Episodes Of Chest Pain Research Articles

The role of cardiovascular magnetic resonance in patients presenting with chest pain, raised troponin, and unobstructed coronary arteries

Troponin measurement is used in the assessment and risk stratification of patients presenting acutely with chest pain when the main cause of elevation is coronary artery disease. However, some patients have no coronary obstruction on angiography, leading to diagnostic uncertainty. We evaluated the incremental diagnostic value of cardiovascular magnetic resonance (CMR) in these patients. Sixty consecutive patients (mean age 44 years, 72% male) with a troponin-positive episode of chest pain and unobstructed coronary arteries were recruited within 3 months of initial presentation. All patients underwent CMR with cine imaging, T2-weighted imaging for detection of inflammation, and late gadolinium enhancement imaging for detection of infarction/fibrosis. An identifiable basis for troponin elevation was established in 65% of patients. The commonest underlying cause was myocarditis (50%), followed by myocardial infarction (11.6%) and cardiomyopathy (3.4%). In the 35% of patients where no clear diagnosis was identified by CMR, significant myocardial infarction/fibrosis was excluded. CMR is a valuable adjunct to conventional investigations in a diagnostically challenging and important group of patients with troponin-positive chest pain and unobstructed coronary arteries.

Anomalous Coronary Artery From the Wrong Sinus of Valsalva: A Physiologic Repair Strategy

A coronary artery arising from the wrong aortic sinus, with or without a proximal course between the aorta and the pulmonary artery, may predispose to myocardial ischemia, myocardial infarction, or sudden death. We repaired this lesion in 5 symptomatic patients, all of whom had experienced exercise-related chest pain, dyspnea, or syncopal episodes. All patients underwent patch angioplasty of the proximal anomalous coronary artery with glutaraldehyde-treated autologous pericardium. When the coronary artery coursed between the aorta and the main pulmonary artery, the main pulmonary artery was translocated toward the left pulmonary artery to create additional space and prevent compression. All patients recovered well and to date have demonstrated no evidence of recurrent myocardial ischemia. The combination of coronary artery angioplasty and translocation of the pulmonary artery seems to effectively address all the mechanisms that can generate ischemia.

Anomalous coronary artery causing transmural ischaemia and ventricular tachycardia in a high school athlete

A previously asymptomatic 15-year-old boy was treated at our institution after an episode of chest pain, palpitation, and syncope while playing in a high school soccer game. The patient's resting electrocardiogram was normal. A transthoracic echocardiogram showed an anomalous left main coronary artery originating from the right sinus of Valsalva. Contrast-enhanced multidetector computed tomography demonstrated clearly that the anomalous vessel coursed between the aorta and the pulmonary trunk (interarterial subtype). Treadmill testing registered several nonsustained polymorphic ventricular tachycardias and transmural myocardial ischaemia in the early recovery phase (ST-elevation up to 5mm in CM5 and V2 leads). The patient underwent bypass grafting. One year later, he remains asymptomatic, and new treadmill tests have been normal. In this patient, severe transmural myocardial ischaemia was detected, possibly due to collapse or vasospasm of the anomalous vessel, triggering life-threatening ventricular arrhythmias.

Myocardial infarction: contemporary management strategies

Myocardial infarction (MI) is a common clinical diagnosis, associated with significant morbidity and mortality, not only in the short term, but also years following the index event. A more complete understanding of the pathophysiology of MI has ushered the era of multipronged treatment approach, with a combination of goal-directed revascularization, a broad adjunctive pharmacological therapy and aggressive secondary prevention measures. The goals of this article are to review the basic pathophysiological processes, which lead up to a clinical diagnosis of MI, to highlight the essential elements of clinical presentation and to summarize the evidence for comprehensive therapy. Emphasis has been placed on the choice of primary reperfusion therapy for ST-elevation MI, on risk-stratification of patients with non-ST elevation MI, and on rationale behind the selection of anti-ischaemic and antithrombotic therapy. Finally, evidence-based approach to secondary prevention is outlined.

Successful percutaneous treatment of an intraprocedural left main stent thrombosis with the support of an automatic mechanical chest compression device

A 71 year-old female was admitted to a community hospital with acute pulmonary edema and ventricular tachycardia. In the preceding year she suffered several episodes of atypical chest pain and another acute pulmonary edema. Inducible or spontaneous ischemia was not documented. Further comorbidities were type 2 diabetes, hypercholesterolemia and hyperthyroidism, which was poorly treated. A coronary angiography did not show significant stenoses, apart from mild ostial and proximal atherosclerosis in the left anterior descendens (LAD) (Fig.

Myocardial Bridge in Hypertrophic Cardiomyopathy; Imaging with Color Doppler Echocardiography

A 50-year-old man presented with chest pain and recurrent episodes of syncope. Physical examination revealed a loud systolic murmur at the left sternal border with accentuation in erect position. Transthoracic echocardiography demonstrated severe asymmetrical septal hypertrophy and systolic anterior motion of the anterior mitral valve leaflet which were diagnostic for hypertrophic cardiomyopathy. Interestingly, color Doppler examination of the left ventricle showed aliasing of the left anterior descending coronary artery and intra-myocardial coronaries.

Theophylline Improves Esophageal Chest Pain?A Randomized, Placebo-Controlled Study

The treatment of esophageal (noncardiac) chest pain is unsatisfactory and there is no approved therapy. A previous uncontrolled study suggested that theophylline may be useful. Our aims were to investigate the effects of theophylline on esophageal sensorimotor function and chest pain. In a double-blind study, sensory and biomechanical properties of the esophagus were assessed using impedance planimetry in 16 patients with esophageal hypersensitivity, after intravenous theophylline or placebo. In a second, randomized 4-wk crossover study, oral theophylline and placebo were administered to 24 patients with esophageal hypersensitivity. Frequency, intensity, and duration of chest pain episodes were evaluated. After IV theophylline, chest pain thresholds (P=0.027) and esophageal cross-sectional area (P=0.03) increased and the esophageal wall became more distensible (P=0.04) compared with placebo. After oral theophylline, the number of painful days (P=0.03) and chest pain episodes (P=0.025), pain duration (P=0.002), and its severity (P=0.031) decreased. Overall symptoms improved in 58% on theophylline and 6% on placebo (P<0.02). There was no order effect. Theophylline relaxed the esophageal wall, decreased hypersensitivity, and improved chest pain. Theophylline is effective in the treatment of functional chest pain.

Intra-atrial course of the right coronary artery: a previously missed anomaly

A 77-year-old woman with recurrent episodes of atypical chest pain was referred to computed tomography (CT) coronary angiography to rule out coronary artery disease. Her history was remarkable with regard to the risk factors arterial hypertension, hyperlipidaemia, and a positive family history for cardiovascular disease. Contrast-enhanced, retrospectively electrocardiography-gated dual-source CT coronary angiography (Siemens Medical Solutions) demonstrated no significant coronary stenoses with normal anatomy of the left main, left anterior descending, and left circumflex artery, whereas the right coronary artery showed an anomalous course. …

Transjugular Liver Biopsy via the Left Internal Jugular Vein

To retrospectively review the indications and outcomes of transjugular liver biopsy (TJLB) with the left internal jugular vein (IJV) approach. A retrospective review of all TJLBs performed at one institution was performed. From August 1995 to October 2004, 293 liver biopsies were performed. Nineteen of the 293 procedures (6.5%) were performed from the left IJV in 17 patients. There were 11 men and six women aged 36-59 years (mean, 49.3 years). All patients were suspected of having diffuse hepatic parenchymal disease and had contraindications to conventional percutaneous liver biopsy. The stiff metal biopsy cannula was advanced across the mediastinum and through the heart over a stiff guide wire. Biopsy was performed from the right hepatic vein in 15 procedures, the middle hepatic vein in two, and the intrahepatic IVC in two. The indications for using the left IJV approach were nonusable right IJV in 12 procedures, difficult previous catheterization of the hepatic veins from the right IJV due to distorted hepatic anatomy in six procedures, and the operator's predilection for this approach in one procedure (the patient had previously undergone liver transplantation). All biopsies were successful, with diagnostic tissue obtained in 100% of cases. Two patients had chest pain during the procedure associated with placement of the rigid cannula through the mediastinal veins. One patient had a vaso-vagal episode that necessitated the use of intravenous atropine but subsequently underwent successful biopsy. All episodes of chest pain resolved after the cannula was removed. There were no recorded hemorrhagic or cardiac complications. TJLB can be safely and repeatedly performed from the left IJV when the right IJV is not available or the hepatic anatomy prevents catheterization of the hepatic veins from the right IJV.

Unusual Balloon Rupture During Direct Stenting with a Taxus™Express2™ Stent in a Venous Graft Complicated by Vessel Rupture: A Device‐Related Fatal Event

A 70-year-old male with a prior coronary artery bypass operation presented with increasing episodes of chest pain. Coronary angiography revealed severe disease of the left anterior descending artery (LAD), CX, and RCA. A left internal mammary artery to LAD was patent. A jump venous graft, with four distal anastomoses, had two significant stenoses. Percutaneous coronary intervention with distal protection, and direct stenting with a drug-eluting stent, was planned. A 3.00 x 16 mm TaxusExpress (Boston Scientific) was used. At an inflation pressure of 10 atm the stent balloon seemed to extend 20 mm proximally with a diameter of 4.5 mm, and the balloon ruptured. Angiography showed rupture of the vessel proximal to the implanted stent, and the patient developed severe hypotension. The rupture was treated with a covered stent and pericardiocentesis was performed with evacuation of 600 mL blood. However, it was not possible to resuscitate the patient, who died due to severe pump failure and incessant ventricular fibrillation.

Transient Mid-Ventricular Ballooning: A Variant of Takotsubo Syndrome

In the majority of cases, Takotsubo syndrome is characterized by the fact that it presents in association with a situation of stress and shows clinical symptoms and electrocardiogram findings consistent with acute myocardial infarction (AMI) and slightly elevated enzymes. Transient left ventricular apical ballooning is produced in this condition and recovers over several days or weeks. Takotsubo syndrome is not associated with coronary lesions and has an uncertain etiology. According to some authors, the primary cause seems to be activation of adrenergic receptors. A new variant of this entity has been described, transient midventricular ballooning syndrome, which shares all the characteristics of Takotsubo syndrome, with the exception that the wall motion alterations only affect the midventricular segments. We present the case of a 45-year-old woman who came to the emergency room for an episode of oppressive central chest pain that had lasted 5 hours and was triggered by a situation of considerable stress. The only datum of IMAGE IN CARDIOLOGY

Isolated Costal Hyperostosis

Chest pain due to hemothorax is rare. However, the possibility of traumatic hemothorax must always be suspected. We report a case of a 15-year-old girl with hemothorax after erosion of the intercostal artery of the left seventh rib by a histological proved solitary costal hyperostosis. She presented with a 2-month history of intermittent left-sided chest pain and 3 episodes of acute chest pain followed by dizziness and loss of consciousness. The chest radiograph revealed a large left pleural effusion and a thin-section chest computed tomography scan that was performed after drainage of the hemothorax indicated a spicule projecting inward into the chest from the left seventh rib. After thoracotomy, a solitary costal hyperostosis causing a traumatic pseudoaneurysm of the intercostal artery was removed by partial resection of the left seventh rib, the intercostals vessels were ligated, and the pseudoaneurysm excised.

A Man With Abdominal Pain and Acute Renal Failure

Case Presentation A 33 year-old African American male with a past medical history significant for HIV on HAART therapy presented to the emergency department (ED) with acute onset of right upper quadrant abdominal pain and mild shortness of breath. The abdominal pain was not associated with any fevers, chills, nausea, vomiting or diarrhea. The patient denied any chest pain, palpitations, lightheadedness or syncopal episodes. He did report some dysphagia with solids more than liquids over the last 2 months as well as decreased oral intake. His review of systems was otherwise significant for weight loss which he was unable to quantify.

Características da tuberculose em idosos no Recife (PE): contribuição para o programa de controle

To describe the demographic characteristics, everyday habits, socio-economic conditions, clinico-epidemiological profiles and access to health care services among the elderly patients with tuberculosis diagnosed and treated in the city of Recife, Brazil, comparing them to those observed in young adults with tuberculosis. A case-control type strategy was used to evaluate a cohort of patients with tuberculosis, all of whom were treated in public health care facilities in Recife between May of 2001 and July of 2003. The final cohort consisted of 1127 patients: 136 elderly patients (cases) and 991 young adults (controls). In both groups, males predominated, and the most common form of tuberculosis was the pulmonary form. Alcoholism was more common in the control group, whereas illiteracy was more common in the case group. There were fewer complaints of cough, sweats and chest pain among the patients in the case group than among those in the control group. Serological testing for the human immunodeficiency virus was performed in only 29 patients (2.6%). The percentage of positive sputum smear microscopy results, as well as that of positive cultures, was higher in the controls. Prior to being diagnosed with the disease, patients in both groups had sought treatment at more than two health care facilities and had waited more than two months (after first seeking treatment). The elderly patients presented higher indices of cure and were more often compliant with the treatment regimen, yet presented higher mortality rates. In the population studied, the elderly presented less cough, fewer episodes of night sweats and less chest pain, as well as less often presenting positivity on complementary exams. Nevertheless, the mortality rate was higher among the elderly patients than among the young adult patients. Elderly patients with tuberculosis constitute a population that should be given special attention in public health care facilities.

Effect of Time Delay on the Diagnostic Use of Contrast Echocardiography in Patients Presenting to the Emergency Department with Chest Pain and no S-T Segment Elevation

The purpose of this study was to assess the effect of time delay on the diagnostic and prognostic use of contrast echocardiography (CE) in patients presenting to the emergency department (ED) with chest pain (CP) and no S-T segment elevation. Patients (n = 957, 498 men) presenting to the ED within 12 hours of suggested cardiac CP underwent CE. Regional function (RF) and myocardial perfusion were interpreted separately by expert readers blinded to all other clinical data. Primary (acute myocardial infarction and total mortality) and secondary (unstable angina and revascularization) events within 24 hours of enrollment were determined. Patients were divided into 4 quartiles based on the time interval between their last episode of CP and CE. Patients in quartile I had CE during CP (time delay of 0 minutes). The time delay in quartiles II, III, and IV were 54 +/- 45, 213+/-54, and 556 +/- 184 minutes, respectively (P < .001). The incidence of events was similar among the 4 quartiles. In each quartile, patients with normal RF had the lowest incidence of events, whereas those with both abnormal RF and myocardial perfusion had the highest incidence of events. Patients with abnormal RF but normal myocardial perfusion had an intermediate event rate. In patients presenting to the ED within 12 hours of CP, the timing of CE does not influence its ability to predict events that occur 24 hours later. These findings have important implications in the performance of CE in the ED.

Panic Attacks, Daily Life Ischemia, and Chest Pain in Postmenopausal Women

Chest pain is a common symptom of panic attacks, but little is known about the relationship in older women among panic attacks, chest pain, and daily life ischemia. The authors conducted a cross-sectional survey of 3063 community-dwelling, generally healthy postmenopausal women enrolled between 1997 and 2000 in the Myocardial Ischemia and Migraine Study in 10 clinical centers of the 40-center Women's Health Initiative. Participants, ages 50 to 79 years, completed a questionnaire about occurrence of panic attacks in the previous 6 months and underwent 24-hour ambulatory electrocardiogram monitoring (AECG); 2705 women had valid AECG recordings and panic attack questionnaires. ST depression on AECG, heart rate variability (HRV), and chest pain episodes were compared among women with and without a 6-month history of panic attack. There was no difference in overall prevalence of ischemic episodes during AECG between women with and without panic attacks. Women with a recent history of panic were more likely to experience chest pain during AECG after controlling for potential confounders (odds ratio [OR] = 2.01; 95% confidence interval [CI] = 1.40-2.88), including both nonischemic (OR = 1.83; 95% CI = 1.26-2.65) and ischemic chest pain (OR = 4.94; 95% CI = 1.41-17.30). Although mean HRV was lower in those with panic attacks (p = .017), this was not significant after controlling for confounders. Postmenopausal women with a recent history of panic attacks do not appear to have more daily life ischemia as measured by occurrence of ST depression during 24-hour monitoring, but do have more chest pain and possibly lower HRV, suggesting that even sporadic panic attacks may be related to cardiovascular risk.

A case of acute myocardial infarction during 5-fluorouracil infusion

Cardiac toxicity is an uncommon side-effect of 5-fluorouracil (5-FU) treatment, consisting mainly of chest pain episodes with or without electrocardiographic changes and dysrhythmias. Here, we describe the case of a 56-year-old male patient with a diagnosis of advanced colorectal cancer who developed an acute myocardial infarction during 5-FU infusion. The patient was not affected by prior heart disease and did not show any classic risk factors for coronary heart disease. Coronary angiography examination revealed no evidence of coronary stenosis, supporting the hypothesis of a coronary artery spasm related to 5-FU infusion. Given the great number of cancer patients receiving 5-FU containing chemotherapeutic regimens, this rare but severe cardiac side-effect may be observed in both cardiologic and oncologic clinical practice. We suggest a tight clinical monitoring of all patients receiving 5-FU infusions, even in those without a prior history of heart disease.

Unusual location in the left ventricular outflow tract and atypical symptoms of cardiac papillary fibroelastoma

Cardiac papillary fibroelastoma, though potentially fatal, are rare benign tumours. Therefore, high index of suspicion is needed in order to identify these lesions and to limit complications at surgery or during long-term oral anticoagulation if the patient is not a surgical candidate. We present a case report of unusual location and presentation, highlighting the pathological findings. A 55-year-old white male, without risk factors for ischaemic cardiomyopathy, presented several episodes of chest pain. Nine years previously, the patient had had a convulsive attack without any organic neurological finding and was treated with different anticonvulsive drugs for five years. Echocardiography showed a mobile mass in the left ventricular outflow tract. The patient underwent surgical excision of the mass, which was later identified as cardiac papillary fibroelastoma.

A 13-year-old female with shortness of breath and pleuritic chest pain

A 13-yr-old Caucasian female was referred to the Dept of Paediatric Diseases (Havana, Cuba) with shortness of breath and pleuritic chest pain located in her right hemithorax. The pain had occurred the day before while doing physical activity and lasted ∼1 h. The patient reported a 2-month history of recurrent episodes of pleuritic chest pain, which were either self-limited or relieved by paracetamol, as well as growing fatigue in the previous few weeks. Her past history was remarkable for a diagnosis of pneumonia after exposure to fumigation during a dengue haemorrhagic fever epidemic 2 yrs earlier, which was treated with steroids and antibiotics. On admission, the patient had no weight loss, no fever or dyspnoea. Physical examination showed decreased breathing sounds in the inferior part of both hemithoraces. Cardiovascular, abdominal and neurological examination, as well as ear, nose and ophthalmologic investigations were unremarkable. The chest radiograph showed bilateral pneumonia with moderate right-sided pleural effusion. The leukocyte count was 9.8×109 cells·L−1 with 54% neutrophils and 32% lymphocytes. The erythrocyte sedimentation rate was 85 mm·h−1. Serum chemistry, renal and liver function tests were in the normal range. Blood cultures were negative. Antibiotic therapy with ceftriaxone and amikacin was started. During the treatment the patient reported 2 days of moderate fever and various episodes of left-sided pleuritic chest pain, which occurred especially during forceful diaphragm contractions ( i.e. sneezing, laughing and coughing). Following a short stay in the Cuban hospital, the patient was transferred to an Italian hospital (Como). Amikacin was discontinued and clarithromycin added. A new chest radiograph (fig. 1⇓), 14 days after the previous one, and a computed tomography (CT) scan of the thorax were performed. Echocardiography and abdominal ultrasound were both negative. An increased value of the tumour marker CA-125 (220 U·mL−1, versus a normal value <35 U·mL−1) was found. Microbiological …

Acute concomitant pulmonary artery and aortic dissection with rupture

Pulmonary artery (PA) dissection is uncommon and may lead to rupture and sudden death if encountered. A 63-year-old man presented to our emergency room with episodic left chest pain radiating to the back followed by shortness of breath. A 64-row multidetector computed tomography (MDCT) revealed ruptured dissection of the PA and the aorta with hemopericardium, hemomediastinum, and prominent extravasated blood along the central bronchovascular bundles of both lungs. The patient experienced cardiogenic shock immediately following CT study and died after resuscitation. Concomitant PA and aortic dissection with rupture is extremely rare with the pathogenesis remaining investigated. MDCT proves to be a powerful tool in its diagnosis for a timely surgical repair if the patient could survive to have the operation.