Nonspecific Chest Pain Research Articles

Management of iatrogenic atrial perforation caused by pacemaker electrodes: a case report

BackgroundThe complications associated with cardiac device implants ranges between 5.3% and 14.3%. Cardiac perforation due to “leads” represent a very rare complication of cardiac device implantation, ranging between 0.3% and 0.7%. Clinically, they can manifest different, nonspecific symptoms; hence, the diagnosis may not be immediate.Case presentationOur clinical case describes the successful treatment of cardiac tamponade occurring in a Caucasian 79-year-old man following a pacemaker implantation. Two days after the procedure, the patient reported an episode of nonspecific chest pain associated with syncope. The echocardiogram performed revealed a pericardial effusion in the apical area, along the right chambers, with a thickness of 7 mm, not hemodynamically significant. A chest computed tomography scan with contrast showed hemopericardium (maximum thickness of 11 mm), caused by an atrial perforation. A few hours later, the patient experienced hemodynamic instability. For this reason, an urgent sternotomy was performed with drainage of a significant hemopericardial effusion, revealing a perforation of the upper free wall of the right atrium with pericardial injury caused by the retractable screw lead. The perforation site was sutured and the sternal wound was closed. The patient was discharged after 4 days without further complications. At the control visit, scheduled 30 days after the hospital discharge, the patient was in good conditions.ConclusionsAlthough the atrial perforations from leads are very rare complications of pacemaker implantation procedures, they are potentially lethal. In conclusion, this clinical case highlights the need, before hospital discharge, of an accurate screening for evaluation the pericardial effusion in patients that undergo to the cardiac implantable electronic devices.

Chronic Coronary Syndromes with/without obstructive coronary arteries: are there differences in ongoing chest pain?

Abstract Background Stable coronary artery disease (CAD) is the archetype chronic coronary syndrome, clinically manifesting as angina with obstructive CAD on angiography and managed via evidence-based guidelines. In contrast, patients with Angina with Non-Obstructive Coronary Arteries (ANOCA) are often diagnosed with ‘non-specific chest pain’ and not appropriately managed. Purpose To compare the Seattle Angina Questionnaire (SAQ) responses and 3-year rates of chest pain hospital presentations in patients with ANOCA compared to Stable CAD. Methods Consecutive angina patients undergoing elective coronary angiography enrolled in the CADOSA (Coronary Angiogram Database of South Australia) Registry between 2012-18 were included. Consenting patients participated in a longitudinal health status assessment utilising the SAQ. In-hospital clinical data was extracted from CADOSA and mortality and hospitalisation data over 12-months was extracted via administrative records. Results Of 6,372 consecutive patients undergoing elective angiography for the investigation of chest pain 2,287 had ANOCA and 4,085 Stable CAD. ANOCA patients were younger (61±11 vs 66±11, p<0.05) and more often female (59% vs 27%, p<0.05) compared to Stable CAD. The SAQ health status assessment was completed at baseline, 1 and 12-months for 377 patients (ANOCA n=156, Stable CAD n=221). At 12-month follow-up, there were no differences in SAQ scores amongst all domains (physical limitation- 92±16 vs 92±15, angina stability- 64±25 vs 62 ±24, angina frequency- 91±17 vs 92±16, treatment satisfaction- 94±13 vs 94±13 and quality of life- 78±22 vs 81±21) between ANOCA and Stable CAD, all p>0.05. However, in the 12-month follow-up, ANOCA patients were less likely to have a chest pain hospital emergency department presentation (10% vs 15%, p<0.001) or admission (6% vs 12%, p<0.005) compared to the Stable CAD cohort. Conclusion Although patient-reported outcomes were identical between Stable CAD and ANOCA patients, the latter were less likely to present to emergency department or be admitted to hospital than their Stable CAD counterparts, reflecting the clinical nihilism encountered in the ANOCA patient journey.

Computed Tomography Angiography as a Method for Diagnosing Intracavitary Coronary Arteries.

The intracavitary coronary arteries (ICCA) course is a rare phenomenon, where the segments of the coronary artery go through the atria or ventricles of the heart. In the past, these changes were incidentally detected during invasive diagnostic procedures for other reasons, as well as during postmortem examinations. As the use of multidetector computed tomography angiography (CTA) becomes more widespread, it has emerged that the incidence of ICCA has been underestimated. We present images from two coronary computed tomography angiography cases, which document the existence of ICCA in patients with non-specific chest pain. In the first case, in a 66-year-old woman, in addition to confirming coronary artery disease without significant stenosis (CAD-RADS 2-category 2 in the coronary-artery-disease-reporting and data system), the course of the middle section of the right coronary artery (RCA) in the lumen of the right atrium was demonstrated. In the second case, in a 47-year-old man in whom the presence of atherosclerotic lesions in the coronary arteries was excluded (CAD-RADS 0), the course of the distal segment of the left anterior descending (LAD) was found in the lumen of the apical layers of the right ventricle. To sum up, it should be stated that coronary CTA is a non-invasive diagnostic method that allows for visualization of the ICCA. In coronary CTA performed for indications consistent with the guidelines of scientific societies, attention should also be paid to the possible intracavitary course of the coronary arteries. The identification of such a course of the coronary arteries may be useful when preparing the patient for potential future invasive procedures involving the cardiac cavities.

Investigating Genetic Overlap between Alzheimer's Disease, Lipids, and Coronary Artery Disease: A Large-Scale Genome-Wide Cross Trait Analysis.

There is evidence to support a link between abnormal lipid metabolism and Alzheimer's disease (AD) risk. Similarly, observational studies suggest a comorbid relationship between AD and coronary artery disease (CAD). However, the intricate biological mechanisms of AD are poorly understood, and its relationship with lipids and CAD traits remains unresolved. Conflicting evidence further underscores the ongoing investigation into this research area. Here, we systematically assess the cross-trait genetic overlap of AD with 13 representative lipids (from eight classes) and seven CAD traits, leveraging robust analytical methods, well-powered large-scale genetic data, and rigorous replication testing. Our main analysis demonstrates a significant positive global genetic correlation of AD with triglycerides and all seven CAD traits assessed-angina pectoris, cardiac dysrhythmias, coronary arteriosclerosis, ischemic heart disease, myocardial infarction, non-specific chest pain, and coronary artery disease. Gene-level analyses largely reinforce these findings and highlight the genetic overlap between AD and three additional lipids: high-density lipoproteins (HDLs), low-density lipoproteins (LDLs), and total cholesterol. Moreover, we identify genome-wide significant genes (Fisher's combined p value [FCPgene] < 2.60 × 10-6) shared across AD, several lipids, and CAD traits, including WDR12, BAG6, HLA-DRA, PHB, ZNF652, APOE, APOC4, PVRL2, and TOMM40. Mendelian randomisation analysis found no evidence of a significant causal relationship between AD, lipids, and CAD traits. However, local genetic correlation analysis identifies several local pleiotropic hotspots contributing to the relationship of AD with lipids and CAD traits across chromosomes 6, 8, 17, and 19. Completing a three-way analysis, we confirm a strong genetic correlation between lipids and CAD traits-HDL and sphingomyelin demonstrate negative correlations, while LDL, triglycerides, and total cholesterol show positive correlations. These findings support genetic overlap between AD, specific lipids, and CAD traits, implicating shared but non-causal genetic susceptibility. The identified shared genes and pleiotropic hotspots are valuable targets for further investigation into AD and, potentially, its comorbidity with CAD traits.

Australia's first cardiac emergency department: Patient profile, activity and performance in the initial 6 months.

To profile the initial 6-month experience at the Victorian Heart Hospital (VHH) cardiac emergency (CE). The primary objective was to describe VHH CE patient characteristics, including presenting complaint, final diagnosis and disposition. Secondary objectives were to report on patient numbers, patient source and quality indicator performance including ambulance off-load by 40 min, waiting time and length of stay (LOS). A retrospective review included all patients who presented to the VHH CE from 9 March 2023 to 8 September 2023. Patient reports containing the relevant clinical information were generated from the CE electronic medical record system. Diagnoses of MI were checked for accuracy by full record review. There were 3303 CE presentations in the first 6 months of operation, of which 6% were transferred from other sites. Median age was 65 years (interquartile range [IQR]: 53-77), 56% were males; the most common presenting complaints were presumed cardiac chest pain (67%) and arrhythmia (17%). The admission, discharge and transfer rates were 38%, 54% and 8%, respectively. In total, 15% were diagnosed with MI. The most common diagnoses for discharged and admitted patients were non-specific chest pain (57%) and ST-elevation MI (22%), respectively. Ambulance off-load by 40 min was met for 96%. Median waiting time was 6 min (IQR: 3-10). Median CE LOS for discharged and admitted patients was 3.2 h (IQR: 2.5-4.0) and 3.7 h (IQR: 1.8-6.0), with 75% and 56% being <4 h, respectively. The population predominantly had cardiovascular disease as expected. Some performance indicators, including ED LOS, were identified as requiring intervention.

Community Emergency Care Use by Veterans in an Era of Expanding Choice

Recently passed legislation aimed at improving access to care has considerably expanded options for veterans to receive emergency care in community, or non-Veterans Affairs (VA) settings. However, national trends in community emergency department (ED) use by veterans are unknown. To examine national, temporal trends in the frequencies and types of ED visits provided in community settings and explore the association between facilities' purchase of community care with facility and regional characteristics. Retrospective, observational cross-sectional study of ED visits over fiscal years (FY) 2016 to 2022. VA and community ED encounter data were obtained from the VA Corporate Data Warehouse and the Office of Integrated Veteran Care. Participants were veterans receiving ED care at VA facilities or paid for by the VA in the community. Data were analyzed from June to September 2023. The primary outcome measures included community ED visit volume, disposition, and payments over time. Also, the most common and costly ED visits were assessed. Negative binomial regression analysis examined associations between facility and regional characteristics and the rate of ED visits purchased in community settings relative to all ED visits. There were 19 787 056 ED visits, predominantly at VA facilities (14 532 261 visits [73.4%]), made by 3 972 503 unique veterans from FY 2016 to 2022. The majority of ED users were male (3 576 120 individuals [90.0%]), and the median (IQR) age was 63 (48-73) years. The proportion of community ED visits increased in absolute terms from 18% in FY 2016 to 37% in FY 2022. Total community ED payments, adjusted to 2021 dollars, were $1.18 billion in FY 2016 and over $6.14 billion in FY 2022. The most common reasons for ED visits in the community were for nonspecific chest pain (305 082 visits [6%]), abdominal pain (174 836 visits [3%]), and septicemia (149 968 visits [3%]). The average proportion of ED visits purchased by a VA facility increased from 14% in FY 2016 to 32% by FY 2022. In multivariable analyses, facilities with greater ED volume and low-complexity facilities had higher expected rates of community emergency care than lower volume and high-complexity facilities, respectively. As veterans increasingly use community EDs for acute, unscheduled needs, attention to factors associated with veterans' use of acute care services in different settings are important to identify access barriers and to ensure veterans' health care needs are met.

Factors influencing the indication of coronary angiography in patients presenting with chest pain unspecified: an analysis of two decades (1994-2014).

Guidelines for cardiac catheterization in patients with non-specific chest pain (NSCP) provide significant room for provider discretion, which has resulted in variability in the utilization of invasive coronary angiograms (CAs) and a high rate of normal angiograms. The overutilization of CAs in patients with NSCP and discharged without a diagnosis of coronary artery disease is an important issue in medical care quality. As a result, we sought to identify patient demographic, socioeconomic, and geographic factors that influenced the performance of a CA in patients with NSCP who were discharged without a diagnosis of coronary artery disease. We intended to establish reference data points for gauging the success of new initiatives for the evaluation of this patient population. In this 20-year retrospective cohort study (1994-2014), we examined 107 796 patients with NSCP from the Myocardial Infarction Data Acquisition System, a large statewide validated database that contains discharge data for all patients with cardiovascular disease admitted to every non-federal hospital in NJ. Patients were partitioned into two groups: those offered a CA (CA group; n = 12 541) and those that were not (No-CA group; n = 95 255). Geographic, demographic, and socioeconomic variables were compared between the two groups using multivariable logistic regression, which determined the predictive value of each categorical variable on the odds of receiving a CA. Whites were more likely than Blacks and other racial counterparts (19.7% vs. 5.6% and 16.5%, respectively; P < .001) to receive a CA. Geographically, patients who received a CA were more likely admitted to a large hospital compared to small- or medium-sized ones (12.5% vs. 8.9% and 9.7%, respectively; P < .05), a primary teaching institution rather than a teaching affiliate or community center (16.1 % vs. 14.3% and 9.1%, respectively; P < .001), and at a non-rural facility compared to a rural one (12.1% vs. 6.5%; P < .001). Lastly from a socioeconomic standpoint, patients with commercial insurance more often received a CA compared to those having Medicare or Medicaid/self-pay (13.7% vs. 9.5% and 6.0%, respectively; P < .001). The utilization of CA in patients with NSCP discharged without a diagnosis of coronary artery disease in NJ during the study period may be explained by differences in geographic, demographic, and socioeconomic factors. Patients with NSCP should be well scrutinized for CA eligibility, and reliable strategies are needed to reduce discretionary medical decisions and improve quality of care.

Idiopathic Bilateral Pulmonary Vein Thrombosis.

Pulmonary vein thrombosis (PVT) may present as chest pain, especially in patients with a history of prior blood clots and can occur without an underlying malignancy or coagulation disorder.Utilising a chest CT angiogram with delayed contrast timing is effective in detecting pulmonary vein thrombus.Systemic anticoagulation proves effective in managing pulmonary vein thrombus; however, further data on dosage and duration are required for better guidance.

Canadian Association of Radiologists Thoracic Imaging Referral Guideline.

The Canadian Association of Radiologists (CAR) Thoracic Expert Panel consists of radiologists, respirologists, emergency and family physicians, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 24 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 30 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 48 recommendation statements across the 24 scenarios. This guideline presents the methods of development and the referral recommendations for screening/asymptomatic individuals, non-specific chest pain, hospital admission for non-thoracic conditions, long-term care admission, routine pre-operative imaging, post-interventional chest procedure, upper respiratory tract infection, acute exacerbation of asthma, acute exacerbation of chronic obstructive pulmonary disease, suspect pneumonia, pneumonia follow-up, immunosuppressed patient with respiratory symptoms/febrile neutropenia, chronic cough, suspected pneumothorax (non-traumatic), clinically suspected pleural effusion, hemoptysis, chronic dyspnea of non-cardiovascular origin, suspected interstitial lung disease, incidental lung nodule, suspected mediastinal lesion, suspected mediastinal lymphadenopathy, and elevated diaphragm on chest radiograph.

IgG4-related disease - a clinical case

Immunoglobulin G4-related disease (IgG4-RD) is a systemic disease affecting one or more organs. Pathomorphologically, a dense infiltrate of lymphocytes and IgG4 plasmocytes, and subsequent fibrosis is detected. Despite the many hypotheses of genetic predisposition, molecular mimicry and autoimmune nature of the disease, the etiology still remains unclear. Both innate and acquired immunity are believed to play a key role in disease pathogenesis. The involvement of occupational risk factors is also discussed. The possible involvement of multiple organs and systems (most often lacrimal and salivary glands, kidneys, lungs, aorta, pancreas, hepatobiliary duct, lymph nodes, as well as retroperitoneal fibrosis) is the reason for the multidisciplinary approach in this disease. In pulmonary involvement, clinical manifestations are nonspecific (cough, dyspnea, chest or back pain, hemoptysis, low-grade fever, weight loss) or patients are asymptomatic and pulmonary changes are an incidental finding on imaging. Up to 60% of cases of autoimmune pancreatitis represent a pancreatic manifestation of IgG4-related disease, with the majority of patients being elderly men. The most common differential diagnosis is a malignant process due to the tumor-like changes of the affected organ. Treatment with corticosteroids, immunosuppressors and symptomatic agents in most cases has a good effect, although relapses of the disease are also observed. We present a clinical case of a 72-year-old patient whose first complaints were nonspecific, for which a chest computed tomography was performed with visualization of four solid nodules in the right lung. After antibiotic therapy, without effect and deterioration of the patient's condition, video-assisted thoracoscopy, biopsy, histology and immunohistochemistry were performed. A diagnosis of IgG4-RD with pleural and lung involvement was confirmed. Anemic syndrome, increased values ​​of amylase, lipase, and acute phase parameters were found from the laboratory tests. Through endoscopic retrograde cholangio-pancreatography, autoimmune pancreatitis was diagnosed in the course of IgG4-RD. A plastic stent was placed on the common bile duct. Treatment with Prednisolone 40 mg/day was started with a subsequent dose reduction. Follow-up computed tomography of the lung after 9 months demonstrated a reduction of the described changes in the lungs, but with persistent lymphadenopathy and fibrotic changes. Azathioprine 100 mg daily was added to prednisone therapy. Against the background of the combined treatment, an improvement of the clinical condition and laboratory parameters was established.

Prognostic significance of T2 mapping in evaluating myocardium alterations in patients with ST segment elevation myocardial infarction

To investigate the value of T2 mapping in the assessment of myocardial changes and prognosis in patients with acute ST segment elevation myocardial infarction (STEMI). A retrospective study was conducted. A total of 30 patients with acute STEMI admitted to Tianjin First Central Hospital from January 2021 to March 2022 were enrolled as the experimental group. At the same time, 30 age- and sex-matched healthy volunteers and outpatients with non-specific chest pain with no abnormalities in cardiac magnetic resonance (CMR) examination were selected as the control group. CMR was performed within 2 weeks after the diagnosis of STEMI, as the initial reference. A plain CMR review was performed 6 months later (chronic myocardial infarction, CMI). Plain scanning includes film sequence (CINE), T2 weighted short tau inversion recovery (T2-STIR), native-T1 mapping, and T2 mapping. Enhanced scanning includes first-pass perfusion, late gadolinium enhancement (LGE), and post-contrast T1 mapping. Quantitative myocardial parameters were compared between the two groups, before and after STEMI myocardial infarction. The receiver operator characteristic curve (ROC curve) was used to evaluate the diagnostic efficacy of native-T1 before myocardial contrast enhancement and T2 values in differentiating STEMI and CMI after 6 months. There were no statistically significant differences in age, gender, heart rate and body mass index (BMI) between the two groups, which were comparable. The native-T1 value, T2 value and extracellular volume (ECV) were significantly higher than those in the control group [native-T1 value (ms): 1 434.5±165.3 vs. 1 237.0±102.5, T2 value (ms): 48.3±15.6 vs. 21.8±13.1, ECV: (39.6±13.8)% vs. (22.8±5.0)%, all P < 0.05]. In the experimental group, 12 patients were re-examined by plain CMR scan 6 months later. After 6 months, the high signal intensity on T2-STIR was still visible, but the range was smaller than that in the acute phase, and the native-T1 and T2 values were significantly lower than those in the acute phase [native-T1 value (ms): 1 271.0±26.9 vs. 1 434.5±165.3, T2 value (ms): 34.2±11.2 vs. 48.3±15.6, both P < 0.05]. ROC curve analysis showed that the area under the ROC curve (AUC) of native-T1 and T2 values in differentiating acute STEMI from CMI was 0.71 and 0.80, respectively. When native-T1 cut-off value was 1 316.0 ms, the specificity was 100% and the sensitivity was 53.3%; when T2 cut-off value was 46.7 ms, the specificity was 100% and the sensitivity was 73.8%. The T2 mapping is a non-invasive method for the diagnosis of myocardial changes in patients with acute STEMI myocardial infarction, and can be used to to evaluate the clinical prognosis of patients.

Genetic Liability to Posttraumatic Stress Disorder Symptoms and Its Association With Cardiometabolic and Respiratory Outcomes

Posttraumatic stress disorder (PTSD) has been reported to be a risk factor for several physical and somatic symptoms. However, the genetics of PTSD and its potential association with medical outcomes remain unclear. To examine disease categories and laboratory tests from electronic health records (EHRs) that are associated with PTSD polygenic scores. This genetic association study was conducted from July 15, 2021, to January 24, 2023, using EHR data from participants across 4 biobanks. The polygenic scores of PTSD symptom severity (PGS-PTSD) were tested with all available phecodes in Vanderbilt University Medical Center's biobank (BioVU), Mass General Brigham (MGB), Michigan Genomics Initiative (MGI), and UK Biobank (UKBB). The significant medical outcomes were tested for overrepresented disease categories and subsequently tested for genetic correlation and 2-sample mendelian randomization (MR) to determine genetically informed associations. Multivariable MR was conducted to assess whether PTSD associations with health outcomes were independent of the genetic effect of body mass index and tobacco smoking. Polygenic score of PTSD symptom severity. A total of 1680 phecodes (ie, International Classification of Diseases, Ninth Revision- and Tenth Revision-based phenotypic definitions of health outcomes) across 4 biobanks and 490 laboratory tests across 2 biobanks (BioVU and MGB). In this study including a total of 496 317 individuals (mean [SD] age, 56.8 [8.0] years; 263 048 female [53%]) across the 4 EHR sites, meta-analyzing associations of PGS-PTSD with 1680 phecodes from 496 317 individuals showed significant associations to be overrepresented from mental health disorders (fold enrichment = 3.15; P = 5.81 × 10-6), circulatory system (fold enrichment = 3.32; P = 6.39 × 10-12), digestive (fold enrichment = 2.42; P = 2.16 × 10-7), and respiratory outcomes (fold enrichment = 2.51; P = 8.28 × 10-5). The laboratory measures scan with PGS-PTSD in BioVU and MGB biobanks revealed top associations in metabolic and immune domains. MR identified genetic liability to PTSD symptom severity as an associated risk factor for 12 health outcomes, including alcoholism (β = 0.023; P = 1.49 × 10-4), tachycardia (β = 0.045; P = 8.30 × 10-5), cardiac dysrhythmias (β = 0.016, P = 3.09 × 10-5), and acute pancreatitis (β = 0.049, P = 4.48 × 10-4). Several of these associations were robust to genetic effects of body mass index and smoking. We observed a bidirectional association between PTSD symptoms and nonspecific chest pain and C-reactive protein. Results of this study suggest the broad health repercussions associated with the genetic liability to PTSD across 4 biobanks. The circulatory and respiratory systems association was observed to be overrepresented in all 4 biobanks.

Pulmonary Aspergilloma Co-Existing with Pulmonary Tuberculosis: A Case Report in Type 1 Diabetes Mellitus (T1DM) Patient

Introduction: Pulmonary aspergilloma is a disease frequently found in immunocompromised patients. In Indonesia, around 18% of diabetes mellitus (DM) patients suffer from chronic pulmonary aspergilloma. However, data on type 1 DM (T1DM) are still limited. Case: We presented the case of a 22-year-old male admitted to the emergency room due to hemoptysis of approximately 200 ml within six hours before admission, nonspecific chest pain during cough, fever, night sweats, and weight loss of 3 kg over the last months. The patient had a history of T1DM and no prior history of respiratory diseases. Physical examination showed tachycardia, tachypnoea, subfebrile, normal body mass index, and rhonchi on the left thorax. Routine laboratory tests revealed increased blood sugar level (503 mg/dL) and HbA1c 16.4%. Chest X-ray and high-resolution computed tomography (HRCT) showed a cavity with an opaque lesion, crescent sign, consolidation, and reticulonodular infiltrate on the left lung. Rapid molecular tests, tuberculosis (TB), and serum galactomannan (GM) were negative. The patient was diagnosed with pulmonary aspergilloma, T1DM, and clinical TB. He was treated with fluconazole, insulin, and a fixed-dose combination of anti-TB. The patient refused the surgery procedure. Immediately, the hemoptysis stopped, blood glucose level was normal, and concomitant with weight gain. Conclusion: Due to innate and acquired immunity impairment, T1DM is a risk factor for pulmonary infections, including TB and pulmonary aspergilloma. Chest HRCT may help diagnose fungal balls. Though the patient refused to undergo surgery, administering antifungal, anti-TB drugs, and glucose control as initial treatment presented a good prognosis in the patient.

A rare case of single coronary artery with congenital absence of right coronary artery

A single coronary artery (SCA) is a relatively rare coronary artery anomaly. Absent right coronary artery (RCA) is the rarest of coronary artery anomalies occurring when the right coronary artery doesn’t develop. In the past 14 years till 2020, only 26 cases of congenital absence of RCA have been reported in 24 articles. We report a rare case of single left coronary artery with congenital absence of right coronary artery detected by coronary angiography and confirmed by coronary CT angiography. The RCA territory was being supplied by a branch from left circumflex (LCX) artery. The patient presented with nonspecific central chest pain. We aim to shed light on this rare anomaly and raise awareness among medical practitioners.

Thirty-Day Unplanned Readmissions Following Elective and Acute Percutaneous Coronary Intervention.

Prior studies have reported a high rate of unplanned readmissions following acute percutaneous coronary intervention (PCI). Data outside the USA comparing 30-day unplanned readmissions following elective PCI to those who undergo acute PCI remain limited. Patients who underwent a PCI procedure in Australia and New Zealand between 2010 and 2015 were included. We determined the rates, causes and predictors of 30-day unplanned readmissions, as well as rates of repeat revascularisation procedures, for patients who underwent an elective or acute PCI. Predictors of readmissions were identified using logistic regression. A total of 199,686 PCI encounters were included, of which 74,890 (37.5%) were elective and 124,796 (62.5%) were acute procedures. Overall, 10.6% of patients had at least one unplanned readmission within 30 days of discharge with lower rates following elective PCI (7.0%) compared to acute PCI (12.7%) (p<0.01). Non-specific chest pain was the commonest cause of readmission after elective and acute PCI, accounting for 20.7% and 21.5% of readmission diagnoses, respectively. Readmissions for acute myocardial infarction (13.0% vs 4.6%, p<0.01) and heart failure (6.5% vs 3.3%, p<0.01) were higher following acute PCI compared to elective PCI. Among readmitted patients, 16.7% had a coronary catheterisation, 12.2% had a PCI and 0.7% had coronary artery bypass surgery. Multivariable predictors of 30-day unplanned readmission included female sex and comorbidities such as heart failure, metastatic disease, chronic lung disease and renal failure (p<0.0001 for all). Unplanned readmissions following elective or acute PCI are high. Clinical and quality-control measures are required to prevent avoidable readmissions in both settings.

Comparing twodefinitions of pediatric complexity among children cared for in general and pediatric emergency departments in a statewide sample.

The number of children cared for in emergency departments (EDs) with medical complexity continues to rise. We sought to identify the concordance between 2 commonly used criteria of medical complexity among children presenting to a statewide sample of EDs. We conducted a retrospective cross-sectional study of children presenting to a statewide sample of Illinois EDs between 2016 and 2021. We classified patients as having medical complexity when using 2 definitions (≥1 pediatric Complex Chronic Condition [CCC] or complex chronic disease using the Pediatric Medical Complexity Algorithm [PMCA]) and compared their overlap and clinical outcomes. Of 6,550,296 pediatric ED encounters, CCC criteria and PMCA criteria were met in 217,609 (3.3%) and 175,708 (2.7%) encounters, respectively. Among patients with complexity, 100,015 (34.1%) met both criteria, with moderate agreement (κ=0.49). Children with complexity by CCC had similar rates of presentation to a pediatric hospital (16.3%vs 14.8%), admission (28.5%vs 33.7%), ICU stay (10.0%vs 10.1%), and in-hospital mortality (0.5%vs 0.5%) compared to children with complexity by PMCA. The most common visit diagnoses for children with CCCs were related to sickle cell disease with crisis (3.9%), abdominal pain (3.6%), and non-specific chest pain (2.7%). The most common diagnoses by PMCA were related to depressive disorders (4.9%), sickle cell disease with crisis (4.8%), and seizures (3.2%). The CCC and PMCA criteria of multisystem complexity identified different populations, with moderate agreement. Careful selection of operational definitions is required for proper application and interpretation in clinical and health services research.

Single Coronary Artery as a Rare Developmental Variant in Cardiac Computed Tomography Angiography

Cardiac computed tomography angiography (CCTA) is a non-invasive method for the diagnosis of coronary artery disease. In addition to the assessment of possible stenoses in the coronary arteries, this method also allows the assessment of other abnormalities of coronary and extracoronary heart structures. CCTA is the optimal method for assessing the relationship of coronary arteries to other anatomical structures; thus, it is used as a method of diagnosing developmental variants of coronary circulation. We present images of a single left coronary artery in a 384-slice CCTA in a 69-year-old Caucasian female patient with non-specific chest pain and low intermediate cardiovascular risk as an example of a rare developmental coronary variant. In conclusion, the importance of CCTA as a method of diagnosing developmental variations of the heart and vessels should be emphasized.

Why do emergency department clinicians miss acute aortic syndrome? A case series and descriptive analysis

Objectives: To understand why the diagnosis of AAS is missed in the ED, and to characterise the presenting features of cases in which a diagnosis of AAS was missed.&#x0D; Methods: A retrospective case series cohort study was performed, identifying and analysing cases where AAS was misdiagnosed in three UK EDs between 1st January 2011 and 31st December 2020.&#x0D; Results: 43 cases were included, 22 of which were type A aortic dissections. The most common incorrect presumed diagnoses made were acute coronary syndrome (28%), pulmonary embolism (12%) and ‘non-specific chest pain’ (12%). In 31 cases (72%) there was no evidence from the notes that the clinician had considered AAS in the differential diagnosis. In 10 cases (23%), AAS was considered, but the clinician was falsely reassured by atypical or resolved symptoms, clinical examination, or normal chest x-ray.&#x0D; Conclusions: ED clinicians may miss AAS by not considering it as a possibility, being falsely reassured by atypical or resolved symptoms, or mistaking it for other more common conditions. Further prospective work is necessary to establish the role of diagnostic aids and biomarkers in UK EDs.

Successful completion of treadmill testing provides relief and reassurance for children with non-specific chest pain.

Non-specific chest pain is one of the leading causes of admissions in paediatric cardiology outpatient clinics, and its management usually consists of extensive reassurance of patients and their families. As we have often observed that successful completion of treadmill testing during diagnostic work-up provides relief and reassurance in these patients and their families, we planned this study to quantitatively assess anxiety levels and perception of illness among children with non-specific chest pain before and after treadmill testing. We studied 50 children (aged 11.8 ± 3.0 years, range 7-17 years; 24 females, 26 males) with a chief complaint of non-specific chest pain and negative history and echocardiography. They were asked to fill the Revised Children's Anxiety and Depression Scale before the treadmill testing and 1-10 days after successful completion of treadmill testing. Average total anxiety scores (36.38 ± 19.09 versus 33.36 ± 19.09, respectively) and average of total anxiety + depression scores (44.3 ± 24.92 versus 40.8 ± 26.97, respectively) of the children were found to be significantly lower after negative treadmill testing as compared to scores before testing (p < 0.05). Alterations in separation anxiety, panic, social phobia, obsession-compulsion scores were not statistically significant (p > 0.05). Children with non-specific chest pain feel relieved and reassured after successful completion of treadmill testing. To the best of our knowledge, our study is the first in the literature to show this relationship quantitatively.

Abstract 13011: A Rare Case of Spontaneous Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare condition; an intimal tear or bleeding of vasa vasorum leads to the creation of a false lumen filled with intramural hematoma. The hematoma causes coronary stenosis, leading to subsequent myocardial ischemia. SCAD is the cause of Acute Coronary Syndrome (ACS) in 0.1 to 4% of cases. Men account for less than 10% of cases, with a mean age of 48.6. Case Study: A 19-year-old male with prior medical history of morbid obesity and marijuana use was transferred from another hospital to our service after presenting with non-ST elevation MI. He was admitted following 30 minutes of a throbbing/pressure-like sensation in his throat, one episode of vomiting, and paresthesia in his left arm that spontaneously resolved. Initial EKG showed sinus rhythm with early repolarization changes. His troponin rose from 0.2 to 18 ng/mL. Upon admission, his high sensitivity troponin peaked at 15,000 pg/mL. Repeat EKG showed dynamic changes with T wave inversions in the inferolateral leads. The patient underwent an angiogram showing a diffuse, mid-LAD 40% de novo spontaneous dissection and a diffuse, distal-LAD 20% de novo spontaneous dissection with TIMI grade 3 and 2 flow, respectively. A repeat angiogram two days later showed improved coronary artery flow and deemed a low-risk lesion with stable patient hemodynamics; no intervention followed. The patient was treated conservatively with DAPT and discharged home with an outpatient Cardiology follow-up. A plan to have further imaging in 4 weeks to assess hematoma resolution was made. Conclusions: This case demonstrates an atypical presentation of SCAD in a very low-risk patient, given his sex, age, and clinical presentation of nonspecific chest pain. This case highlights the importance of high clinical suspicion for SCAD regardless of ACS risk profile in a patient presenting with chest pain.