Chest Pain Research Articles

EVALUATION OF EARLY OUTCOMES OF PERMANENT PACEMAKER IMPLANTATION IN HYPERTENSIVE PATIENTS WITH BRADYARRHYTHMIAS

Objective: This study aims to describe the clinical characteristics and the features of bradyarrhythmias on 24-hour Holter monitoring and to evaluate the early outcomes of permanent pacemaker implantation in hypertensive patients with bradyarrhythmias. Subjects and method: This cross-sectional study was conducted on 57 subjects with hypertension and bradyarrhythmias who were indicated for permanent pacemaker implantation. Results: The most common clinical symptoms recorded were fatigue, dizziness, and chest pain, accounting for 47.4%, 45.6%, and 42.1% respectively. The majority of patients had sinus node dysfunction (73.7%) and most underwent dual-chamber permanent pacemaker implantation (87.7%). The 24-hour Holter monitoring results showed that 42.1% had sinus atrial block - sinus pause in the sinus node dysfunction group and 15.8% of patients had third-degree atrioventricular block (AV block) in the AV block group. A good treatment outcome was observed in 72.0% of cases. Age > 70 (OR: 6.1; 95% CI: 1.2-30.1), female gender (OR: 4.2; 95% CI: 1.2-15.4), and single-chamber pacemaker (OR: 8.9; 95% CI: 1.5-52.1) were associated with a higher risk of moderate to poor treatment outcomes. Conclusion: Permanent pacemaker implantation generally tends to have good short-term outcomes. However, it should be noted that older age, female, and single-chamber pacemaker implantation in association with worse outcomes.

Canadian Association of Radiologists Cardiovascular Imaging Referral Guideline.

The Canadian Association of Radiologists (CAR) Cardiovascular Expert Panel is made up of physicians from the disciplines of radiology, cardiology, and emergency medicine, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 30 clinical/diagnostic scenarios, a rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 48 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 125 recommendation statements across the 30 scenarios (27 unique scenarios as 2 scenarios point to the CAR Thoracic Diagnostic Imaging Referral Guideline and the acute pericarditis subscenario is included under 2 main scenarios). This guideline presents the methods of development and the referral recommendations for acute chest pain syndromes, chronic chest pain, cardiovascular screening and risk stratification, pericardial syndromes, intracardiac/pericardial mass, suspected valvular disease cardiomyopathy, aorta, venous thrombosis, and peripheral vascular disease.

Factors influencing cardiovascular system-related post-COVID-19 sequelae: A single-center cohort study.

COVID-19 sequelae are long-term symptoms of COVID-19. Cardiovascular disease is not only a risk factor for the occurrence of COVID-19 sequelae but also a potential result directly or indirectly caused by COVID-19 infection. The aim of this study is to investigate the cardiovascular system-related symptoms of outpatients and inpatients of the Cardiovascular Department of the Affiliated Hospital of Shandong University of Traditional Chinese Medicine after recovery from novel coronavirus infection, analyze the influencing factors, and symptom characteristics of related symptoms, and thereby provide a basis for further formulating a reasonable diagnosis and treatment plan. From January 15, 2023 to February 15, 2023, 452 recovered patients with novel coronavirus infection who were admitted to the Cardiovascular Department of the Affiliated Hospital of Shandong University of Traditional Chinese Medicine due to symptoms of the cardiovascular system (complaints of chest pain and palpitations) were involved in this study. A unified questionnaire was used to record the general information, past medical history, characteristics of chest pain or palpitations, and other COVID-19-related sequelae of the selected patients. All data were statistically analyzed by SPSS 26.0 statistical software. A total of 226 patients with cardiovascular symptoms and 226 patients without cardiovascular symptoms were included in this study. After univariate and multivariate logistic regression analysis, women (OR 2.081, 95% CI = 1.358-3.189) and young people (OR 2.557, 95% CI = 1.44-4.54) had a higher risk of cardiovascular symptoms; prehypertension (OR 1.905, 95% CI = 1.091-3.329) and hypertension (OR 2.287, 95% CI = 1.433-3.649) increased the risk of cardiovascular symptoms; patients with history of previous cardiovascular disease (OR 1.862, 95% CI = 1.16-2.988) and history of diabetes (OR 2.138, 95% CI = 1.058-4.319) had a higher risk of developing cardiovascular symptoms. The main symptoms related to COVID-19 sequelae reported by all 452 patients were fatigue (76.8%), shortness of breath (54.2%), dry mouth and bitter mouth (46.0%), gastrointestinal symptoms (42.7%), sleep disturbances (37.4%), sweating (31.9%), chills (29%), dizziness (25.7%), confusion of brain fog (25.2%), and tinnitus (14.6%). Compared with patients without cardiovascular symptoms, patients with cardiovascular symptoms were more likely to have shortness of breath (OR 3.521, 95% CI = 2.226-5.472), gastrointestinal symptoms (OR 2.039, 95% CI = 1.226-3.393), and dry mouth and bitter mouth (OR 1.918, 95% CI = 1.229-2.992). The differences were statistically significant (P < 0.05). In this new coronavirus infection, women, young people, the elderly, people with prehypertension, hypertension, and patients with a history of cardiovascular disease and diabetes have a higher risk of developing cardiovascular symptoms, and patients with cardiovascular symptoms are more likely to develop other COVID-19 sequelae.

The prognostic value of HEART score in patients with known heart failure evaluated at the emergency department for acute chest pain

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Heart Lung and Blood Institute (United States). Background Chest pain is a common and concerning symptom in emergency care, often necessities further risk stratification for adverse cardiovascular events on short-term follow up. Patients with known heart failure (HF) constitutes a unique sub-population that would greatly benefit from short-term risk stratification to guide appropriate clinical interventions and optimize resource allocation. HEART (History, ECG, Age, Risk factors, Troponin) is a well-validated risk score that has been shown to outperform other clinical risk scores in patients with chest pain. It remains unknown if HEART score can be safely used in patients with known HF presenting to the emergency department with chest pain. Purpose We sought to evaluate the prognostic value of HEART score in patients with known HF compared to their counterparts. Method This was a prospective observational cohort study of consecutive adult patients evaluated at the emergency department for non-traumatic chest pain. HEART score was computed from charts by independent physician reviewers. The primary study outcome was major adverse cardiac events (MACE) defined as acute coronary syndrome, invasive revascularization, reinfarction, death, cardiac arrest, ventricular tachyarrhythmia, or acute exacerbation within 30 days of indexed admission. Outcomes were adjudicated by two independent reviewers (Kappa = 0.908). Classification performance between groups was compared using area under receiver operator characteristic curve (AUROC), sensitivity, and negative predictive value (NPV). Results Our cohort included 4,132 patients (age 59±16, 47% female, 33% Black). Overall, 921 patients (22.3%) experienced 30-day MACE. The classification performance of HEART score in those without HF (n = 3,329, 81%) was AUROC of 0.831 (95% CI 0.813-0.848), compared to only 0.633 (95% CI 0.592-0.673) in those with known HF (n = 803, 19%) (z score = 8.771, p &amp;lt; 0.001, Figure). The sensitivity and NPV of HEART score among those without HF were 87.4% and 95.3%, compared to 81.2% and 73.3%, respectively, among those with known HF. Conclusion Our findings suggest that the prognostic value of HEART score for predicting 30-day MACE is inferior and suboptimal in patients with known HF evaluated for chest pain at the emergency department compared to their counterparts. These findings emphasize the need for more tailored risk assessment and management strategies in this specific patient population. Further research is warranted to better understand the limitations and potential enhancements of the HEART score in patients with HF.Classification Performance of HEART score

Is the cardioprotective effect of pre-infarction angina blunted by age?

Abstract Funding Acknowledgements None. Background Pre-infarct angina (PIA) has been demonstrated to reduce infarct size and improve prognosis in ST-elevation myocardial infarction (STEMI). However, the effects of ischemic preconditioning with aging are still controversial. Purpose We aimed at comparing the effect of pre-infarction angina (PIA) on infarct size between two age groups. Methods We retrospectively studied consecutive STEMI patients treated by primary percutaneous coronary intervention (PCI) from January 2008 to December 2017. PIA was diagnosed if a patient had arm, jaw, or chest pain in the preceding eight days. Peak creatine kinase (CK) concentration was used as a surrogate of infarct size. Patients were divided into two groups, based on the median age: ≤62 years and &amp;gt;62 years. Multiple linear regression was used to identify independent predictors for infarct size that included total ischemic time and classic cardiovascular risk factors (hypertension, diabetes, dyslipidaemia, and smoking). Interaction between age and PIA was evaluated by 2-way factorial ANOVA. Results From the 1131 patients included in the study, 590 (52,2%) had ≤62 years and 541 (47,8%) had &amp;gt;62 years. Older patients were more often women (17.2% vs 8.6%, p&amp;lt;0.001) and had longer total ischemic time [4.6(3.0-9.0) vs 3.5(2.3-6.0) hours, p&amp;lt;0.001]. They also had higher prevalence of hypertension (32.8% vs 22.8%, p&amp;lt;0.001), diabetes (30.7% vs 18.7%, p&amp;lt;0.001) and were less likely to be smokers (26.9% vs 71.4%, p&amp;lt;0.001). The prevalence of PIA was similar across age groups (≤62Y 31.2% vs &amp;gt;62Y 32.0%, p=0.668). In older patients, PIA was associated with smaller infarct size [1.29(0.72-2.33) vs. 1.76(0.97-2.91) U/Lx103, p&amp;lt;0.001]. This difference was not observed for younger patients [1.72(0.95-3.40) vs. 1.81(0.94-3.37) U/Lx103, p=0.392]. There was no significant interaction between the existence of PIA and age on peak CK (p=0.280 for interaction) (Figure 1). In multivariate analysis, overall, PIA was associated with reduced peak CK (β=-0,320, p=0.011). On subgroup group analysis, PIA was a predictor of infarct size only in the older patients (β=-0,459, p=0.005), but not in the younger group (β=-0,182, p=0.394). Conclusion Older patients with PIA had significantly lower infarct size compared to patients in the same age group without PIA. After adjustment for risk factors and total ischemic time, PIA was a predictor of lower infarct size only for the older patients. These results suggest that the effect of pre-ischemic conditioning is not blunted by age, indicating that older patients should not be excluded from clinical trials investigation of cardioprotective strategies in STEMI patients.

Psychotropic medication use and mortality in patients with acute myocardial infarction complicated by cardiogenic shock

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation the Research Foundation of Odense University Hospital &amp; Rigshospitalet. Background The impact of pre-existing mental illness on mortality in patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) remains unclear. Purpose This study aims to assess the relation between pharmacologically treated mental disorders at the time of AMICS admission with patient characteristics and mortality. A surrogate marker for mental illness was defined as having at least one reimbursed prescription for psychotropic medication (Anatomical Therapeutic Chemical (ATC) group and subgroups N05, N06) within one year prior to admission with AMICS. Patients were divided into three therapy categories: None, one ATC subgroup, or two or more ATC subgroups. One-year survivors were further stratified by therapy status one year before admission and one year after discharge. Mortality was assessed at 30 days (5 years for one-year survivors). Kaplan-Meier estimates and univariable and multivariable Cox proportional hazards models were used to assess mortality rates stratified by treatment group. Results Of the cohort, 425 patients (25%) received therapy with psychotropic medication within the previous year at the time of presentation with AMICS. Polypharmacy (two or more ATC N05, N06 subgroups) was identified in 132 patients (8%). In these patients, there was a higher prevalence of comorbidities and a greater proportion of females (42% vs. 21%, p&amp;lt;0.001), compared to no treatment. More patients in the polypharmacy group presented with chest pain (60% vs. 52%, p=0.031), they were less often triaged directly to an invasive center (55% vs. 70%, p&amp;lt;0.001), and 30-day mortality was higher (73% vs. 51%, p&amp;lt;0.001). Among the 712 one-year survivors, 121 (17%) were treated with one or more drugs within one year before and after their AMICS admission. 149 (21%) began receiving therapy in the year following their AMICS admission. 422 (59%) never received psychotropic medication. In an unadjusted Cox model, therapy with two or more drugs, compared to no therapy, was associated with higher 30-day mortality (hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.43-2.19, p&amp;lt;0.001). This association remained significant in multivariable analysis (HR 1.66, 95%CI 1.22-2.26, p=0.001). Among one-year survivors, therapy with one or more drugs before and after AMICS was tied to an almost two-fold increase in five-year mortality (adjusted HR 1.95, 95%CI 1.23-3.10, p=0.004). Conclusions AMICS patients with pharmacologically treated mental illnesses were associated with higher mortality rates, as well as less favorable clinical profiles and treatment patterns. This increased risk remains evident among one-year survivors.

Should the left internal mammary artery (LIMA) be imaged before radiotherapy in cases of unexpected early acute coronary syndrome?

Abstract Funding Acknowledgements None. Case A 41-year-old male patient presented to the cardiology outpatient clinic with a complaint of exertional chest pain persisting for the past 4 months, along with occasional palpitation attacks. In his medical history, aside from being diagnosed with lymphoma 15 years ago, there were no known additional comorbidities. The electrocardiogram (EKG) revealed sinus rhythm (84 beats/minute), and the blood tests showed creatinine: 0.81 mg/dL, WBC: 11.26 mm^3, LYM: 3.69 mm^3. Transthoracic echocardiography demonstrated an ejection fraction (EF) of 60%, with no additional pathologies except for grade 1 diastolic dysfunction. Considering the presence of typical chest pain, coronary imaging was performed to assess for stable angina. The coronary imaging revealed a lesion extending from the left main coronary artery (LMCA) to the proximal left circumflex artery (CX), with an 80% stenosis in the mid-segment of the LMCA, a 60% stenosis at the narrowest point of the CX proximal segment, and an 80% stenosis in the proximal right coronary artery (RCA). The left circumflex artery obtuse marginal branches (CX OM) appeared thin and extensively diseased (Figure-1) The patient was promptly scheduled for early coronary artery bypass grafting (CABG), transferred to the cardiac surgery intensive care unit, and underwent a successful coronary bypass procedure with LAD-LIMA, Ao-saphenous-IM-saphenous-CxOM1 (sequential) grafting. Throughout the postoperative follow-up period, the patient continued to experience exertional chest pain despite medical treatment. A repeat coronary angiography was performed, revealing that the bypass grafts were opened, but a diffuse 80% stenosis was detected at the mid-segment of the LIMA graft, prior to the anastomosis.(Figure-2) Successful stent placement was performed at the narrowest point of the LIMA mid-segment (Figure-3).The patient had no anginal complaints during post-procedure follow-up and has been stable under observation. Discussion Routine clinical practice does not involve LIMA imaging in patients who have undergone diagnostic coronary angiography with multi-vessel involvement and a CABG decision. However, the use of coronary artery bypass graft surgery (CABG) may entail a risk of rendering the graft unusable due to extensive mediastinal fibrosis and radiation-induced damage to the left or right mammary artery. Therefore, in patients with a history of radiation exposure in the thoracic region and a CABG decision, the visualization of the intermammary artery during coronary angiography and the consideration of alternative grafts, such as the radiation-free radial artery, or the necessity for high-risk percutaneous stent implantation, should be discussed.figure-1figure-2

Early outcome in patients with STEMI undergoing primary PCI and high Zwolle risk score discharged within 72 hours

Abstract Funding Acknowledgements None. Introduction Zwolle risk score has been used to guide decision for early discharge in patients with ST- elevation acute myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). There is limited evidence on the outcome of patients with high score discharged within 72 hours from primary PCI. Our study aim is to evaluate the outcomes via 1 - month follow up in patients with STEMI undergoing primary PCI, with different Zwolle risk who were discharged within 72 hours from the hospital. Purpose To evaluate 1-month outcome of STEMI patients treated with primary PCI discharged within 72 hours according to Zwolle risk score. Methods We studied 187 consecutive STEMI patients from April 2022 to December 2022, presented in hospital within 12 hours of initial of chest pain, treated with primary PCI and discharged within 72 hours from hospital admission based on physician’s clinical judgement and patient’s preference. Patients were divided in two groups according to Zwolle risk score – low risk (≤3) and high risk (&amp;gt;3). The composite of major adverse events (MACE) consisting of: death, non-fatal re-infarction, stroke and repeat intervention at 1-month follow up was the primary endpoint. Follow up rate was 100%. Results There were 131 patients in the low risk and 56 in high risk groups. Males were 90% versus 80.3% in the low vs high risk group; in addition, mean age was 58.64 ± 10.6 vs 67.8± 6.24 years, respectively; mean ischemic time was 4.78± 3.03 vs 6.9 ± 3.6 hours, respectively; anterior localization was present in 32.8% vs 46.4% of the patients, respectively; 3-vessel coronary artery disease was present in 29.0% vs 46.4% of the patients, respectively; final TIMI 3 flow was present in all vs 96.4% of the patients, respectively. MACE occurred in 7 patients (3.8%) in the low risk group versus 3 patients (5.3%) in the high risk group (P = 0.63). Conclusions In our study population at higher Zwolle risk score was not associated with a worse early outcome among STEMI patients discharged within 72 hours.

Impact of misdiagnosis on the treatment and prognosis of acute aortic syndrome

Abstract Funding Acknowledgements None. Introduction Acute aortic syndrome (AAS) embraces a spectrum of pathologies with relatively low prevalence but associated with high mortality. The clinical presentation of AAS is highly variable and the differential diagnosis with other much more common diseases such as myocardial infarction (AMI) or pulmonary embolism (PE) is often difficult to achieve. AAS detection requires a high index of suspicion and the delay in diagnosis is associated with increased morbidity and mortality. Purpose The aim of this study is to characterize the diagnostic approach to AAS patients in the emergency department (ED) and to study the impact of the initial diagnostic suspicion on the treatment and prognosis of patients with AAS. Methods The "Aorta Code" is an inter-hospital and interdisciplinary care protocol for the management of patients with AAS in a 4-Hospital network. Patients with AAS were prospectively and consecutively collected from 2019 to 2022. The sample was classified into two groups according to whether the initial suspicion was AAA or another clinical entity. The diagnosis of AAS was established by computed tomography in all patients. Time, clinical, treatment and prognostic variables were analyzed. Results A total of 113 patients with AAS were included. Of them, only 38% (34) were initially suspected of having an AAS (Figure). AMI and PE were the initial diagnosis in 34% of patients (Figure). There were no significant differences in age, history of hypertension or other cardiovascular risk factors between the groups (table). Anterior chest pain was more frequent in the "AAS-suspicion" group. The diagnostic time delay was longer in patients with initial misdiagnosis (table). Patients with type A AAS with initial misdiagnosis underwent surgery in a lower proportion (table). Although the differences were not significant, patients with initial misdiagnosis had more postoperative complications and higher mortality. Conclusion It is essential to maintain a high index of diagnostic suspicion for AAS in the ED. Initial misdiagnosis is associated with a delayed diagnosis, delayed surgical treatment and a lower rate of surgery. In addition, although it is a small sample size, this group of patients had more postoperative complications and higher mortality.

Comparison of myocardial infarction with non-obstructive coronary arteries (MINOCA) versus type 2 MI with NSTEMI presentation; an Italian observation study

Abstract Funding Acknowledgements None. Background In the last decades, NSTEMI, is the predominant phenotype of myocardial infarction (MI) and many NSTEMI patients(pts) have a non-obstructive CAD. NSTEMI, represents an umbrella for many different conditions with distinct underlying pathogenesis and exhibits significant gender discrepancies and survival differences. Further, in absence of non-obstructive CAD, pts could be wrongly comforted about their prognosis. Purpose In this study, we compared the characteristics and the prognosis of pts with MINOCA and type 2 MI with non-obstructive CAD. The primary outcome was a composite of all-cause mortality, non-fatal MI, hospitalization for heart failure (HF) and transitory ischemic attack or non-fatal stroke. Methods Were screened 18223 pts with MI, who underwent coronary angiography between 2005 and 2022. Among them, 7815 pts had NSTEMI presentation, of which 693 pts (9%) had a non-obstructive CAD. After reviewing the angiographic data and clinical presentation, 155 pts were excluded because they belonged to one of the categories known as "MINOCA mimichers" (Fig 1). Five hundred and thirty eight pts with MI, NSTEMI presentation and with non-obstructive CAD were included in the final cohort: 301 (56%) had MINOCA and 237 pts (44%) had type 2 MI (Fig 1). Results The mean age of the population was 68 years, and females were predominant in both groups. MINOCA pts were younger, more frequently had adverse events during pregnancy and endocrine disorders. Pts with type 2 MI were more likely to have typical CV risk factors and comorbidities such as CKD and HF. Pts with type 2 MI had a worse diastolic function, a more dilated left atrium and left ventricle(LV), and non-coronary distribution of regional LV wall-motion abnormalities. At initial clinical presentation, the MINOCA group had typical chest pain upon awakening or at night, responsive to nitrates, while type 2 MI were more often to present with dyspnea, palpitations, and with higher blood pressure. Coronary vasospasm and embolization were the most common identified aetiologies in MINOCA pts while tachyarrhythmias were the most common trigger of type 2 MI, followed by hypertensive crisis. The final model of the predictors of MINOCA at multivariate logistic regression analysis listed in Fig 2, yielded an AUC of 0.865, p&amp;lt;0.01 at ROC analysis(Fig 2a). These variables were used for the generation of nomogram for MINOCA prediction(Fig 2b). During the median follow-up of 61 months (IQR 34.2-100.35), pts with MINOCA had a significantly better survival rate; 135 of 538 pts (25.1%) reached the primary combined endpoint(Fig 3a). The primary end-point was mainly driven by the all-cause mortality, followed by HF hospitalization, non-fatal stroke, non-fatal MI recurrence. Results of Cox multivariable analysis are presented in Fig 3b. Conclusions MINOCA cohort was associated with unconventional risk factors and had a better prognosis compared to T2 MI, which is closer to the classical AMI-CAD.

Biobehavioral approach to distinguishing panic symptoms from medical illness

Panic disorder is a common psychiatric diagnosis characterized by acute, distressing somatic symptoms that mimic medically-relevant symptoms. As a result, individuals with panic disorder overutilize personal and healthcare resources in an attempt to diagnose and treat physical symptoms that are often medically benign. A biobehavioral perspective on these symptoms is needed that integrates psychological and medical knowledge to avoid costly treatments and prolonged suffering. This narrative review examines six common somatic symptoms of panic attacks (non-cardiac chest pain, palpitations, dyspnea, dizziness, abdominal distress, and paresthesia), identified in the literature as the most severe, prevalent, or critical for differential diagnosis in somatic illness, including long COVID. We review somatic illnesses that are commonly comorbid or produce panic-like symptoms, their relevant risk factors, characteristics that assist in distinguishing them from panic, and treatment approaches that are typical for these conditions. Additionally, this review discusses key factors, including cultural considerations, to assist healthcare professionals in differentiating benign from medically relevant symptoms in panic sufferers.

Mediastinitis and septic shock complicating spontaneous esophageal rupture “Boerhaave’s syndrome”: a case report

Boerhaave’s syndrome, also known as spontaneous esophageal rupture, is a rare but life-threatening condition characterized by a tear in the esophagus. It is most commonly caused by a sudden increase in intraesophageal pressure, often due to severe vomiting or retching.Early diagnosis of Boerhaave’s syndrome is crucial for improving patient outcomes. The classic triad of symptoms includes severe chest pain, vomiting, and subcutaneous emphysema (air under the skin). However, not all patients present with this triad, and the diagnosis can be challenging, especially in patients without the typical symptoms.In this case report, we present the clinical details of a 52-year-old male patient who presented to the emergency department (ED) with severe abdominal pain and vomiting for several days. The patient had a history of chronic alcohol abuse and a recent episode of vigorous vomiting.

Acute Coronary Syndrome at Altitude: Diagnostic Dilemma on Aconcagua Using Point-of-Care Ultrasound.

At the Plaza de Mulas medical tent, located at 4300 m (14,100 ft) along the Normal Route to the 6960 m (22,837 ft) summit of Aconcagua in Argentina, a Korean male in his 50s with no known medical conditions presented with lightheadedness and shortness of breath. He had taken sildenafil and acetazolamide that morning without improvement. Vital signs on arrival were notable for oxygen saturations in the high 60s with basilar crackles on lung auscultation, concerning for high altitude pulmonary edema. The patient was started on oxygen via nasal cannula and given dexamethasone. History was limited secondary to language barriers, but on review of systems the patient noted mild chest pressure. Bedside cardiac echocardiogram was performed, which revealed a septal wall motion abnormality. The patient was therefore given aspirin and clopidogrel and was flown to a lower trailhead, where he was met by local Emergency Medical Services. A 12-lead electrocardiogram revealed an anterior ST-elevation myocardial infarction, and the patient was taken emergently to the catheterization lab in Mendoza and underwent stent placement with a full recovery.

Comparison of Forward-Leaning and Fowler Position: Effects on Vital Signs, Pain, and Anxiety Scores in Children With Asthma Exacerbations.

It is essential to relieve bronchospasm or specific asthma symptoms by administering immediate inhaler treatment during an asthma exacerbation. The present study compared the effect of Fowler position and forward-leaning positions during nebulization on heart rate, SpO2 , breathing frequency, pain, and anxiety levels in children experiencing asthma exacerbations. The data originated from a randomized trial that compared 86 participants (study group n = 43, control group n = 43) who presented to the pediatric emergency department with asthma exacerbations between October 2019-February 2020. The subjects were administered nebulization 3 times, during which the study group was placed in the forward-leaning position and the control group in the routine Fowler position. The subjects provided information on chest pain and anxiety levels before and after nebulization, and heart rate, SpO2 , and breathing frequency were measured before and after each nebulization. The difference in the mean SpO2 measured at admission and after the third nebulization was significantly higher (3.2 ± 1.5% vs 2.3 ± 1.9%, P = .01); the difference in the mean breathing frequency was considerably higher (-6.0 ± 1.7 breaths/min vs -3.2 ± 1.8 breaths/min, P < .001), and the difference in the mean pain scores was significantly higher (-3.3 ± 2.5 vs -2.0 ± 2.3, P = .02) in the study group than in the control group. In addition, after the third nebulization, the breathing frequency (22.8 ± 2.8 breaths/min vs 24.2 ± 2.7 breaths/min, P = .02) and pain score of the study group were lower (0.8 ± 1.3 vs 1.5 ± 1.5, P = .01). There was no difference in the mean heart rate (20.6 ± 16.2 beats/min vs 20.0 ± 15.4 beats/min, P = .85) and anxiety levels (-2.0 ± 2.2 vs -1.9 ± 2.2, P = .90) between the groups. Placing children in a forward-leaning position during nebulization was effective in improving SpO2 and reducing breathing frequency and chest pain. The forward-leaning position implemented during nebulization is a non-pharmacologic method that supports recovery in children with asthma exacerbations.

Panic Disorder Versus Thyroid Medication Overuse: A Case Report

Introduction: Panic disorder is defined as the occurrence of spontaneous panic attacks that are not triggered by any specific stimulus. The symptoms of panic disorder include panic episodes that occur frequently and unexpectedly, as well as anxiety about the possibility of experiencing further panic attacks, the repercussions of panic attacks, or a change in behavior as a result of panic attacks. This study presented the diagnosis and treatment of panic disorder comorbid with thyroid medication overuse. Case presentation: A 36-year-old female patient presented to the emergency room with a primary concern and symptoms consistent with panic disorder, including experiencing a sense of losing control or impending death, chest pain, difficulty breathing, rapid heartbeat, excessive perspiration, trembling, and dizziness. The patient experienced significant periods of anxiety between episodes, preoccupied with the anticipation of the next occurrence. Each episode had a duration of roughly 15 minutes. The patient refutes any history of alcohol or drug misuse, and her sole medical condition is hypothyroidism. Subsequently, we perform a comprehensive analysis of the thyroid profile and make a referral to an internal medicine specialist for collaborative treatment. We treated the patient with a combination of a selective serotonin reuptake inhibitor (SSRI) fluoxetine 20 mg/day and a course of cognitive-behavioral therapy. Conclusion: Repeated episodes of intense panic attacks, accompanied by feelings of anxiety and observable alterations in behavior, distinguish panic disorder as a medical illness. The treatment involves the use of selective serotonin reuptake inhibitors, antidepressants, and cognitive behavioral therapy.

A rare case of spontaneous spinal epidural hematoma with spontaneous resolution

Spontaneous spinal epidural hematoma (SSEH) is an uncommon cause of acute spinal cord compression. It is a neurological emergency that requires urgent imaging and appropriate treatment to prevent permanent neurological sequelae. Here, we present the case of a 30-year-old male with no known comorbidities who presented to the emergency department with a history of sudden onset of upper backache and chest discomfort followed by bilateral lower limb weakness. On examination, the blood pressure was 220/120 mmHg, and neurological examination showed decreased tone and power of 2/5 in bilateral lower limbs. In view of the initial chest discomfort, a cardiac evaluation was done, which was normal, followed by magnetic resonance imaging of the whole spine, which showed a lesion in the anterior epidural space suggestive of hematoma, causing spinal cord compression. A final diagnosis was C6-T2 dorsal SSEH secondary to a hypertensive emergency.

Patients With Coronary Microvascular Dysfunction Have Less Circulating α-Klotho.

Coronary microvascular dysfunction (CMD) represents an early functional characteristic of coronary vascular aging. Klotho (α-klotho) is a circulating protein inversely linked to physiological aging. We examined low klotho as a potential marker for vascular aging in patients with CMD and no coronary artery disease. Patients undergoing nonurgent angiogram for chest pain who had no coronary artery disease underwent invasive coronary microvascular and endothelial function testing. CMD was defined by ≤50% increase in coronary blood flow (percentage change in coronary blood flow) in response to intracoronary acetylcholine or coronary flow reserve ≤2. Fresh arterial whole blood was used to analyze circulating endothelial progenitor cells with flow cytometry. Stored arterial plasma was used for klotho analysis by ELISA. Participants with CMD (n=62) were compared with those without CMD (n=36). Those with CMD were age 55±10 years (versus 51±11 years; P=0.07) and 73% women (versus 81%; P=0.38). Traditional risk factors for coronary artery disease were similar between groups. Patients with CMD had less klotho (0.88±1.50 versus 1.75±2.38 ng/mL; P=0.03), and the odds of low klotho in CMD were significant in a logistic regression model after adjusting for traditional cardiovascular risk factors (odds ratio [OR], 0.80 [95% CI, 0.636-0.996]; P=0.05). Higher klotho was associated with higher numbers of endothelial progenitor cells with vascular regenerative potential (CD34+ and CD34+CD133+KDR+). Among a subgroup of patients with atherosclerotic cardiovascular disease risk <5% (n=58), CMD remained associated with lower klotho (OR, 0.80 [95% CI, 0.636-0.996]; P=0.047). Klotho may be a biomarker for CMD and may be a therapeutic target for groups of patients without significant traditional cardiovascular risk.

Diagnosis of Pulmonary Tuberculosis by Xpert MTB/RIF Assay Using Gastric Aspirate in Children with Pneumonic Consolidation

Background: In Bangladesh, there is increased evidence of TB-associated pneumonia in children are currently missed or diagnosed too late resulting in deterioration of condition. The objective of this study was to detect the frequency of pulmonary TB in children presented with pneumonic consolidation by Xpert MTB/RIF assay using gastric aspirate. Materials &amp; Methods: This was a prospective observational study. Admitted children from 6 months to 14 years old from January to December 2020 with clinical features consistent with pneumonia and radiographically confirmed consolidations were enrolled in this study. MT and Xpert MTB/RIF assay using gastric aspirates were done in all cases. Data regarding frequency of TB, clinical features and lab findings of enrolled patients were collected and analyzed. Results: Total 7/60 (11.67%) enrolled patients, were confirmed as Pulmonary Tuberculosis by Gene Xpert using gastric aspirates. The most common clinical signs were fever and cough in all (100%) patients. Others had chest pain 23(38.33%), breathing difficulty 21(35%), vomiting 17(28.33%). Younger children less than 5 years (P=.045), contact with TB patient (P= .001), long duration of fever (P = .001), presence of severe acute malnutrition (P = .001) high ESR (P= .009), positive MT (P=.017) were associated with positive rate of Xpert MTB/RIF assay in children. Conclusions: Xpert MTB/RIF assay can assist in fast diagnosing childhood pulmonary TB especially in patients with fever more than one week, malnutrition and having contact with TB patient. BANGLADESH J CHILD HEALTH 2022; VOL 46 (2) : 65-70

Exploring Roemheld syndrome: acomprehensive review with proposed diagnostic criteria.

Roemheld syndrome (RS) is acondition that triggers cardiac symptoms due to gastrointestinal compression of the heart. It is often misdiagnosed as other types of cardiac or digestive disorders, leading to unnecessary treatments and reduced quality of life. Here, we provide athorough review of RS, covering its pathogenesis, etiology, diagnosis, treatment, and outcome. We found that anumber of conditions, including gallstones, hiatal hernia, excessive gas, and gastroesophageal reflux syndrome, can cause RS. The symptoms of RS can include chest pain, palpitations, shortness of breath, nausea, vomiting, bloating, and abdominal pain. Clinical history, physical examination, electrocardiograms, and improvement in symptoms following gastrointestinal therapy can all be used to identify RS. We also propose aset of criteria, the IKMAIR criteria, to improve the diagnostic approach for this condition. Dietary changes, lifestyle adjustments, pharmaceutical therapies, and surgical procedures can all be used to control RS. Depending on the underlying etiology and the outcome of treatment, RS has avarying prognosis. We conclude that RS is acomplicated and understudied disorder that needs more attention from researchers and patients as well as from medical professionals. We recommend the inclusion of RS in the differential diagnosis for individuals with gastrointestinal problems and unexplained cardiac symptoms. Additionally, we advise treating RS holistically by attending to its cardiac and gastrointestinal components.

Effective Strategies for Managing Sudden Hemoptysis Caused by Aorto-Bronchial Fistula during Cardiopulmonary Bypass: A Case Report

Aorto-bronchial fistula (ABF) is a rare but life-threatening complication that can occur after thoracic endovascular aortic repair (TEVAR). The ABF clinical diagnosis can be challenging due to its insidious symptoms and potential for misdiagnosis. Managing endobronchial hemoptysis caused by ABF during cardiopulmonary bypass (CPB) is challenging due to limited clinical experience. We present a case of a patient who was previously treated with TEVAR for a thoracic aortic dissection and endovascular abdominal aortic aneurysm repair for an abdominal aortic aneurysm. The patient was admitted with intermittent hemoptysis over 1 year and chest pain for 3 days. Aortic computed tomography angiography (CTA) showed a recurrent dissection of the aortic arch. We encountered endotracheal hemoptysis during total arch replacement combined with a stented frozen elephant trunk under CPB. Due to the patient's prior history of TEVAR, the ABF was eventually diagnosed during the procedure; however, with the implementation of a series of measures, we were able to successfully resuscitate the patient. The literature suggests that this may be an exceedingly rare case of ABF successfully treated during CPB. Currently, there are no established clinical guidelines or consensus for the diagnosis and treatment of ABF after TEVAR due to the lack of case reports with extensive data. Timely identification of the bleeding bronchus, early activation of blood cell salvage, early neutralization of heparin activity, and timely resection of the diseased lobe are key to treating patients with ABF during CPB.