Episodes Of Chest Pain Research Articles

Non-ST-elevation myocardial infarction following foam ultrasound-guided sclerotherapy

The objective of the study was to describe a very rare complication of foam ultrasound-guided sclerotherapy (FUGS). An unusual case of persisting chest discomfort following FUGS in a 61-year-old woman led to a diagnosis of non-ST-elevation myocardial infarction. The patient was found to have a patent foramen ovale (PFO). The differential diagnoses of paradoxical embolism, gas embolism or vasospasm are discussed, with reference to relevant literature. A hypothesis of post sclerotherapy release of endothelin-1 (in a patient with a known PFO) leading to sustained coronary artery spasm causing sufficient myocardial damage to be reflected in elevated troponin levels is suggested. Any episode of chest tightness or pain following FUGS should be considered as possibly cardiac in origin. Sustained symptoms warrant admission to hospital for troponin monitoring and ECG assessment.

Abstract 472: Fractional Flow Reserve (FFR): FAR FROM REALITY

Fractional Flow Reserve (FFR) is the ratio of maximal blood flow in a stenotic artery to normal maximal flow. It is the “gold standard” technique used in diagnostic angiography to determine whether percutaneous intervention is needed in a moderate coronary stenosis (estimated 50-70% lesion). An FFR less than 0.8 may be falsely reassuring in a patient with unstable plaque who may be actively forming and dissolving clot. This is a case of a 36 year old gentleman, with no significant past medical history, who presented to another local hospital with complaints of episodic chest pain that was located in the sub-sternal region and radiated to his left upper extremity. He was found to be mildly hypertensive, with elevated cardiac markers and with no EKG findings. On cardiac catheterization the patient was found to have a 50% lesion of left anterior descending artery and an FFR measurement of 0.93-0.91, therefore the lesion was not stented. The patient was subsequently discharged home. Two months later the patient presented to the hospital with crushing chest pain, and found to be having a ST elevation myocardial infarction. On repeat cardiac catheterization, the patient was found to have a 99% lesion of his left anterior descending coronary artery requiring placement of a drug eluting stent. Cardiac catheterization is a life saving diagnostic and interventional modality for many patients with coronary artery disease. Fractional Flow Reserve is a new diagnostic tool used to guide management of coronary lesions with intermediate stenosis. It does not, however, take into account the pathophysiology of the lesion itself, for example a stable versus an unstable plaque. As in this case, a non flow-limiting lesion can still be unstable and plaque rupture can create a life-threatening myocardial event. With the development of intravascular ultrasound and optical computed tomography, the ‘gold standard’ seal of FFR will require reevaluation in regards to diagnostic modalities.

Su1887 The Role of Esophageal Manometry and 24 Hour pH With Impedance Studies in the Evaluation of Patients With Non-Cardiac Chest Pain

Background: Gastroesophageal reflux disease (GERD) is thought to be the most common cause of Non-Cardiac Chest Pain (NCCP), present in up to 60% of these patients. Esophageal manometry (EM) and 24 pH with impedance are commonly used in the evaluation of NCCP once an empiric proton pump inhibitor (PPI) trial has failed. However, the diagnostic utility of EM and 24 hour pH with impedance in NCCP patients has not been well studied. Aim: To evaluate the utility of esophageal EM and 24 hour pH with impedance in the evaluation of NCCP Methods: A retrospective chart review was performed on patients referred for the evaluation of NCCP. All patients underwent EM and 24-hour pH with impedance studies between 2006 and 2011. Esophageal manometry results were reviewed for underlying neuromuscular dysfunction and motility disorders. 24 hour pH with impedance data was reviewed for the presence or absence of acid or non-acid reflux. The validated JohnsonDeMeester (JD) score (normal , 22) was used to assess for the presence of GERD. Additionally, correlation between chest pain and reflux events was assessed. Prior endoscopic reports were reviewed for the presence of esophageal changes, such as, erosive esophagitis, salmon colored tongues, Schatzki's ring or changes suggestive of eosinophilic esophagitis. Categorical data was expressed as percentages and continuous data as means and standard deviation. Fisher's exact tests and parametric statistics were used to analyze data. A p-value ≤ 0.05 was considered statistically significant. Results: Esophageal manometry and 24-hour pH with impedance studies of 112 patients were reviewed (52.3% male, 60.4% Caucasian, mean age 51 ± 13.4, mean BMI 27.8 ± 5.1). Of the cohort, 65% of EM studies were normal (mean DCI 1574 ± 1107, mean lower esophageal sphinchter (LES) pressure 14.91 ± 9.75). Of the 34.5% abnormal manometry studies, ineffective esophageal motility disorder (n=25), hypotensive LES (n=5), nutcracker esophagus (n=4), and hypertensive LES (n=1) were present. Ninety percent (n= 88) had normal 24 hour pH studies (mean JD score 9.86 ¬¬± 17.9). Eighty-six percent (n= 88) had normal impedance studies and only 6.25% of patients (n=7) had at least one episode of chest pain correlating with acid or non-acid reflux. On endoscopy, 16% of patients (n=18) had esophageal changes suggestive of reflux and 8% (n=9) had a hiatal hernia. Conclusion: The majority of patients who underwent EM and 24 hour pH with impedance examination had normal studies. The role of these studies for the evaluation of NCCP is limited.

Three Japanese patients (Mother and Two Children) with familial Mediterranean fever associated with compound heterozygosity for L110P/E148Q/M694I and an autosomal true dominant inheritance pattern

Familial Mediterranean fever (FMF) is characterized by repeated episodes of fever, peritonitis, pleuritis, and synovitis. We describe here 3 Japanese patients (a mother and 2 children) in whom FMF was diagnosed on analysis of MEFV. A 40-year-old woman presented with fever and abdominal pain. The patient had had these symptoms on and off since childhood and consulted many hospitals. A 38-year-old man had abdominal pain and fever since the age of 30 years. A 59-year-old woman had had episodes of fever, abdominal pain, and chest pain for more than 20 years. MEFV gene analysis showed compound heterozygosity for L110P, E148Q, and M694I in all three patients. In Japanese patients with FMF, this mode of autosomal true dominant inheritance has not yet been reported. FMF is difficult to diagnose unless it is included in the differential diagnosis by physicians. We hope that our valuable experience will promote increased awareness and understanding of FMF.

Compression of the Left Main Coronary Artery by a Giant Pulmonary Artery Aneurysm

We present a 70-year–old man who had a past medical history of dilated idiopathic pulmonary artery, incidentally diagnosed at the age of 23 years. He was asymptomatic until a year ago when he was admitted for an episode of anginal chest pain in the context of paroxysmal atrial fibrillation. At rapid rates, he showed pathological ST segment descent. A coronary angiography showed a slight stenosis of the left main coronary artery (LMCA). At that time, the mean pulmonary artery pressure was 36 mm Hg. After recovering sinus rhythm, the patient became asymptomatic and was discharged with β-blockers. A year later, the patient was admitted with resting angina. The echocardiogram (Figure A) and the computed tomography-angio showed that the aneurysm had increased to 80 mm and compressed the LMCA (Figure B). This finding was …

Comparison Between Botulinum Injection and Removable Covered Self-Expanding Metal Stents for the Treatment of Achalasia

Intrasphincteric injection of botulinum toxin (BTX) and removable self-expanding metal stents (SEMS) have both been used for the treatment of achalasia. To compare the effectiveness and long-term outcome of SEMS placement and BTX injection in patients with achalasia. A total of 110 patients with newly diagnosed achalasia were enrolled in the study between July 2003 and December 2009. The patients received either BTX injection (n = 51) or SEMS placement (n = 59). Clinical symptoms, objective parameters, and long-term clinical outcomes were evaluated after 7 and 30 days and then every 6 months until withdrawal from the study. The mean duration of follow-up was 28 months (range 10-36 months). Improvements in global symptom and dysphagia scores and in basal lower esophageal sphincter pressure were significantly more marked in the SEMS group than in the BTX group (all P < 0.05). After 12 months, the remission rate in the SEMS group (81.28 %) was statistically significantly higher than that in the BTX group (64.58; P < 0.05). At 36 months, the remission rates in the two groups were 49.1 and. 4.2 %, respectively (P < 0.01). The symptom-free interval was 831 ± 46 days in the SEMS group and 522 ± 42 days in the BTX group (P < 0.01). No side effects were reported with BTX treatment. In the SEMS group there were 13 episodes of chest pain, nine cases of regurgitation, and four stent migrations. No serious complications occurred. Removable SEMS was associated with better long-term outcomes than BTX injection in patients with achalasia.

204: Clinical and Genetic Characteristics of Brugada Syndrome in a Tunisian Population

The Brugada syndrome (BS) is a clinical entity involving cardiac sodium channelopathy, typical electrocardiogram (ECG) changes and predisposition to ventricular arrhythmia. This syndrome is mainly recognized by specialized cardiologists and electrophysiologists. Data regarding BS largely come from multicentre registries or Asian countries. The objective of this study was to investigate the clinical characteristics and prognosis of native Tunisian subjects with the Brugada-type ECG pattern (BS) BS has been diagnosed in 10 patients (9 men, 1 woman, mean age 38±11 years) at the department of cardiology Sfax since January 2002. Patients were referred from primary care physicians for ECG abnormalities, syncope or ventricular arrhythmia, or were diagnosed incidentally on an ECG obtained for other purposes. Nine patients had had an episode of syncope, dizziness or chest pain, 1 patient was asymptomatic at diagnosis and any patients survived sudden cardiac death. The electrocardiographics (ECGs) of all patients showed spontaneous ST-segment elevation in leads V1–3 at baseline and 8 patients (80%) showed transient normalization of the ST-segment elevation during follow-up. Two patients had a family history of sudden cardiac death at younger than 45 years of age. No patient has been found to have a mutation in the SCN5A gene. An implantable cardioverter-defibrillator was implanted in four patients (40%), including the patient with a history of syncope. No event occurred in our population after a mean follow-up of 26±29 months. BS is present in the Tunisian population and is probably under-recognized. Long-term prognosis of individuals with BS, especially in sporadic, asymptomatic cases, needs to be clarified.

Case of very late stent thrombosis after discontinuation of dual antiplatelet therapy

Stent thrombosis remains the main cause of death after percutaneous coronary intervention. Stent thrombosis prevention refers to optimal stent implantation, as well as to the usage of dual anti-platelet therapy. We report a case of a very late stent thrombosis after discontinuation of dual antiplatelet therapy. The patient had a history of a previous coronary disease, he suffered from acute myocardial infarction (MI) and underwent bare metal stent (BMS) implantation in the left anterior descending artery (LAD) and also (DES) in the right coronary artery (RCA). One year later, he presented again with acute MI, but without angiography documented in stent restenosis in the RCA. He ran out of his medication. Next year he experienced an episode of chest pain and was taken to the cardiac catheterization laboratory, where he was found to have occluded distal RCA with apparent thrombus in the stented segment. The patient had discontinued clopidogrel therapy 15 days prior to this. After the initial dilatation thrombus was seen and two bare metal stents were implanted. The extended treatment by dual anti-platelet therapy after PCI (more than 12 months with patients with low bleeding risk) showed the decrease of ischemic cardiovascular developments rate, including stent thrombosis. Our patient had two episodes and both occurred one month after cessation of clopidogrel therapy. The lack of dual antiplatelet therapy according to this study is a major contributing factor when clopidogrel is discontinued after 12 months.

Partial anomalous pulmonary venous connection (RCD code: II-3C.0)

A 48-year-old woman was admitted to our institution with a year’s history of uncharacteristic chest pain episodes and decrease in exercise tolerance. A CT lung scan performed nine months earlier revealed an anomalous vein arising from the right lower pulmonary lobe and draining into the inferior vena cava. A chest radiogram performed 2 months prior to the admission showed a curved shape adjacent to the right heart border. Right heart catheterization revealed: normal systolic, diastolic and mean pulmonary artery pressures, normal pulmonary resistance and insignificant shunt volume. Pulmonary artery angiography demonstrated an anastomotic vessel between the aberrant pulmonary vein and the right upper pulmonary vein. The patient was diagnosed with Partial Anomalous Pulmonary Venous Connection in form of Scimitar syndrome. Given a mild character of symptoms, no signs of the right-sided heart volume overload, insignificant shunt fraction and normal pulmonary circulation parameters, the patient was qualified to a conservative treatment with a close medical observation. JRCD 2013 ; 1 (2): 39–41 Key words: partial anomalous pulmonary venous connection, scimitar syndrome, left-to-right shunt, pulmonary hypertension

Percutaneous Closure of an Atrial Septal Defect and 3-Dimensional Echocardiography

c l o r a a AN OTHERWISE HEALTHY 50-year-old man was scheduled for percutaneous atrial septal defect (ASD) closure with an Amplatzer Septal Occluder (AGA Medical Corp, Plymouth, MN). The patient initially had presented to an outside hospital 1 year earlier with an episode of chest pain at rest. A chest x-ray performed during that admission showed a widened mediastinum. A subsequent computed tomography scan and transthoracic echocardiogram (TTE) revealed a 2.1-cm wide secundum ASD (Fig 1) with a dilated right ventricle and moderately dilated right and left atria. The patient did not follow through with recommendations for a TEE and possible ASD closure and was lost to follow-up. A year later, he returned to the authors’ institution with a 6-month long history of dyspnea and episodic chest pain with moderate exertion that was relieved by rest. He underwent cardiac catheterization to assess for the presence of coronary artery disease, but which was negative for any flow-limiting lesions. Resting hemodynamics revealed normal right-sided pressures, and oxygen saturation measurements that were consistent with a left-to-right shunt (Qp/Qs 2.4). He subsequently was referred for ASD closure under TEE guidance. After an uneventful induction of general anesthesia, a TEE examination was performed using an IE-33 Ultrasound System X7-2E Probe (Philips Medical Systems, Andover, MA) capable of real-time 3-dimensional (3D) imaging.

Diffuse Inverted T Waves in a Young Man with Structurally Normal Heart: A Case Report

We discuss a young man with episodes of chest pain and dyspnea accompanied with transient T-wave inversion in precordial and inferior leads that repeated several times. Cardiovascular evaluation did not disclose any structural abnormality. Memory T wave following episodes of idiopathic left septal ventricular tachycardia was the reason of these changes and did not repeat after arrhythmia ablation.

Chest Pain in the Emergency Department

Current clinical practice for patients presenting to the emergency department with a resolved episode of chest pain and no electrographic or biomarker abnormalities is to conduct routine noninvasive testing, in accordance with American College of Cardiology and American Heart Association guidelines. The rationale is to further reduce the risk of missing a myocardial infarction, a major source of suits filed against emergency department physicians. Patients with negative stress test results may be reassured, with low event rates in the subsequent 30 days. Patients with positive stress test results have higher 30-day event rates, and a small fraction undergo revascularization procedures. Despite this endorsement, open questions remain. Does our current practice lead to the stenting of asymptomatic patients in the inevitable cases where the inciting pain was noncardiac? And, most importantly, does our practice improve outcomes? Randomized trials evaluating routine stress testing in other contexts have yielded negative results, despite diagnosing significant coronary artery disease. Population data suggest that our current practice may be increasing the diagnosis of coronary artery disease and the rate of intervention while failing to decrease rates of myocardial infarction. We propose that randomized trials be conducted to evaluate whether any testing is better than no further intervention. Data from such an evidence-based approach has the potential to reverse our current practice.

Symptoms in the presence of a giant windsock eustachian valve remnant

We present the case of a 43 year-old female with an isolated episode of atypical chest pain and an ill-defined cardiac murmur who was coincidentally found to possess a large serpiginious residual embryonic structure in right atrium. Multiple modality imaging was required to confirm this to be a rare giant eustachian valve remnant. The eustachian valve in the fetus directs oxygenated blood towards the foramen ovale. While absent or very small in adult life it rarely persists to any significant degree and must be distinguished from other right atrial shelf anomalies. The true potential of these structures to cause pathological interference with cardiac function or symptoms is unknown due to their rarity.

BILATERAL CORONARY ARTERY FISTULA AS A CAUSE OF ANGINA PECTORIS

ObjectivesA 75-year-old female patients was admitted to our hospital presenting with episodes of exhausted chest pain for 2 years.MethodsA continuous murmur was heard over the precordium. The repeated ECG and...

Triage of acute onset chest pain: now a biochemical rule-out test?

The management of coronary disease has moved forward with the application of more sensitive blood biomarkers for early detection alongside more structured symptom assessment, examination and serial ECG measures. However every episode of exertional chest pain isn't symptomatic coronary disease and given massive public awareness campaigns we now face a different management issue with undiagnosed chest pain sent as a 'rule-out' activity. These urgent referrals are often justified based on the management of the minority with unstable coronary disease without preliminary medical review or examination. Avoiding delay which is valuable in coronary patients may be irrelevant to the majority. The overall effectiveness of this pathway is unclear where the patient does not have coronary disease but also where superficial interpretation can be misleading through non-specificity. Do biomarker assays become the answer to every chest pain patient and has the basic assessment of the individual patient and a prior probability of disease no role to play? Does this activity represent a burden or an irrelevant dead end for non-coronary patients? We have asked for comment from two leading authorities on the evolving role and application of cardiac biomarker technologies in managing this considerable and common clinical dilemma.

“Ischemic” ST elevation in a woman with left ventricular hypertrophy

We report the case of a woman who presented with ST elevation and episodes of chest pain, mimicking an acute myocardial infarction. At coronary angiography no sign of coronary stenosis was found and ECG anomalies were related to asymmetric left ventricular hypertrophy and aortic stenosis.

How should I treat a retrograde dissection of the aortic sinus of Valsalva during a percutaneous coronary intervention?

*Corresponding author: Department of Cardiology, Chang Gung Memorial Hospital at Keelung, 222 Maijin Road, Keelung 20401, Taiwan. E-mail: miran888@ms61.hinet.net PRESENTATION OF THE CASE A 53-year-old man, a 20-cigarettes-per-day smoker, presented to the emergency department because of a new onset of episodic exertional dizziness and chest pain associated with cold sweating over the previous month. He was not obese and on no medications, had no medical history and no family history of cardiac disease. There was no specific abnormality upon physical examination and he had normal blood pressure. An electrocardiogram (ECG) showed sinus rhythm, negative T waves in the inferior leads and flattened T-waves in leads V1 to V4. An echocardiography showed a normal ejection fraction and hypokinesis of the posterior/inferior wall. He was diagnosed as having unstable angina. Coronary angiography revealed a 70% lumen narrowing at the mid-left anterior descending coronary artery (LAD) (Figure 1A and Moving image 1) and a subtotal occlusion in the proximal, mildly calcified RCA, with distal blood flow of thrombolysis in myocardial infarction (TIMI) grade 1 (Figure 1B and Moving image 1). The distal RCA was well-opacified and collateralised from the left coronary artery. Ventriculography revealed mild localised hypokinesis of the inferior wall, with an ejection fraction of 65%. Coronary angioplasty of the occluded RCA was attempted via the right femoral artery using a 6 Fr arterial sheath. The RCA was cannulated with a 6 Fr Judkins right 4 cm curved guiding catheter (JR4; Cordis Corp., Miami, FL, USA). Fifteen minutes into the procedure, during the application of a 0.014 inch Miracle 3 wire (Asahi Neo’s; Asahi Intecc Co. Ltd; CASE SUMMARY

Thoraxschmerzen bei Kindern und Jugendlichen - das Herz?

Chest pain in children and adolescents is a frequent observation, although potentially relevant disease is rather rare and then found in situations with acute presentation. In children with an inflammatory/infectious clinical context the differential diagnosis is oesophagitis, pleuropneumonia or pericarditis. Potentially dangerous complications may be found in youth with predisposing conditions for aortic dissection, pneumothorax or pulmonary embolism, or even in rare instances for an acute coronary complication. In these cases aggressive diagnostic work-up is mandatory. In the frequent elective outpatient evaluation of teenagers with long-lasting episodes of chest pain, relevant underlying cardiovascular disease only rarely can be found as the cause. In the elective outpatient evaluation for chest pain, usually patient history and clinical examination may be enough to track the problem, the main role of the physician is to provide reassurance with minimal but appropriate testing.

A Diagnostic Long Shot

A 32-year-old African American man with a medical history of hypertension and gunshot wound to the abdomen 8 years prior presented to the emergency department complaining of several weeks of exertional dyspnea, episodes of midsternal chest pain, and lower-extremity edema (more pronounced in the left leg). He stated that the dyspnea had progressed to that point at which he could only walk 2 blocks before having to rest, and he was unable to participate in his normal recreational activities. He also claimed that the lower-extremity swelling was a new development during the past several months. His social history was notable for smoking 1 pack a day for 15 years and a recent escalation of ethanol intake during the past 4 months, up to a pint or more of liquor a day. He denied drug use but had a history of cocaine use 5 to 6 years ago. On arrival, the patient was afebrile, tachycardic (110 bpm), and hypertensive (180/103 mm Hg); his breathing rate was 16/min. His physical examination was …

Socio-demographic variation in chest pain incidence and subsequent coronary heart disease in primary care in the United Kingdom

We know little about socio-demographic differences in chest pain presenting to primary care and subsequent coronary heart disease (CHD) diagnosis. We conducted a cohort study with 198,209 patients aged 30 years and over with a first episode of chest pain, using data from 339 general practices in The Health Improvement Network (THIN) primary care database during 1997-2007. We calculated incidence of chest pain and subsequent CHD by age, gender and quintiles of Townsend area deprivation score. Chest pain incidence was 19.6/1000 person years at risk (PYAR, 95% CI 19.5-19.7). Incidence rose with age and increasing deprivation, with minimal gender differences. The incidence of CHD in the year following chest pain in primary care was 96.6/1000 PYAR (95% CI 95.1-98.0). There were significant interactions with age/deprivation and gender/deprivation on subsequent CHD diagnosis. The effect of deprivation was less for those over 60 years, and greater for younger women. Women in their 30s with chest pain in deprived areas had 8.77 times (95% CI 3.34-23.06) the CHD incidence compared to those in the most affluent areas. The absolute risk difference was small (8/1000 PYAR, 95% CI 4.5-11.5/1000 PYAR). There was a modestly greater incidence of chest pain in primary care in more deprived areas compared to the least deprived areas. There were interactions between age, gender and deprivation on subsequent CHD diagnosis, with the greatest effect of deprivation on CHD diagnosis seen in younger women. This observation suggests the need for targeting health promotion and CHD prevention among younger women in deprived areas.