Episodes Of Chest Pain Research Articles

The Rise and Fall of Cardiac Troponin T.

A 65-year-old man presented to the emergency department. He reported experiencing a 20-min episode of central chest pain with an aching character and no radiation. He had no significant past medical history. Serial electrocardiograms showed no ST segment or T-wave abnormalities. High-sensitivity cardiac troponin T (hs-cTnT)4 concentrations (Roche Elecsys, 99th percentile 14 ng/L, CV <10% at 13 ng/L) were …

Epileptic Angina

PurposeTo investigate the probable ictal origin of unexplained episodic chest pain and if possible to lateralize and localize the epileptic focus.MethodsA 14 year old boy presented with episodic short lasting localized chest pain. His cardiac and other systemic work-up were normal. MRI brain did not reveal any structural pathology. Video telemetry was done for characterization of the paroxysms.ResultsInterictal record showed left fronto-central epileptiform discharges. A left hemispheric, predominantly centroparietal ictal rhythm was identified. The possible localizations of this unusual semiology are somatosensory areas I and II, supplementary sensorimotor area, posterior insula and cingulate cortex. Patient responded remarkably to antiseizure drugs.ConclusionPain is a rare manifestation of epilepsy observed in less than 1% of patients. When present, it is usually accompanied by other focal features. This rare occurrence of epileptic seizures masquerading as angina is a novel observation.

Management standards for stable coronary artery disease in India

Coronary artery disease (CAD) is one of the important causes of cardiovascular morbidity and mortality globally, giving rise to more than 7 million deaths annually. An increasing burden of CAD in India is a major cause of concern with angina being the leading manifestation. Stable coronary artery disease (SCAD) is characterised by episodes of transient central chest pain (angina pectoris), often triggered by exercise, emotion or other forms of stress, generally triggered by a reversible mismatch between myocardial oxygen demand and supply resulting in myocardial ischemia or hypoxia. A stabilised, frequently asymptomatic phase following an acute coronary syndrome (ACS) is also classified as SCAD. This definition of SCAD also encompasses vasospastic and microvascular angina under the common umbrella.

Surgical repair of a complex renal artery aneurysm through bench surgery and autotransplantation

Abstract A 58-year-old woman with underlying medically controlled hypertension presented after an episode of sudden-onset chest pain. Chest computed tomography imaging revealed a left renal artery aneurysm (RAA) measuring 1.6 cm in diameter with mural thrombi in the distal left renal artery at bifurcation level. An interval enlargement of approximately 0.4 cm in diameter was noted within a 6-month period; however, endovascular intervention was not feasible because of the complex RAA pattern. She was hospitalized and received a hand-assisted laparoscopic nephrectomy, ex vivo repair of the RAA, and autotransplantation into the left iliac fossa. The procedure was successful, and the postoperative course went smoothly. The kidney graft was evaluated using a magnetic resonance angiography 1-year postoperatively, which showed no signs of surgical complications or RAA recurrence.

Transient right bundle branch block in a patient with acute pulmonary embolism

We report the case of an 86-year-old man found at home with acute chest pain and dyspnea. He presented some episodes of left chest pain combined with dyspnea. The physical examination revealed crackling sounds on the bases of the lungs without other anomalies. Electrocardiograms revealed a transient and complete right bundle branch block with inverted T waves in leads V1, V2, and V3. He was diagnosed with a proximal bilateral acute pulmonary embolism without acute cor pulmonale. We describe a case of a transient bundle branch block, without tachycardia or acute cor pulmonale, revealing a pulmonary embolism.

Common functional pain syndromes

### Key points When a patient presents with pain of no obvious organic origin, they are often labelled as having ‘functional’ pain. The exact diagnosis is derived from the organ system displaying the predominant symptoms e.g. musculoskeletal pain in fibromyalgia (FM) or visceral pain in irritable bowel syndrome (IBS). The worldwide prevalence of all functional pain syndromes (FPS) is 15–20%. World Health Organization (WHO) surveys reveal that ∼10% of primary care patients develop a chronic pain condition within 12 months of initial registration. Of these, at least 50% continue to have symptoms beyond 1 yr. FPS cause enormous economic burden on society with concurrent ramifications for the individual's family in particular and society in general. FM alone has been estimated to cost around £4000 per patient per year. There has been a paradigm shift in the understanding of FPS. The old model of multiple discrete chronic pain conditions is being replaced by a more overarching, although no less complex, state of central sensitivity syndrome (CSS). Evidence is being accrued that FPS represent the phenotypic output of a complex interplay between genetic susceptibility, gene–environment interactions, and environmental triggers. Four common FPS will be reviewed in this article: FM, IBS, temporomandibular dysfunction (TMD), and chronic cardiac chest pain (CCCP). The pathophysiology and management of each will be examined and the case presented for a shared underlying mechanism called CSS. Once this new mechanism is adopted more widely, it will allow for future novel management options to be …

Gastric Volvulus Presenting as Chronic, Intermittent Chest Pain and Retching of Unclear Etiology

AIM: To describe a case of gastric volvulus which presented as chronic, intermittent chest pain and retching. CASE REPORT: A 59 yo female presented for further evaluation after relocating from another area. Her past medical history was unremarkable and she was taking only pantoprazole each day. She related a one year history of severe, intermittent lower chest pain with associated retching. Symptoms occurred exclusively in the intraprandial and early postprandial period. Symptoms occurred a few times each week and led to multiple ER visits. She underwent extensive cardiac evaluation, blood testing, gallbladder sonography, abdominal CT scanning and upper GI endoscopy (EGD). Her prior gastroenterologist detected a “moderate-sized” hiatal hernia and non-dysplastic, ultra-short-segment Barrett's esophagus (“irregular z-line”) at the time of EGD. Given her symptoms and her new diagnosis of Barrett's esophagus one year earlier, I recommended repeat EGD which revealed a large hiatal hernia (with approximately half of the stomach being intrathoracic) and there appeared to be a paraesophageal component. At this point, it was strongly suspected that her symptoms were related to the endoscopic findings. An upper GI series confirmed that a large portion of the stomach was intrathoracic, and there was organoaxial gastric volvulus (see Figure 1). The patient was urgently referred for surgical consultation and she underwent intervention. After nearly 2 years of follow-up, she has had durable resolution of all of her previous symptoms.Figure 1CONCLUSION: Chronic episodic chest pain in association with meal-related retching should raise the specter of intermittent gastric volvulus, especially in a patient with a history of a hiatal hernia. Although a bit less usual, in this case, the chronic symptoms were related to an organoaxial, as opposed to a mesenteroaxial gastric volvulus. Surgical repair was successful in alleviating the patient's symptoms.

Guided Internet-delivered cognitive behavioural therapy in patients with non-cardiac chest pain - a pilot randomized controlled study.

BackgroundPatients with recurrent episodes of non-cardiac chest pain may experience cardiac anxiety and avoidance behavior, leading to increased healthcare utilization. These patients might benefit from help and support to evaluate the perception and management of their chest pain. The purpose of this study was to test the feasibility of a short guided Internet-delivered cognitive behavioural therapy (CBT) program and explore the effects on cardiac anxiety, fear of body sensations, depressive symptoms, and chest pain in patients with non-cardiac chest pain, compared with usual care.MethodsA pilot randomized controlled study was conducted. Fifteen patients with non-cardiac chest pain with cardiac anxiety or fear of body sensations, aged 22–76 years, were randomized to intervention (n = 7) or control (n = 8) groups. The four-session CBT program contained psychoeducation, physical activity, and relaxation. The control group received usual care. Data were collected before and after intervention.ResultsFive of seven patients in the intervention group completed the program, which was perceived as user-friendly with comprehensible language, adequate and varied content, and manageable homework assignments. Being guided and supported, patients were empowered and motivated to be active and complete the program. Patients in both intervention and control groups improved with regard to cardiac anxiety, fear of body sensations, and depressive symptoms, but no significant differences were found between the groups.ConclusionsThe Internet-delivered CBT program seems feasible for patients with non-cardiac chest pain, but needs to be evaluated in larger groups and with a longer follow-up period.Trial registrationClinicaltrials.gov NCT02336880. Registered on 8 January 2015.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-016-1491-1) contains supplementary material, which is available to authorized users.

Sudden death due to lethal strangulation of heart by congenital partial pericardium

Cases of strangulation of heart are usually seen in post-operative heart surgery. However such strangulation of heart can occur due to defect in pericardium. Here, we report a case of 32year old male who had complaint of chest pain while working on a building construction site. He had previous episodes of intermittent chest pain which remained undiagnosed. On post-mortem examination, it was observed that the deceased had defect in pericardium with bilateral absence of pericardial sac. In absence of any previous surgical record it was found to be of congenital in nature. Such absence of pericardial sac may remain dormant and can aggravate in situations like stress which laid to constriction of pericardial sac to the ventricular wall leading to blockage of heart vessels causing sudden stoppage of circulation to heart muscle itself. On post-mortem examination opinion as to the cause of death was given as strangulation of heart due to bilateral congenital partial pericardium. Such type of case is reported for its rarity.

PTU-129 Ambulatory High Resolution Oesophageal Manometry: A Novel Tool to Investigate Non-Cardiac Chest Pain

Introduction Non-cardiac chest pain can present a clinical challenge to the gastroenterologist. Many causes remain undiagnosed and untreated. Oesophageal spasm is frequently considered a cause of non-cardiac chest pain, but current diagnostic tools are often poor at making this diagnosis. High resolution oesophageal manometry is now the gold standard oesophageal motility test, and is a swallow-based assessment. Unfortunately most episodes of chest pain in this context are not swallow-related, and are usually sporadic and unpredictable. Thus most manometry assessments occur in the absence of a symptom event. We propose that prolonged, ambulatory high resolution may be a tool that can detect these sporadic chest pain events and allow correlation to symptom episodes. We aimed to test the diagnostic yield of a novel, ambulatory high resolution oesophageal manometry device in the diagnosis of non-cardiac chest pain. Methods We studied 17 patients (7 male, 10 female, age range 14 to 66) with chest pain. All had cardiac pain excluded by cardiology review, and all had been studied with normal upper GI endoscopy. All had also had major oesophageal motor disorder (including spasm) excluded by swallow-based high resolution manometry (with liquid and solid swallows). An ultra-thin high resolution solid-state catheter was inserted transnasally into the oesophagus. This was connected to a small laptop and battery pack carried in a backpack. Patients were sent home and encouraged to mobilise. Patients were asked to keep the catheter in place at least until a symptomatic pain event was perceived. Symptom events were self-marked on a recorder device that was subsequently synchronised with the manometry output. Manometry tracings were read manually, and motor events at the time of symptoms were examined in detail. Results The median duration of recording with the system was 12 hours, 13 minutes (range 5 hours, 30 minutes to 26 hours, 40 minutes). 12 of the 17 patients perceived typical chest pain symptom during recording. Of the 12 with typical symptoms, 3 (25%) had clinically important findings that changed management. They had significant oesophageal spasm, pressurisation and shortening associated with pain events. These have been treated successfully with oesophageal body Botox injections (2 patients) and with long laparoscopic myotomy (1 patient). The remaining 9 patients either had no abnormalities, or minor abnormalities that did not correspond to symptoms. Conclusion Ambulatory high-resolution manometry is a novel tool for investigation of non-cardiac chest pain. In our series, we identified management-altering abnormalities in 3 of 17 patients who had previously been investigated with normal cardiac, endoscopic and stationary manometric evaluation. Disclosure of Interest J. Ooi: None Declared, E. Yazaki: None Declared, K. Nikaki: None Declared, D. Sifrim Grant/research support from: Research grant from Sandhill Scientific, P. Woodland: None Declared

Investigating the Role of IL-33 in the Pathogenesis of Familial Mediterranean Fever

Abstract Familial mediterranean fever (FMF) is an autosomal recessive genetic disorder familial disease with inflammatory reactions of serosal membranes characterized by recurrent episodes of abdominal chest and joint pain, and fever. During the acute attacts, increased several proinflammatory cytokines have been described. IL-33 is a member of the IL-1 cytokine superfamily. It has been reported that IL-33 plays an important role in inflammation and homeostasis. Here, we analyzed serum IL-33 concentration in patients with FMF to assess its possible role in the pathophysiology of this disease. Material and method In this study, 58 patients with FMF (21 female, 37 male; mean age 27.8 ± 5.2 years, mean disease duration 8.2 ± 3,7 years) and 22 healthy controls (10 female, 12 male, mean age 26,5 ± 5,9 years) were included. Serum IL-33 levels were measured by ELISA. Results The mean serum IL-33 levels were 3,88 ± 2,25 pg/ml in patients with FMF and 2,89 ± 0.48 pg/ml in the healthy controls. The mean levels of serum IL-33 were 5,48 ± 2,13 pg/ml in active stage and 2,27 ± 0,36 pg/ml in inactive stage. According to these results; serum IL-33 levels were significantly higher in patients with FMF compared with healthy controls (p&amp;lt;0.01). In addition, Serum IL-33 levels were significantly higher in active stage compared to in inactive stages and controls (p&amp;lt;0.0001 and p&amp;lt;0.0001). In the inactive patients with FMF, serum IL-33 concentrations were found to be lower compared to healthy controls (p&amp;lt;0.05). In active FMF patients, the mean serum IL-33 level was correlated with arthritis (p&amp;lt;0.05). Conclusion The high levels of serum IL-33, in active patients with FMF suggest that IL-33 may play a significant role of in the pathogenesis of FMF.

SUPRAVENTRICULAR TACHYCARDIA ABLATION IN THE TREATMENT OF SPONTANEOUS CORONARY ARTERY DISSECTION

A 42 year old female with history of SCAD of her left anterior descending artery that was diagnosed 1 month prior presented with her second episode of chest pain. She had mild ST elevation in her anterior leads and a mildly elevated troponin. A repeat angiogram revealed recurrent dissection of her

MEN-2A SYNDROME PRESENTING AS CATECHOLAMINE-INDUCED CARDIOMYOPATHY VERSUS A MYO-PERICARDITIS

Pheochromocytomas are rare endocrine tumors that can affect various organ systems. Some cardiac manifestations include catecholamine induced cardiomyopathies, myopericarditis, and myocardial infarction. A 22-year-old woman presented with two months of episodic chest pain and severe headaches and

Cardiovascular adverse events complicating the administration of rituximab: report of two cases.

Rituximab is a murine/human chimeric monoclonal antibody directed against the CD20 antigen. It is widely used in combination with polychemotherapy regimens for the treatment of hematological disorders. There is no evidence of direct cardiotoxicity of the drug but a few cases of cardiovascular adverse events have been reported in the literature. We report on two patients affected by stage IV non-Hodgkin lymphoma with bone marrow infiltration and peripheral blood involvement who experienced cardiovascular accidents temporally related to rituximab infusion. In both cases the monoclonal antibody was administered in association with a polychemotherapy regimen but administration was postponed several days later in order to avoid severe cytokine release syndrome because of the high tumor burden. The first case concerns an episode of atrial fibrillation in a patient with a diagnosis of small B-cell lymphoma. The episode happened immediately after rituximab infusion. In the second case there was an episode of chest pain associated with fever and chills during rituximab infusion in a patient with a diagnosis of mantle cell lymphoma. In both cases we noticed an unusual correlation between symptom recurrence and the speed of rituximab infusion. Both patients presented several cardiovascular risk factors but preliminary cardiac function assessment excluded signs of heart dysfunction. The pathogenesis of cardiovascular events during rituximab infusion remains unclear. A key role might be played by cytokine release from B cells as a consequence of rituximab activity. Moreover, pre-existing silent cardiac damage could be co-responsible for the clinical manifestations we reported. We consider our clinical experience relevant because it raises an issue of good clinical practice: despite rituximab's good tolerability profile, patients with cardiovascular risk factors should undergo accurate cardiac assessment so that silent heart disease can be detected. If the suspicion of cardiac damage is high, more extensive cardiac assessment is recommended.

Long-Term Preservation of Left Ventricular Systolic Function in Patients With Refractory Angina Pectoris and Inducible Myocardial Ischemia on Optimal Medical Therapy

Refractory angina pectoris (RAP) represents a clinical condition characterized by frequent episodes of chest pain despite therapy optimization. According to myocardial stunning and myocardial hibernation definitions, RAP should represent the ideal condition for systolic dysfunction development. We aim to investigate the evolution of left ventricular (LV) function in patients with RAP. A retrospective study which encompasses 144 patients with RAP referred to our institution from 1999 to December 2014 was performed. Of them, 88 met the inclusion criteria, and LV function was assessed by echocardiography. All of them had persistent angina episodes on top of optimal medical therapy and evidence of significant inducible myocardial ischemia and no further revascularization options. Nitrates consumption rate, time of angina duration, and the number of angina attacks were evaluated. In the whole population, ejection fraction (EF) was 44% ± 2. EF was significantly lower in patients with previous myocardial infarction (41% ± 1.5 vs 51% ± 1.8, p <0.0001). The duration time and the number of angina attacks did not correlate with EF in the whole population and in patients without previous myocardial infarction. In patients with previous myocardial infarction, the number of anginal attacks did not correlate with EF, but EF appeared higher in patients with angina duration >5years (<5years EF 37% ± 1 [n= 26]; >5years 44% ± 2 [n= 44]; p 0.02). Long-term LV function in patients with RAP is generally preserved. A previous history of myocardial infarction is the only determinant in the development of systolic dysfunction. In conclusion, frequent angina attacks and a long-term history of angina are not apparently associated to worse LV function.

Chest Pain: The Need to Consider Less Frequent Diagnosis

Chest pain is one of the most frequent patient's complaints. The commonest underlying causes are well known, but, sometimes, in some clinical scenarios, it is necessary to consider other diagnoses. We report a case of a 68-year-old Caucasian male, chronically hypertensive, who complained of recurrent episodes of chest pain and fever with elevated acute phase reactants. The first investigation was negative for some of the most likely diagnosis and he quickly improved with anti-inflammatory drugs. Over a few months, his symptoms continued to recur periodically, his hypertension was aggravated, and he developed headaches and lower limbs claudication. After a temporal artery biopsy that was negative for vasculitis, he underwent a positron emission tomography suggestive of Takayasu Arteritis. Takayasu Arteritis is a rare chronic granulomatous vasculitis of the aorta and its first-order branches affecting mostly females up to 50 years old. Chest pain is experienced by >40% of the patients and results from the inflammation of the aorta, pulmonary artery, or coronaries.

Recurrent chest pain after treatment of spontaneous coronary artery dissection: An enigma

Spontaneous coronary artery dissection (SCAD) is a rare entity. It has been described in various settings like pregnancy, collagen vascular diseases, cocaine abuse, heavy exercise, variant angina, eosinophilic arteritis, or fibro muscular dysplasia. It is also easy to miss a dissection during angiography, as the typical radiolucent lumen seen in coronary angiography may be absent in many cases.In this report, we describe the case of a 35-year-old female who presented with acute ST elevation myocardial infarction due to spontaneous coronary dissection. She had been having episodic chest pain for one year and had been seen by two different cardiologists but was thought to have non-cardiac symptoms. Even during the index hospitalization, she underwent coronary angiography three times before coronary dissection could be identified as the cause of her symptoms.She underwent coronary artery bypass graft surgery uneventfully. However, even after myocardial revascularization, she has had multiple episodes of chest pain requiring hospitalization. However, we have not been able to find a specific cause for it and the cause of her recurrent chest pain remains an enigma. This case highlights the problems, which arise while managing a case of SCAD. More research is needed to find the exact etiology and long-term prognosis of this condition.

EARLY DISCONTINUATION OF FONDAPARINUX IN LOW-RISK PATIENTS HOSPITALIZED WITH NON-ST-ELEVATION ACUTE CORONARY SYNDROME: MARKERS OF HEMOSTASIS ACTIVATION AND IN-HOSPITAL OUTCOMES

Current guidelines recommend use of anticoagulants (preferably fondaparinux) until hospital discharge in non-invasively treated patients (pts) with non-ST-segment elevation acute coronary syndrome (NSTEACS). however, some evidence exists that anticoagulants may be safely stopped earlier in low-risk aspirin-treated pts. Aim. To assess markers of hemostasis activation and in-hospital events rate after very early discontinuation of fondaparinux in non-invasive treatment of low-risk pts hospitalized with NSTEACS. Material and methods. 53 pts admitted with NSTEACS at median 2,3 h after last episode of chest pain were included into prospective non-comparative study. All pts had GRACE score ≤108, negative tn t (cut-off 0,03 ng/ml), and no st-segment deviation &gt;0,1 mV. Aspirin and beta-blockers were used in all cases while clopidogrel in 35 (66,0%) only. After single subcutaneous injection of fondaparinux at presentation no anticoagulants were used. Plasma thrombin-antithrombin (tAt), d-dimer (dd), plasmin-antiplasmin (PAP) levels, plasminogen activator inhibitor-1 (PAI-1) activity and its complex with tissue plasminogen activator (tPA/PAI-1) level were measured at median 18,0 and 42,5 hours after fondaparinux. 12-lead ECG monitoring was started at median 21,2 h after fondaparinux and continued for median 38,6 h. Treadmill stress test was performed on days 4-18 (median 9) after hospitalization. Pts were followed until hospital discharge (median 14 days). Results. Plasma tAt , dd and PAP levels increased after discontinuation of fondaparinux: medians 3,1 and 3,3 ng/l (p=0,002), 359 and 486 ng/l (p=0,002), 471 and 498 ng/l (p=0,052), respectively. Increase at least one of these markers of hemostasis activation was revealed in 49 (92,5%) pts. Ischemic st-segment deviations on ambulatory ECg were found in 13 pts (24,5%). First episode appeared at median 51,8 hours after fondaparinux and only one was symptomatic. tAt , dd and PAP levels as well as their changes were not associated with recurrence of ischemia. Positive result of treadmill test was obtained in 12 Conclusion. While in non-invasive treatment of low-risk nstEACs pts very early discontinuation of fondaparinux was associated with activation of coagulation this laboratory finding was not related to recurrence of ischemia and clinical events rate was low. (25,0%) pts (5 with and 7 without ischemic st-segment deviations on ambulatory ECg; p=0,25). during hospital stay, no patient died or had myocardial infarction; 3 had recurrent angina.

A woman with recurrent chest pain and ST-segment elevation

A 32-year-old female presents with recurrent episodes of unprovoked chest pain associated with inferior ST-segment elevation and reciprocal ST-segment depression. Coronary angiography during one of these episodes revealed coronary artery spasm that spontaneously resolved followed by resolution of these electrocardiographic changes. There was no atherosclerotic occlusive disease. Her cardiac markers were normal and echocardiogram showed no regional wall motion abnormalities. Electrocariogram and angiography findings are shown in Fig. 1.

Abstract 18729: Prosthetic Valve Positioning - Not a Static Question

A 65-year-old female with a history of bicuspid aortic valve s/p AVR with a Medtronic Hall mechanical valve presented with chest pain. Her recent history was notable for one week of intermittent substernal chest pain present when lying in the left lateral position. Initial ECG, obtained during an episode of chest pain, revealed 2 mm ST segment depression in the anterolateral leads and ST segment elevation in lead aVR. The ECG changes normalized with cessation of her chest pain. Laboratory evaluation showed an INR of 3.5 (on warfarin), and normal cardiac biomarkers. Chest imaging, including CT angiography, was unremarkable. Physical examination demonstrated a normal jugular venous pressure, a mechanical second heart sound, and a II/VI crescendo-decrescendo systolic murmur at the right upper sternal border. Transthoracic echocardiography (TTE) revealed normal biventricular systolic function and a mechanical valve in the aortic position, associated with mild aortic regurgitation. Valve fluoroscopy revealed an aortic monoleaflet mechanical prosthesis with normal opening and closing angles in the supine position, but with closing restriction when in the left lateral decubitus position (closing angle 46 degrees, associated with recurrent chest pain and ischemic ECG changes). Transesophageal echocardiography (TEE) showed moderate aortic stenosis, mild aortic regurgitation, and multiple linear echodensities on the aortic prosthesis. These echogenicities were felt to represent thrombi, and the patient was treated with 5 doses of tPA and intravenous heparin. Subsequent TEE and valve fluoroscopy revealed improved prosthetic leaflet motion in supine and lateral decubitus positions. This case describes an unusual presentation of mechanical aortic valve thrombosis. The contiguous association of the mechanical valve with the coronary ostia can contribute to ischemic complications, in this case positionally induced. It also highlights the value of timely valve fluoroscopy and the consideration of patient maneuvers to delineate valve function. Current guidelines support the use of thrombolytic therapy for small, left-sided thrombi, with recent literature suggesting that slowly infused low-dose tPA provides the optimal risk-benefit profile.