until the event or chest pain within 48hrs of onset of their ACS and consequently would not have been routinely screened for coronary artery disease (CAD) by any anatomical or functional methods. Conclusion(s) ASCVD risk score and symptoms fail to identify majority of patient below 65 years of age with their first MI. Given high prevalence of CAD and associated mortality, improved screening tools, in addition to symptomatology or risk scores, would be more effective in identifying individuals at risk.

Coronary inflammation stratifies risk in patients undergoing coronary CT angiography: the Oxford Risk Factors and Non-Invasive Imaging (ORFAN) study

Abstract Background Patients with chest pain symptoms often undergo coronary CT angiography (CCTA) for the diagnosis of obstructive coronary artery disease (CAD) to guide revascularisation. However, acute cardiac events could occur in the absence of obstructive CAD. Further risk stratification of patients could potentially be useful by quantifying coronary inflammation using the Fat Attenuation Index (FAI) Score, and an artificial intelligence (AI)-assisted prognostic model that captures the inflammatory risk by integrating CCTA-derived metrics (including FAI Score and plaque burden) and the patient’s clinical risk factors. Purpose To evaluate the risk of cardiac events among patients without obstructive CAD, and the prognostic value of integrating coronary inflammation in risk stratifying this patient group. Methods From the Oxford Risk Factors and Non-invasive imaging (ORFAN) study, patients undergoing CCTA in 7 UK Hospitals (n=40,091) were followed up for the incidence of cardiac mortality over a median(IQR) of 2.7(1.4-5.3) years. In a nested cohort of 3,393 patients with long-term follow up, we evaluated the long-term prognostic value of FAI Score and the performance of AI-Risk algorithm over a median(IQR) follow up of 7.7(6.4-9.1) years. Reclassification of risk category from AI-Risk was compared with contemporary clinical risk score (QRISK3). Results Patients without obstructive CAD (n=32,533, 81.1%) accounted for 63.7% of all cardiac deaths (n=1,754) during follow up, highlighting the substantial proportion of cardiac events in absolute terms given a large proportion of patients without obstructive CAD. In the nested cohort with long-term follow up, FAI Score in any of the 3 epicardial coronary arteries was significantly associated with cardiac mortality with or without obstructive CAD. In the whole cohort, the highest quartile of FAI Score in LAD showed 20-times higher risk of cardiac death compared with the lowest quartile (Panel A). Integrating coronary inflammation with clinical risk factors and plaque burden, patients with very-high AI-Risk classification showed 6-fold higher risk of cardiac mortality compared to low/medium risk, with good alignment of the incident predicted events from AI-Risk and observed events. (Panel B) The predicted cardiac mortality from AI-Risk also demonstrated good calibration with the observed events in the whole population. (Panel C) Finally, AI-Risk significantly reclassify the risk above clinical risk factor-based prediction (QRISK3) (Panel D). Conclusion Patients with high coronary inflammation measured by FAI Score showed significantly elevated risk for cardiac mortality. The AI-enabled absolute risk prediction algorithm leads to significant reclassification of patients undergoing routine CCTA, and can be used as a precision medicine tool.

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

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.

Impact of sex, age, comorbidities, and culprit lesion location on symptoms in patients with non-ST-segment elevation myocardial infarction

Abstract Background Among patients with non-ST-segment elevation myocardial infarction (NSTEMI) about 80% present with chest discomfort. Others have less obvious symptoms, but early diagnosis is crucial. Sex differences in symptoms have been reported to delay diagnosis in about half of women. This study aims to analyze the symptoms and its disparities caused by sex, age, comorbidities, and culprit lesion location. Methods Patients presenting with troponin elevation and at least one angiographically confirmed atherosclerotic lesion causing the myocardial ischemia (culprit lesion) between February 2018 and July 2023 were prospectively included in a single-center, all-comers, real-world registry. Results Information regarding symptoms was available for 842 NSTEMI patients with an identifiable culprit lesion. Chest discomfort was reported by 684 patients (81.2%), dyspnea by 361 (42.9%) with it being the primary symptom in 102 (12.1%), and atypical symptoms by 317 (37.6%) with it being the primary symptom in 56 (6.7%). Concretely, dizziness or syncope was reported by 82 patients (9.7%), nausea, vomiting or any other gastrointestinal symptoms by 73 (8.7%), epigastric, shoulder, arm, back, neck or jaw pain by 57 (6.8%), diaphoresis by 66 (7.8%), other vegetative symptoms like palpitations or anxiety by 56 (6.7%), fatigue by 37 (4.4%), and neurologic symptoms like sensory or motor impairments by 28 (3.3%). In women, the primary complaint was less often chest discomfort (76.3 vs. 82.9%, p=0.040), more often atypical symptoms (9.8 vs. 5.6%, p=0.049) and equally often dyspnea (14.0 vs. 11.5%, p=0.403). Gastrointestinal symptoms were more often reported by women (13.5 vs. 7.0%, p=0.006). Elderly, i.e., age ≥80 years, reported chest discomfort less often (75.4 vs. 83.0%, p=0.023), dyspnea more often (19.5 vs. 9.9%, p<0.001) and atypical symptoms equally often (5.1 vs. 7.1%, p=0.418). Likewise, diabetic had chest discomfort less often (74.3 vs. 84.5%, p<0.001), dyspnea more often (18.2 vs. 9.2%, p<0.001), and atypical symptoms equally often (7.4 vs. 6.3%, p=0.633). No differences regarding primary symptoms were observed for dyslipidemia (82.1 vs. 78.9% for chest discomfort, 12.1 vs. 12.1% for dyspnea, 5.8 vs. 9.0% for atypical symptoms, p>0.05 for all) and obesity (84.5 vs. 81.2% for chest discomfort, 9.8 vs. 12.5% for dyspnea, 5.7 vs. 6.3% for atypical symptoms, p>0.05 for all). For LM culprit lesions, dyspnea was more often the primary symptom compared to LAD, LCX, and RCA culprit lesions (17.4% for LM vs. 13.6% for LAD, 5.7% for LCX, and 13.2% for RCA, p=0.023), while no differences were observed for chest pain (73.9% for LM, 80.6% for LAD, 86.1% for LCX, and 80.2% for RCA, p=0.235) and atypical symptoms (8.7% for LM, 5.9% for LAD, 8.1% for LCX, and 6.6% for RCA, p=0.758). Conclusions Chest discomfort is significantly less often the primary symptom of NSTEMI in women, elderly and diabetic making these groups more vulnerable for delayed diagnosis or misdiagnosis.

Update Motility Disorders: Gastro-Oesophageal Reflux Disease – Diagnostic and Conservative Approach

Background: Gastro-oesophageal reflux disease (GORD) is extremely common, with at least 1 in 10 people in the general population reporting heartburn and acid regurgitation on a weekly basis. GORD can also be associated with a variety of atypical symptoms, including chest pain, chronic cough, and laryngopharyngeal symptoms. The causes of GORD are multifactorial, and the severity of symptoms is influenced by peripheral and central factors, including psychosocial stress and anxiety. Therefore, for a variety of reasons, no single investigation provides a definitive diagnosis, and standard treatment with acid suppressants is not always effective. Summary: This review introduces the Lyon Consensus, now in its second iteration, a classification system that provides a “conclusive” positive or negative diagnosis of GORD by integrating the results of endoscopy, ambulatory reflux monitoring, and high-resolution manometry. Different algorithms are applied to patients with high and low pre-test probability of a causal relationship between reflux episodes and patient symptoms. The results of these studies identify patients with “actionable” results that require escalation, revision, or discontinuation of GORD treatment. Guidance is provided on the range of conservative treatments available for GORD, including dietary and lifestyle advice, antacids and alginates, and drugs that suppress acid secretion. Key Messages: GORD is a common disorder; however, the causes of reflux and symptoms can be complex. As a result, the diagnosis can be missed, and management is sometimes challenging, especially for patients with atypical symptoms. The Lyon classification establishes a conclusive diagnosis of GORD, based on results of endoscopic and physiological investigation. Typical symptoms usually respond to empiric use of alginate-antacid preparations and acid suppression; however, the management of treatment refractory symptoms is tailored to the individual.

Delayed diagnosis and treatment of achalasia: a case report

BackgroundAchalasia is characterized as an esophageal motility disorder with incomplete relaxation of the lower esophageal sphincter. Achalasia can be associated with abnormal peristalsis and symptoms of dysphagia, acid reflux, and chest pain. The exact pathophysiology of achalasia remains unclear, but it is hypothesized to be due to degeneration of the myenteric plexus.Case presentationIn this case, a 46-year-old Hispanic man presented to the emergency room with a 12-year history of progressive discomfort with swallowing solids and liquids. Due to many years of incomplete follow-up care and lack of understanding of the course of his disease, this patient’s symptoms escalated to complete intolerance of oral intake and significant weight loss. He was diagnosed with achalasia during his hospital stay and treated successfully with laparoscopic Heller myotomy.ConclusionsThis case discussion illustrates the importance of follow-up care and patient education so that diagnosis and treatment of achalasia are not delayed.

Acute and long-term SARS-CoV-2 infection and neurodegeneration processes—circulus vitiosus

The global pandemic of COVID-19 caused by SARS-CoV-2 has had a devastating impact. Although many survived the acute effects of the pandemic, a significant number of survivors, including those with only mild symptoms, are now experiencing a prolonged and debilitating post-viral syndrome known as LC/PASC (long COVID/post-acute sequelae of SARS-CoV-2). Typical symptoms of LC/PASC include fatigue, breathlessness, chest pain, impaired cognition, difficulty sleeping, fever and gastrointestinal symptoms. Anxiety and depression can also last for weeks to months and range from mild to disabling. The association between neuropsychiatric symptoms and SARS-CoV-2 infection raises questions about the possible routes of SARS-CoV-2 entry to the central nervous system (CNS) and long-term effects of the virus on the CNS, their molecular basis, and the potential risk of neuronal damage associated with the subsequent development of neurodegenerative diseases.

Impact of admission glucose and 30-day major adverse cardiovascular events on patients with chest pain in an emergency setting: insights from the China EMPACT registry.

Although the association between admission glucose (AG) and major adverse cardiac events (MACE) is well-documented, its relationship with 30-day MACE in patients presenting with cardiac chest pain remains unclarified. In light of this, this study aims to examine the correlation between AG levels and the incidence of MACE in patients with chest pain in an emergency setting. We consecutively enrolled patients who presented to the emergency department for chest pain symptoms within 24 h from the EMPACT cohort in Eastern China (clinicaltrials.gov, Identifier: NCT02536677). The primary outcome was 30-day MACE, including all-cause death, recurrent myocardial infarction, urgent target vessel revascularization, stroke, cardiogenic shock, and cardiac arrest (CA). The associations of AG levels with 30-day MACE were analyzed using Kaplan-Meier analysis and Cox regression models. Among 1,705 patients who were included in this study, 154 (9.03%) patients met the primary outcome at 30 days. The average age of the patients was 65.23 ± 12.66 years, with 1,028 (60.29%) being male and 500 (29.33%) having diabetes. The median AG levels were 7.60 mmol/L (interquartile range: 6.30-10.20). Kaplan-Meier survival analysis revealed significant differences in the 30-day MACE risk (P < 0.001 according to the log-rank test). We found that the highest AG level (Q4) was associated with increased MACE risk compared with the lowest AG level [adjusted hazard radio (aHR): 2.14; 95% confidence interval (CI): 1.2-3.815; P = 0.010]. In addition, Q4 level was also associated with increased all-cause death risk (aHR: 3.825; 95% CI: 1.613-9.07; P = 0.002) and increased CA risk (aHR: 3.14; 95% CI: 1.251-7.884; P = 0.015). An elevated AG level significantly correlates with a higher incidence of 30-day MACE in patients with acute chest pain. The findings reveal the importance of managing AG levels to potentially reduce the risk of adverse cardiac events.

A case of bronchoscopic treatment for endobronchial chondroma

Endobronchial chondroma is a rare benign bronchial tumor that originates from bronchial cartilage. As the disease progresses, it can obstruct the airway and cause clinical symptoms such as fever and cough. It is difficult to detect Endobronchial chondroma on a Chest X-ray, but chest CT can provide a more accurate diagnosis. Bronchoscopy is an effective means of diagnosing and treating this disease, and the diagnosis of the disease still depends on the pathological results of the biopsy. Currently, most cases of Endobronchial chondroma are treated by bronchoscopic resection or by surgery. Treatment should be based on the size, type and location of the tumor. As long as the diagnosis of Endobronchial chondroma is confirmed, it should be removed as soon as possible to avoid obstructive pneumonia, atelectasis or irreversible damage to lung tissue caused by tumor compression of the bronchi. This article reported a case of Endobronchial chondroma in a 19-year-old man whose main clinical manifestations were fever, cough and chest pain, with no apparent improvement after antibiotic treatment. Chest CT showed consolidation and atelectasis of the left upper lobe, and bronchial foreign body was considered by bronchoscopy in another hospital. However, the patient did not improve significantly after the foreign body was removed. After admission, the patient was considered to have left pulmonary obstructive pneumonia due to bronchial foreign body. A white tough foreign body was seen under bronchoscopy, which was too seriously adhered with the bronchus to be removed as a whole. After two bronchoscopic interventional treatments, the foreign body was successfully removed, and the bronchial lumen blocked by the foreign body was restored to patency. Pathology confirmed the diagnosis of endobronchial chondroma. The patient's symptoms improved and he was subsequently discharged. To date, the patient's symptoms of fever, cough, or chest pain have never recurred, and there is no obvious abnormality on repeat chest CT. This case provides an empirical reference for the diagnosis and treatment of endobronchial chondroma.

Diagnostic Utility of High-resolution Esophageal Manometry and Its Correlation with Symptoms.

Primary esophageal motility disorders present with a spectrum of symptoms where manometry plays an important role. We designed this study to evaluate the utility of esophageal manometry among various symptoms. This is a single-center observational study conducted over 5 years in a tertiary referral center. A total of 564 patients who underwent high-resolution esophageal manometry (HREM) using a 16-channel water perfusion system were included in the study. Their clinical profile and manometric findings, as per the Chicago classification version 4.0, were recorded, and the diagnostic utility of HREM with respect to symptoms was studied. Motility disorders were identified in 48.8% of patients, the most common being Achalasia cardia (32.4%). Dysphagia (55.5%) was the most common indication of manometry, followed by gastroesophageal reflux disease (GERD) (34.9%), chest pain (6.2%), and symptoms such as belching, globus, and hiccoughs (3.4%). Among those who were re-classified from Chicago classification v3.0 to v4.0, 21.2% had a newer diagnosis. Among the patients with dysphagia, HREM revealed the highest yield of detecting an abnormal esophageal motility test (70.6%); meanwhile, this yield was much lower in those with GERD (21.8%), chest pain (22.8%), and other symptoms (15.7%). The most common finding among those with dysphagia was Achalasia cardia (55.9%), while the study was normal among those with GERD (78.1%), chest pain (77.1%), and other symptoms (84.2%). The sensitivity and specificity of dysphagia for major motility disorders were 65% and 91%, respectively, with a positive predictive value of 90%. HREM has high accuracy and a good diagnostic yield among patients with dysphagia, with the most common finding being Achalasia cardia.

Primary extraskeletal osteosarcomas of the pleura: A clinicopathological, immunohistochemical, and molecular analysis of 4 cases

Four primary extraskeletal osteosarcomas of the pleura are presented. The patients were men between the ages of 63 and 78 years (average: 70.5 years) who presented with symptoms of chest pain, cough, and shortness of breath. Diagnostic imaging showed variably calcified, pleural-based masses and/or diffuse pleural thickening, clinically mimicking mesothelioma. Thoracoscopic surgical material was obtained for histopathological diagnosis. Histological findings showed the presence of a neoplastic spindle cell proliferation composed of fusiform cells with scant cytoplasm, elongated nuclei and inconspicuous nucleoli. Mitotic activity was easily identified. Additionally, all tumors showed extensive osseous differentiation in the form of osteoid matrix production; one tumor demonstrated additional chondrosarcomatous elements and another showed focal myxoid changes. Immunohistochemical analysis revealed that the tumor cells were uniformly negative for a wide variety of antibodies, including keratin AE1/AE3, keratin 5/6, D2-40, EMA, calretinin, WT-1, BerEP4, and HEG1; BAP1 was retained in all cases. In addition, fluorescence in situ hybridization for CDKN2A (p16) was negative for homozygous deletion in all tumors. Clinical follow-up showed that one patient had died 8 months after diagnosis and one had remained alive with short post-diagnostic follow-up. The tumors herein described highlight a challenging issue in the separation of mesothelioma with heterologous elements from true osteosarcomas of pleural origin. We propose that a diagnosis of extraskeletal osteosarcoma of the pleura is rendered for tumors with malignant osseous and/or cartilaginous differentiation in which comprehensive immunohistochemical studies and FISH analysis have failed to provide support for a diagnosis of mesothelioma with heterologous elements.

Characterization of ST-Elevation Myocardial Infarction cases: Association between specific dispatcher-assigned dispatch determinant codes and hospital-confirmed STEMI cases in Qatar

ABSTRACT OBJECTIVES ST-elevation myocardial infarction (STEMI) is an Acute Myocardial Infarction (AMI) with the greatest risk of death and disability. Getting diagnosed patients rapid definitive treatment at the correct facility is crucial in improving their outcome. Using a Question-and-Answer algorithm (Mobile Priority Dispatch System (MPDS®)), trained Emergency Medical Dispatchers (EMDs) can help identifying STEMI at the time of dispatch. This can assist Emergency Medical Services (EMS) pre-planning transport to potential STEMI-receiving hospitals. The study aimed to determine whether hospital-confirmed STEMI cases transported by ambulance are associated with certain dispatch determinant codes and identify the treatments performed. METHODS The retrospective study analyzed deidentified dispatch and hospital data of STEMI patients who were transported by Qatar’s Ambulance Service between January 2018 and May 2021. Data analysis compared patient demographics with dispatch measures, considering chief complaint and determinant codes, and Percutaneous Coronary Intervention (PCI) treatment received. RESULTS A total of 3,724 STEMI cases with MPDS® dispatch codes were retrieved. After excluding patient transfer and pandemic-related cases, a final sample of 2,607 cases was analyzed. Most STEMI patients (86.0%) were classified as high priority levels at dispatch, had chest pain as chief complaint (62.9%), and were male (90.8%). Approximately, 99.0% of the STEMI patients received PCI treatment. Distributions of STEMI cases and PCI treatment did not significantly differ by patient demographics and dispatch measures. CONCLUSIONS Qatar’s STEMI patients are more likely to be male and to receive adequate acute care irrespective of any demographic factor and despite potential language issues. This study highlights that the chief complaint may be described or interpreted differently when the questioning language is not their mother tongue, or when there is a language barrier between the caller, call taker, or when using the MPDS® protocols language or when self-translating questions instantly in another language. Therefore, EMDs should be made aware of the language differences and be encouraged to further clarify the chief complaint when appropriate. There may be a need for potential refinements of the MPDS® questioning algorithm and EMD training with AMI symptoms reinforcement. This could help improve their early identification of STEMI cases with non-classic chest pain symptoms.

A 70-year-old Male with Traumatic Empyema Presented with Symptoms of Chest Pain and Dyspnea

&lt;p&gt;老年病患當同時有胸痛及呼吸喘症狀時，需要考慮到各種急症的可能性，若加上非典型的臨床表徵，更可能造成一線醫療人員鑑別診斷的困難度。案例是一位70歲男性，此次因胸痛及呼吸喘入院，初步臆測肺炎及肋膜積水，但亦不能排除其他急症之心肌梗塞、肺栓塞或主動脈剝離的可能性。經由理學及影像學檢查來排除上述急症之診斷，進而偏向肺炎及肋膜積水診斷的可能性。住院期間，病患出現發燒及白血球增高表徵，但細菌培養皆為陰性，且經驗性抗生素使用之下症狀未獲得改善，因考量入院前有創傷史，經胸腔超音波檢查併穿刺引流管放置，及胸部電腦斷層等詳檢確認膿胸診斷，最終以胸腔鏡手術介入治療，同時病理組織確認為第三期膿胸。病患住院中接受手術及抗生素輔助治療，並搭配呼吸訓練之後，症狀改善出院。因此當遇到案例有胸痛合併呼吸喘，加上其他危險因子如：老年人、長期咳嗽、慢性腎臟疾病及胸部創傷史等，必須將創傷後膿胸列為鑑別診斷，以免錯失診斷及治療先機。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;Geriatric patients presenting simultaneously with chest pain and dyspnea require careful evaluation for potential medical emergencies. Atypical symptoms can complicate the differential diagnosis pro-cess. We present the case of a 70-year-old man who was admitted with chest pain and dyspnea. The initial differential diagnosis considered included pneumonia, pleural effusion, myocardial infarction, pulmonary embolism, and aortic dissection. During his admission, he became pyrexial with leuko-cytosis, and all his cultures (blood, sputum, pleural effusion) came back negative. He did not respond to empirical antibiotics. Due to a history of trauma, empyema was suspected. Stage III empyema was further diagnosed by imaging, thoracoscopy and pathological tissue examinations. Surgery, antibiot-ics, and breathing exercises were provided and led to a complete recovery. Taking into account other risk factors such as elderly age, chronic cough, chronic kidney disease, and a history of chest trauma, it is essential to consider empyema as a differential diagnosis for proper and instant treatments.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Screening significance of systemic immune-inflammation index (SII) and systemic inflammation response index (SIRI) in coronary heart disease of symptomatic youth.

The incidence of coronary heart disease (CHD) in youth is rapidly increasing but difficultly recognized in the early stage. In this retrospective study, 194 CHD patients under the age of 45 who previously experienced chest pain symptoms and 170 non-CHD patients were included and demographic data were collected. Systemic inflammation index (SII) and systemic inflammation response index (SIRI) were increased in young CHD patients (p < 001). Spearman's correlation analysis showed that both SII and SIRI were negatively correlated with HDL and positively correlated with hypertension, Gensini score, and hsTnI. Logistic regression analysis indicated that SII and SIRI were independently associated with the presence of CHD in youth with chest pain symptoms. The area under the ROC curve (AUC) of the SII model for young CHD patients was 0.805 (0.728-0.869), and the sensitivity and specificity were 0.65 and 0.823, respectively. Meanwhile, the AUC for the SIRI model was 0.812 (0.739-0.872), and the sensitivity and specificity were 0.673 and 0.8022. The calibration curves of both SII and SIRI models are in good agreement with the actual curves. And the decision curves of both models indicated their clinical practicality. SII and SIRI are independent risk factors for CHD in young adults, which can quickly and effectively identify CHD patients among young adults who have previously experienced chest pain symptoms.

Successful management of a delayed presentation of traumatic descending thoracic aorta pseudoaneurysm: a literature review based on a case report

BackgroundBlunt traumatic aortic injury (BTAI) is the second leading cause of death due to traumas in young patients. The primary presentation might be chest or interscapular pain, difficulty in breathing, and, in severe cases, hypotension. Considering the rapid deterioration of these patients’ clinical conditions, prompt diagnosis and treatment initiation are crucial. In these injuries, the most involved parts of the aorta are the isthmus (distal to the left subclavian artery) and the descending part in the thorax. Therefore, the main diagnostic strategies include transthoracic echocardiography, CT angiography, and endovascular diagnostic approaches.Case presentationThe patient was a 19-year-old male presenting with the symptoms of chest pain, dyspnea, and extremities excruciating pain after a car turnover. The initial evaluation showed no abnormal cardiovascular finding except bilateral hemothorax, addressed with chest tubes. Twelve hours later, when the patient was under observation for orthopedic surgeries, his chest pain and dyspnea started, and TTE and CTA showed a grade three descending aneurysm of the aorta. The patient was treated immediately with an endovascular procedure of stent implantation. A delayed debranching surgery was also performed, which resulted in desirable outcomes and uneventful follow-up.ConclusionAlthough open thoracic surgery is the main and almost the only option for treating aneurysms of the aorta in hemodynamically unstable patients, the endovascular procedure has shown superior outcomes in selected patients with appropriate anatomy. Debranching surgery, which can be done simultaneously or with delay after the initial procedure, has proven protective against thromboembolic cerebral events.Clinical key pointPatients with an aneurysm of the aorta should be transported to a medical center with a multidisciplinary team for an urgent evaluation and treatment. The initial resuscitation and diagnosis are challenging, considering the fatal nature of these injuries, and the selection of the treatment is based on the patient's clinical condition and evaluated anatomy in cardiovascular imaging.

A Patient with Dyspnea, Chest Pain and Fatigue due to Angina Pectoris Treated with Saengmaeg-san-hap-Bojungikgi-tang-gami: A Case Report

Objectives: This case report describes good clinical progress in a patient with symptoms related to angina pectoris treated with a herbal medication.Methods: The 66-year-old male patient hospitalized in Chonnam National University Hospital (CNUH) in May 2020 for symptoms of dyspnea and chest pain was diagnosed with angina pectoris, medicated, underwent PCI in August 2020, and continued to take the medicine prescribed at CNUH during hospitalization. Korean medical treatments, including herbal medicines (Saengmaeg-san-hap-Bojungikgi-tang-gami, Yeonggyechulgam-tang), acupuncture, and cupping therapy were administered for 22 days. Symptom severity was assessed with a daily visual analog scale (VAS) for dyspnea and chest pain and standard deviation of NN (SDNN) score of heart rate variability.Results: Post-treatment, severity of dyspnea, chest pain, and fatigue reduced from VAS 7 to VAS 2, VAS 6 to VAS 1, and VAS 7 to VAS 1, respectively. The SDNN score improved from 16.474 ms to 23.270 ms. There were no side effects from Korean medicine treatment.Conclusion: Traditional Korean treatment could effectively treat symptoms related to angina pectoris.

Relationship between Ocular Manifestations and Chest pain: A frequency based analysis of Systemic and Ocular Signs in COVID-19 Patients

Objective: To find the frequencies of systemic and ocular signs in confirmed polymerase chain reaction (PCR) positive COVID-19 cases and to find association between ocular manifestation and systemic signs in Covid-19 patients. Study Design: A prospective cross-sectional study. Place and Duration: Department of Medicine and Ophthalmology, KRL Hospital Islamabad. The research lasted six months, from 1st January 2021 to 31st August 2021. Methodology: A total of 416 PCR-confirmed COVID-19 positive patients were included. As a sample strategy, purposive sampling was adopted. SPSS version 21 was used for statistical analysis. Descriptive statistics was calculated for continuous variables. Chi square test was applied to find association among systemic and ocular signs. Results: The study included 73% men, and 27% women. Patients presented with body aches 67%, sudden onset retrosternal chest pain 21.9%, abdominal pain 14.4%, ocular symptoms 10.3%, loss of taste 67%, and loss of smell 66.7%, loose motion 1.1% and shortness of breath in 1%. The patients' mean platelet counts were 230.30 ±65.63, mean lymphocyte counts were 3702 ±176, t mean total leucocyte counts (TLCs) were 7.524 ±5, and mean c-reactive protein (CRP) level was 21.816 with SD of ±25.992.Assessing the relation between ocular symptoms and other systemic symptoms, the Chi-square test revealed an insignificant relationship. However, it showed a significant association between chest pain and ocular symptoms with a p-Value 0.001. Conclusion: This study found a significant association between chest pain and conjunctivitis in COVID-19 patients, attributing chest pain to respiratory issues, inflammation, and blood clotting. Conjunctivitis was prevalent, especially in healthy, young individuals. Keywords: COVID-19, Chest Pain, Conjunctivitis, Ocular Symptoms.

Thoracic solitary fibrous tumors with small cell features: A clinicopathological and immunohistochemical analysis of 5 cases

Five cases of thoracic solitary fibrous tumor (SFT) with small cell features are presented mimicking a neuroendocrine neoplasm. The patients were four men and one woman aged 43 to 74 years who presented with symptoms of chest pain, cough, dyspnea or hemoptysis. Two tumors were intrapulmonary neoplasms, while three were pleural-based. Grossly, the tumors ranged in size from 4 to 6 cm and were white and solid; in two tumors necrosis was apparent. Histologically, they were characterized by a cellular proliferation composed of small cells with round nuclei and inconspicuous nucleoli. The cellular proliferation in some areas had a subtle nested pattern, while in other areas the tumor showed extensive sclerosis and small vessel proliferation. Cellular pleomorphism was not marked and the mitotic activity varied from 1 to 5 mitotic figures per 10 high power fields. Microscopically, necrosis was observed in two cases and focally present in one. Immunohistochemical stains showed tumors cells universally negative for pancytokeratin; in the two pulmonary cases, focal staining for synaptophysin, CD56, and INSM1 was observed. The unexpected lack of expression of pancytokeratin led to additional analysis revealing positive staining with CD34 and STAT6 confirming a diagnosis of SFT. Clinical follow-up showed tumor recurrence in one patient while three patients remained alive and well after a period of 12 to 20 months. The current cases highlight an unusual variant of SFT that may be confused with other small cell tumor entities, such as neuroendocrine or neuroectodermal tumors, especially when originating in the thoracic cavity.

EHealth Literacy and the Use of NHS 111 Online Urgent Care Service in England: Cross-Sectional Survey.

Many health care systems have used digital technologies to support care delivery, a trend amplified by the COVID-19 pandemic. "Digital first" may exacerbate health inequalities due to variations in eHealth literacy. The relationship between eHealth literacy and web-based urgent care service use is unknown. This study aims to measure the association between eHealth literacy and the use of NHS (National Health Service) 111 online urgent care service. A cross-sectional sequential convenience sample survey was conducted with 2754 adults (October 2020-July 2021) from primary, urgent, or emergency care; third sector organizations; and the NHS 111 online website. The survey included the eHealth Literacy Questionnaire (eHLQ), questions about use, preferences for using NHS 111 online, and sociodemographic characteristics. Across almost all dimensions of the eHLQ, NHS 111 online users had higher mean digital literacy scores than nonusers (P<.001). Four eHLQ dimensions were significant predictors of use, and the most highly significant dimensions were eHLQ1 (using technology to process health information) and eHLQ3 (ability to actively engage with digital services), with odds ratios (ORs) of 1.86 (95% CI 1.46-2.38) and 1.51 (95% CI 1.22-1.88), respectively. Respondents reporting a long-term health condition had lower eHLQ scores. People younger than 25 years (OR 3.24, 95% CI 1.87-5.62) and those with formal qualifications (OR 0.74, 95% CI 0.55-0.99) were more likely to use NHS 111 online. Users and nonusers were likely to use NHS 111 online for a range of symptoms, including chest pain symptoms (n=1743, 70.4%) or for illness in children (n=1117, 79%). The users of NHS 111 online were more likely to have also used other health services, particularly the 111 telephone service (χ12=138.57; P<.001). These differences in eHealth literacy scores amplify perennial concerns about digital exclusion and access to care for those impacted by intersecting forms of disadvantage, including long-term illness. Although many appear willing to use NHS 111 online for a range of health scenarios, indicating broad acceptability, not all are able or likely to do this. Despite a policy ambition for NHS 111 online to substitute for other services, it appears to be used alongside other urgent care services and thus may not reduce demand.