Onset Of Chest Pain Research Articles

Evaluation of Serum Level of Copeptin as an Endogenous Stress Biomarker in the Early Diagnosis of Subtypes of Acute Coronary Syndrome in Iraqi Patients

Abstract Background: Acute coronary syndrome (ACS) is still one of the main causes of morbidity and mortality worldwide, and an early diagnosis of acute myocardial infarction (MI) aims to decrease mortality in MI patients. The ACS is manifested as one of three subtypes. These subtypes include MI with the electrocardiogram (ECG) is showing ST-segment elevation (STEMI), the other is MI with the ECG is showing no ST-segment elevation (NSTEMI), and the third type is unstable angina (UA). Objectives: The objectives of this study were to evaluate the role of serum copeptin (CPP) level in early diagnosis of subtypes of ACS. Materials and Methods: One hundred and twenty patients (72 males and 48 females) aged ≥30 years were consecutively selected from those who were admitted and diagnosed as ACS. The ACS patients comprised three subgroups: STEMI, NSTEMI, and UA, while apparently, healthy subjects were recruited as controls for this study. For each study subject, serum CPP was measured. Results: The CPP mean level showed an overall significant difference among study groups. On paired comparison, the CPP mean level was significantly higher in STEMI and NSTEMI subgroups (P < 0.001) as well as in UA subgroup of ACS patients than in controls (P < 0.05). On receiver operator characteristic analysis, the CPP levels showed good sensitivity and specificity in differentiation of each ACS subtype patients from controls as well as in differentiation of patients among subtypes of ACS. Conclusion: Serum CPP level is significantly higher in all subtypes of ACS than in controls in the first hours after the onset of acute chest pain in ACS patients in addition to having better sensitivity and specificity in the differentiation of patients among the subtypes of ACS.

Concurrent acute myocardial infarction and acute ischemic stroke in a diabetic patient undergoing chemotherapy for non-Hodgkin lymphoma: Should I administer thrombolytic therapy? A case report.

Concurrent ST-elevation myocardial infarction (STEMI) and acute ischemic stroke (AIS) are extremely rare, and their management remains perplexing due to the absence of high-quality evidence and limited resources. For the first time, we report a rare, preventable, and suboptimally managed case of concurrent AIS and STEMI in a patient with non-Hodgkin lymphoma (NHL) who received cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) chemotherapy. A 59-year-old postmenopausal woman of African origin with a background history of type 2 diabetes mellitus presented to the Jakaya Kikwete Cardiac Institute with sudden onset of left-sided weakness and typical ischemic chest pain for 3days. The patient was recently diagnosed with NHL and started CHOP chemotherapy 3weeks prior. Physical examination revealed left-sided hemiplegia. Emergency brain computed tomography and 12-lead echocardiography (ECG) revealed AIS and STEMI, respectively. A diagnosis of concurrent AIS and STEMI was reached, and the patient was loaded with dual antiplatelets and heparin and rushed for emergency coronary angiography (GAG) and percutaneous coronary intervention (PCI). CAG revealed massive thrombotic occlusion of the mid-segment of the left anterior descending coronary artery (mLAD) and proximal segment of the right coronary artery. Revascularization was achieved in both vessels with a resultant TIMI flow grade of 3. The post-PCI period was marked by significant improvement in chest pain and resolution of ST-elevation, as revealed by 12-lead ECG. However, the patient remained hemiplegic. We have described a rare case of concurrent AIS and STEMI in a postmenopausal woman who had a significant risk of thromboembolism. The patient had uncontrolled type 2 diabetes and received CHOP chemotherapy for NHL, which was diagnosed 3weeks prior. This case underscores the need for thromboembolic prophylaxis for selected cancer patients receiving chemotherapy. The need to individualize management is also emphasized, as both PCI and thrombolysis carry the risk of serious repercussions. In our patient, if thrombolysis was attempted it would have caused myocardial rupture and immediate death. The patient would have benefited from endovascular mechanical embolectomy for AIS; however, this practice is lacking at our institution. This calls for the establishment and strengthening of neurointerventional practices in our tertiary healthcare facilities.

A case of renal cell carcinoma with tumor thrombus extension into the right atrium

Introduction: Over the last half-century, mortality from renal cell carcinoma (RCC) has seen a dramatic reduction, while 5-year survival rates have reached an all-time high (34% to 75%). Case presentation: A 77-year-old female with Stage 4 RCC (cT3c, cN1, cM1) presented with acute onset chest and back pain. Imaging revealed interval enlargement of a left renal mass with propagation of tumor thrombus (TT) throughout the left renal vein, intrahepatic and suprahepatic inferior vena cava (IVC) with extension into the right atrium (RA). The patient successfully underwent a high-risk open left nephrectomy with caval thrombectomy, retroperitoneal lymph node dissection, and atrial thrombectomy. Discussion: Approximately 1% of RCC cases involve the right atrium, and radical nephrectomy with vena caval thrombectomy remains the most effective treatment for cavoatrial TT, with 5-year survival rates between 30% and 72%. While patients with renal vein involvement have better survival rates than those with IVC involvement, advanced TT cases (Types III and IV) often require extracorporeal circulation. Though the patient understood the prognosis of her RCC, discussing the risks of a complex procedure versus not intervening was challenging. Despite a typical median survival of 12 months for level IV tumor thrombus (TT), she remains stable 28 months post-surgery. Conclusion: Although the five-year survival rate for renal cell carcinoma (RCC) has increased from 34% to 75%, the disease still adversely affects patients’ quality of life. A multidisciplinary approach is essential when managing metastatic RCC, particularly involving the heart. Despite the associated risks, surgical intervention is more effective in prolonging life by preventing sudden cardiac death due to embolic events.

A study on the level of serum neopterin a new novel biomarker in acute myocardial infarction

Introduction: Acute myocardial infarction (AMI) is one of the most common diseases, and it is one of the important medical emergencies admitted in the hospitals. It is characterized by the presence of clinical features like sudden onset of severe chest pain with dysponea, palpitation and profuse sweating leading to cardiac arrythmias, cardiogenic shock, cardiac failure and death if not treated early(2). Among the biomarkers for diagnosis and prognosis in AMI, the Neopterin, a pteridine derivative is considered to be one of the new novel bio-markers which is found to be elevated in patients with AMI. Neopterin was first isolated from larvae of bee in 1963(3). Eventually Neopterin was identified as the fluorescent component that was elevated in the urine of mice with Ehrlich ascites tumor (4). Estimation of Serum levels of Neopterin is a new novel biomarker in AMI and seems to be a prognostic marker for MACE in AMI. Aim: To elucidate the role of Neopterin levels and its short term prognostic significance in AMI. Methods: Neopterin is an activation marker for monocytes / macrophages and its circulating levels in the Serum is considered to be one of the prognostic markers in the treatment of AMI.

Impact of Drug Eluting Stents’ Length and Diameter on Short Term Outcome in Patients Undergoing Primary Percutaneous Coronary Intervention

Abstract Introduction Little information is available on the impact of drug eluting stents (DES) on Major adverse cardiac events (MACEs). Aim was to assess the impact of stent length and diameter on angiographic and MACE outcomes during in-hospital & short term follow up in patients undergoing primary percutaneous coronary intervention (PPCI). Methods This is a single-center prospective observational study that included 404 patients who underwent primary PCI. Exclusion criteria were previous PCI, ectatic lesions, multi-vessel disease, and complex lesions. Stent length was divided into <20 mm, 20 - 40 mm and > 40 mm. Stent diameter was divided into < 3.0 mm, 3.0 – 3.5 mm and > 3.5 mm. Outcomes include angiographic data, e.g slow flow/no-reflow (SF-NR), and in-hospital and 3 months’ follow up MACE assessment. Results 404 patients (79% males, mean age 56 ± 11.35 years) were included. There was higher incidence of SF-NR (P=0.016), pre-dilatation (P= 0.01), median door to device time (P=0.011), median of onset of chest pain to wire time (P=<0.001), mean procedure time (P=<0.001) and mean contrast amount (P=0.013) for longer stents vs. medium and shorter stents. Patients having longer stents had significantly higher incidence of recurrent attacks of acute coronary syndrome (ACS) during the follow up period (P=0.003), and no significant difference was detected regarding other MACEs. Side branch compromise was more prevalent in larger diameter stents (P=0.042). In-hospital and 3 months’ follow up MACE incidence was similar. Conclusion Long DESs during PPCI are associated with higher incidence of SF-NR, however stent diameter has no impact on outcomes. Trial registration number in Clinical trials.gov.: NCT04110691

The procedural success of primary angioplasty in a tertiary care center in Pakistan.

This study was conducted to evaluate the procedural success of primary angioplasty in terms of TIMI flow and myocardial blush grade (MBG). We used cross-sectional population data of the patients who underwent primary PCI in Emergency Angiography department of Punjab Institute of Cardiology, Lahore from January 2021 to September 2021. TIMI flow and myocardial blush grades (MBG) were assessed before and after the procedure. All PCIs in which there was improvement in blood flow in infarct related artery of ≥2 grades in TIMI flow and/or in MBG were considered successful. A total of 106 patients were enrolled, 91 patients were male and 15 patients were female with the age range from 22 to 75 (48.7 ± 11.8) years. TIMI flow and MBG was improved ≥ 2 grades in 69 and 58 patients respectively. Improvement in TIMI flow was noted similar in all three vessels. Overall 65% patients showed improvement in TIMI flow and 55% in MBG. Onset of chest pain to balloon time was the most important parameter, shorter the time better the result. The patients in whom MBG was improved, the time was 234.26 ± 156.06 vs 323.59 ± 252.64 minutes. Primary angioplasty is quite effective procedure for the restoration of blood flow in acute ST elevation myocardial infarction but still it is far away from the ideal one. Although most patients benefit from primary PCI, a significant minority of individuals do not, particularly if they present late. What could be the ideal therapy, the answer is still to be answered.

Abstract 4137900: Differences in Echocardiographic Findings Between Epicardial Vasospastic Angina Phenotypes Affect Response to Medical Therapy

Background: The phenotype of epicardial vasospasm is classified as focal or diffuse. However, its echocardiographic characteristics are unknown. Furthermore, patients with diffuse vasospasms have poorer responses to medical therapy than patients with focal spasms because of more extensive areas of endothelial dysfunction. We hypothesized that there are differences in echocardiographic findings between the patients with diffuse and focal vasospasm, which might affect response to medical therapy. Methods: The present study was a single-center retrospective cohort study that included 77 consecutive patients diagnosed with vasospastic angina (VSA) undergoing coronary spasm provocation test using acetylcholine from 2014 to 2024. The patients with a history of cardiomyopathy and significant obstructive coronary artery disease were excluded. Diffuse VSA was defined as vasospasm in 2≧ adjacent coronary segments, and focal VSA was defined as vasospasm in one isolated coronary segment. Patients were divided into diffuse VSA group (n=45) and focal VSA group (n=32). Left ventricular function was assessed using 2D speckle tracking echocardiography. After the diagnosis of VSA and the administration of medical treatment for VSA, an emergency room (ER) visit with a chest pain attack was recorded as the event of poor response to medical therapy. Results: There was no significant difference in the follow-up period and baseline characteristics (Table). LVEF was similar between the two groups (63.1±5.8% vs. 62.9±7.6%, p =0.87). In contrast, the left ventricular global longitudinal strain (LV-GLS) was significantly lower in the diffuse VSA group than in the focal VSA group (17.4±2.8% vs. 20.2±2.4% p <0.001). There is no difference in medical therapy for VSA (Table). Observation of ER visits with a chest was more frequent in the diffuse VSA group [diffuse VSA group (20/45, 44.4%) vs. focal VSA group (3/29, 9.3%), p <0.001]. Kaplan-Meier curves showed that the diffuse VSA group had a higher cumulative rate of ER visits with a chest pain attack (Log-rank p <0.001). On multivariable Cox regression analysis, diffuse VSA (HR=4.2, 95% CI: 1.10-16.06, p =0.030) and low LV-GLS (HR =1.16, 95%CI: 1.01-1.34, p =0.031) were an independent risk factor for poor response to medical therapy. Conclusion: Patients with diffuse VSA had lower LV-GLS than patients with focal VSA. Moreover, diffuse VSA and lower LV-GLS were associated with poor response to medical therapy after diagnosis of VSA.

Abstract 4136480: A Rare Cause of a Classic Presentation of NSTEMI: Case of 39-Year-Old Female with Hypothyroidism Induced Myocarditis

Background: Myocarditis is a cause of non-ischemic cardiomyopathy (NICM) and troponin elevation. There are many causes including uncontrolled thyroid disorder (TD). A thorough history, cardiac MRI (cMRI) followed by an endomyocardial biopsy (EMB) is necessary for diagnosis. This case illustrates a classic presentation of NSTEMI with a rare cause of myocarditis due to uncontrolled hypothyroidism. Description of Case: A 39-year-old female with history of congenital hypothyroidism and tobacco use disorder presented to the Emergency Department with sudden onset of unprovoked sub-sternal chest pain. She stated she had stopped taking her levothyroxine years ago due to side effects such as abdominal discomfort. On admission, work up included high sensitivity troponin (Hs-cTn), EKG, urine drug screen (UDS), and thyroid panel. There was no evidence of ischemic changes on EKG, Hs-cTn was 3600 (normal: 3-54) which up-trended to 43,742, and UDS was negative. She was placed on appropriate medical therapy for NSTEMI and taken for urgent coronary angiography wbich showed normal epicardial arteries. A transthoracic echocardiogram (TTE) was unremarkable with a normal ejection fraction (EF). However, she continued to complain of chest discomfort and palpitations. Her vital signs remained stable but her thyroid panel revealed a TSH of 127 (normal: 0.27-4.2), T4 of 0.18 (normal: 0.92 – 1.6) and T3 of 1.0 (normal: 2.3-4.2). Inflammatory markers were also elevated. A cMRI was obtained revealing gadolinium enhancement in the anterior septal wall with extension into the subepicardium of the inferior wall suggestive of possible myocarditis. An EMB was performed to elucidate etiology. Pathology results were only remarkable for edema but newly reduced EF of 30-35% was noted on TTE at time of biopsy. Endocrinology was consulted for untreated hypothyroidism and patient was initiated on levothyroxine leading to improvement of her symptoms. Discussion: Our patient's history and work up were consistent with myocarditis induced by severe hypothyroidism. TD is a rare cause of reversible NICM and symptoms improve once TD is controlled. While there are several cases reported on hyperthyroidism associated myocarditis, there are only a few cases of myocarditis associated with uncontrolled hypothyroidism. Clinicians should maintain a broad differential to ensure a thorough work up in a patient presenting with NSTEMI, and a thyroid panel should be included especially if myocarditis is suspected.

Acute Severe Chest Pain with ST-Segment Elevation in Inferior Leads During Pharmacological Cardioversion of Paroxysmal Supraventricular Tachycardia: A Case Report

Paroxysmal supraventricular tachycardia (PSVT) is a frequently encountered arrhythmia in emergency departments, significantly affecting cardiac function and hemodynamics. The sudden onset of severe chest pain with accompanying ST-segment elevation on the electrocardiogram (ECG) during pharmacological cardioversion is rare but requires immediate intervention with coronary vasodilators, anticoagulants, and antiplatelet agents. Continuous ECG monitoring and assessment of cardiac biomarkers are essential. In facilities with appropriate resources, urgent coronary angiography is recommended to evaluate coronary anatomy, blood flow, and collateral circulation. Due to the rarity of this presentation, we report this case as a reference for clinical diagnosis and management.

To determine the accuracy of heart-type fatty acid-binding protein (H-FABP) as a new and early cardiac biomarker in the early diagnosis of acute myocardial infarction (AMI)

Heart diseases including acute myocardial infarction (AMI), are the second leading cause of death all over the world. Therefore, early detection and treatment of AMI have become the most critical and effective life-saving steps. H-FABP is a soluble cytoplasmic protein with a low molecular weight of 14.9 kDa fatty acid carrier protein abundantly present in the cardiac tissue. After myocardial ischemic damage, H-FABP can be detected in blood within 1 hour of onset of chest pain, with peak values at 3-6 hrs. Cardiac troponins, CK-MB, used routinely in the diagnosis of AMI, are not elevated in the initial hours (super acute phase) of AMI, precluding their usefulness in the early diagnosis. Our aim is to determine the accuracy of heart-type fatty acid-binding protein (H-FABP) as a new and early cardiac biomarker in the early diagnosis of acute myocardial infarction. 55 patients with acute chest pain were enrolled. CK-MB, Troponin I and H-FABP and ECG were done on admission (0-4 h) and 8-12 h after the onset of chest pain. Cardio detect combi kit was used to qualitatively determine H- FABP and troponin I for early diagnosis of acute myocardial infarction and results were obtained within 15 minutes. All the results of ECG, CK MB, Troponin I and H-FABP for every patient were obtained and compared for final diagnosis as per standard criteria. At 0-4 h, after the onset of AMI, the diagnostic sensitivity of H-FABP (93%) was higher than that of troponin I (cTnI) (38%) and CK-MB (13%). It is concluded that H-FABP is a reliable and excellent biochemical marker for early diagnosis of AMI.

Cardiac Myosin-binding Protein-C as a Biomarker in the Early Diagnosis of Acute Coronary Syndrome and Differentiation of Its Types

Abstract Background: Coronary heart disease (CHD) is primarily caused by atherosclerotic lesions within the intima of coronary arteries and acute coronary syndrome (ACS) is the main acute clinical manifestation of CHD. The ACS is manifested in one of three subtypes and it is the leading cause of mortality worldwide. The three subtypes of ACS include: acute myocardial infarction (MI) with the electrocardiogram (ECG) presenting ST-segment elevation (STEMI), MI with no ST-segment elevation on ECG (NSTEMI), and the third subtype is unstable angina (UA). The early diagnosis of is important in decreasing morbidity and mortality in ACS patients. Objective: To investigate the role of serum level of cardiac myosin-binding protein-C (cMyC), compared with high-sensitivity cardiac troponin-I (hsCTn-I) in the early diagnosis of ACS and differentiation of its subtypes. Materials and Methods: One hundred and twenty patients (72 males and 48 females), aged ≥30 years selected from those who were admitted to emergency department (ED) of Al-Yarmouk teaching hospital and diagnosed with ACS by cardiologists. The duration between the onset of chest pain and admission to ED should not exceed 3 h in any cohort. Apparenty healthy subjects as controls group for the study were recruited from those who had no current illness, particularly CHD, no other systemic disease and each had a normal ECG. For each study subject, cMybp-C and hsCT-I serum levels on admission were measured using the enzyme-linked immunosorbent assay kits. For each ACS patient, serum level of hsCTn-I level was measured 3 h after admission. Results: The comparison of cMybp-C levels among study groups revealed an overall significant difference and on paired comparison of study groups, the cMybp-C mean level was significantly higher in each ACS subgroup than in controls group (P < 0.001), except in UA subgroup versus controls group. The cMybp-C levels showed a significant positive correlation with hsCT-I levels on admission in STEMI and NSTEMI subgroups but not in UA subgroup. The cMybp-C levels also showed a significant positive correlation with hscT-I levels 3 h after admission in STEMI and NSTEMI subgroups but not in UA subgroup. On receiver operating characteristic curve analysis, the cMybp-C level had a better diagnostic accuracy than hscTn-I on admission in differentiation of patients with “STEMI or NSTEMI” from those with UA or from controls. Conclusion: Serum cMybp-C mean level is significantly higher in ACS patients with STEMI and NSTEMI than in controls and the increase was more significant than hsCTn-I mean level on admission, so it could help the early diagnosis of ACS patients. The serum levels of cMybp-C also had a better diagnostic accuracy than hsCTn-I on admission in differentiation of ACS patients with STEMI or NSTEMI from those with UA or from controls.

Effectiveness of telephone clinics for assessment of new onset chest pain - a retrospective single-centre observational study

Abstract Background The COVID-19 pandemic led to a significant shift in the way clinical consultations are conducted with a rapid transition towards remote consultations (teleclinics). Although face-to-face (F2F) clinics are being re-introduced in the post-pandemic era, a significant proportion of clinics continue to run remotely. Despite the inability to physically examine the patient, remote clinics have notable advantages such as increased accessibility and flexibility for both the clinician and the patient. Purpose As the healthcare model moves increasingly towards a hybrid system where both F2F and teleclinics coexist, we sought to analyse the differences in practice between the two groups. Methods This single-centre retrospective analysis of patients referred to specialist cardiology services with NOCP compared face-to-face (F2F) consultations with teleclinic consultations. 70 patients were randomly selected in each category from a list of patients with NOCP that were referred to a tertiary cardiac centre from January to December 2021. Teleclinic appointments were conducted via telephone while F2F clinics had the patients visit the hospital for their appointments. Results The main findings are tabulated in Table 1. The samples for the two categories were evenly matched. Teleclinic appointments had a significantly reduced waiting time compared to F2F clinic (4 vs 6 weeks, p= 0.0009). As expected, the teleclinic group had reduced access to examination findings such as blood pressure, heart rate, and ECG. There was no significant difference in an initial working diagnosis of typical angina between the F2F group and the teleclinic group (30% and 25.7% respectively, p=0.706). However, patients in the F2F group were more likely to have anti-anginal therapy commenced compared to teleclinic group (50% vs 27.1% respectively, p=0.0089) following initial clinic review. Also, they were more likely to undergo an invasive coronary angiogram (30% vs 12.9% in F2F and teleclinic groups respectively, p=0.0224). However, this did not lead to a significant increase in PCIs performed in the F2F group. More patients had non-invasive tests requested in the teleclinic group compared to the F2F clinic group (62.9% vs 50% respectively, p=0.17) although this was not significant the median number of total investigations requested were the same in both the group. Conclusion Telephone consultations appear to be a reasonable alternative to F2F consultations with reduced waiting times and no significant impact on investigations ordered. However, lack of key examination findings may have hampered prescription of anti-anginal medications. Provisions such as readily available access to GP health care records on examination findings along with a streamlined remote prescription system can help overcome reluctance to prescribe antianginals. Further research is needed to assess clinical outcomes of teleclinic consultations.Table 1

Derivation and external validation of new ESC 0/1-h algorithm cut-offs for high-sensitivity troponin T and I in the cancer population

Abstract Background The diagnostic performance of high-sensitivity cardiac troponin T/I (hs-cTnT/I) and the efficacy of the European Society of Cardiology (ESC) 0/1h-hs-cTnT/I-algorithms for the early diagnosis of non-ST-elevation myocardial infarction (NSTEMI) is reduced in cancer patients presenting to the emergency department (ED) with chest pain.[1] Purpose This study aimed to derive and externally validate new cut-offs for the ESC 0/1h-hs-cTnT/I-algorithms in chest pain patients with active or past cancer. Methods Patients presenting with acute chest discomfort to the ED were prospectively enrolled in an international multicenter diagnostic study. Final diagnoses were centrally adjudicated by 2 independent cardiologists applying the fourth universal definition of myocardial infarction using all available medical records, cardiac imaging, and serial hs-cTnT/I. Hs-cTn concentrations were measured at presentation and after 1 hour. New assay-specific cutoffs for the ESC 0/1h-hs-cTnT/I-algorithm were derived and externally validated in two independent cohorts. Results Among 541 and 516 eligible patients with 0h and 1h hs-cTnT and hs-cTnI values, respectively, application of the current ESC 0/1h-hs-cTnT/I algorithm triaged 317 (58.6%) and 306 (59.3%) patients to either rule-out or rule-in, leaving 224 (41.4%) and 210 (40.7%) patients in the observe-zone of the ESC 0/1h-hs-cTnT/I algorithm, respectively. The novel ESC 0/1h-hs-cTnT cut-offs ruled out NSTEMI with a cut-off <8 ng/L at presentation (if chest pain onset >3 hours) or <14 ng/L together with a 0/1-hour delta <3 ng/L, ruling-out 241 patients (44.5%) with a sensitivity and negative predictive value (NPV) of 99.2% and 99.6%, respectively. The novel ESC 0/1h-hs-cTnI cutoffs ruled out NSTEMI with a cut-off <7 ng/L at presentation (if chest pain onset >3 hours) or <10 ng/L together with a 0/1-hour delta <3 ng/L, ruling-out 281 patients (54.5%) with a sensitivity and NPV of 99.1% and 99.6, respectively. Findings were confirmed in both internal and external validation (Figure 1). A total of 167 (32.8%) patients died at 5-years, of whom 61 died of cardiovascular causes, and 30 (5.9%) patients had an MI at 5 years. 5-year all-cause mortality for the rule-out group was similar for both the current and the novel ESC 0/1-h algorithm, although the novel one identified patients in the observe zone group as having the highest mortality (Figure 2). Incidence of 5-year cardiovascular mortality or AMI provided by the current ESC 0/1h-algorithm was similar for the rule-in and observe zone groups for both hs-cTnT and hs-cTnI. Conclusions In chest pain patients with a history of cancer, new derived assay-specific cutoffs for the ESC 0/1h-hs-cTnT/I-algorithm achieved a higher proportion of patients triaged to either rule-out or rule-in without decreasing safety. The low mortality rate of the rule-out group identified by the new algorithm further reassures on the safety of the new derived cut-offs.Sensitivity analysis in the APACE cohort5-year all-cause mortality

NICE guidance in the rapid access chest pain clinic: does it work?

Abstract Background Rapid Access Chest Pain Clinics (RACPC) were developed following the publication of the National Service Framework for Coronary Heart Disease in 2000(1). The National Institute for Health and Care Excellence (NICE) produces guidelines for the management of patients with recent onset chest pain of suspected cardiac origin(2). In 2016 the guidance was updated and recommended the use of CT coronary angiography (CTCA) as the initial investigation for patients with chest pain which was typical or atypical of angina. Adherence to the guideline may be dependent upon factors such as local availability of CT scanners and clinician preference. The RACPC in this tertiary centre is nurse-run with no medical involvement. There is good engagement with the CT department and in July 2017 the NICE guidance was adopted in the clinic. Purpose To evaluate the use of CTCA as the first line investigation for patients with typical or atypical chest pain. Methods Data from all patients reviewed in the clinic between 01/07/2017 and 31/12/2023 were prospectively collected, entered into a database, and then retrospectively analysed. The data were organised into 3 groups: patients with typical chest pain; atypical pain and those with non-cardiac sounding chest pain. The number of patients in each group who underwent a CTCA, and the outcome of the scan were evaluated. The CT scans were categorised as showing significant coronary artery disease (CAD), non-obstructive CAD, no CAD, or as inconclusive. The outcome of patients who had a positive CTCA was also recorded. Results 2986 patients were reviewed in the RACPC in the above period. 14.2% of patients presented with typical pain, 47.4% with atypical pain, and 30.6% had non-cardiac pain. The remaining patients presented with other symptoms such as breathlessness. CTCA was used as the first investigation in the majority of patients with typical or atypical pain, unless alternative investigations or management were deemed to be more clinically appropriate. In 59.5% of typical and 78.5% of atypical presentations, the CT scan showed no CAD, or non-significant CAD. There was a low incidence of positive scans in both groups, however patients with typical pain were more likely to have significant CAD (Table). All patients who had a CTCA indicating significant CAD, were referred for invasive angiography. 88.0% of typical presentations, and 64.0% of those with atypical pain, underwent revascularisation. No patient who underwent invasive angiography was found to have normal coronary arteries. Conclusion Atypical pain is the most frequent presentation in the RACPC, however the majority of these patients, and most of those with typical pain, do not have significant CAD. Careful assessment and the use of CTCA as the initial investigation, enable the identification of those patients who need invasive angiography. This is a cost-effective strategy which also reduces risk and radiation exposure for patients.

Ruptured solitary fibrous tumor of the pleura with hemothorax: a case report

BackgroundThe majority of the patients with a solitary fibrous tumor (SFT) of the pleura are asymptomatic, and rupture of an SFT with hemothorax is rare.Case presentationA 48-year-old man was taken by ambulance to our hospital because of sudden onset of left chest pain. Two months before the referral, a tumor was detected in the left upper lobe of the lung by screening computed tomography at another hospital, and further observation was recommended, because the tumor was suspected to be benign. Our contrast-enhanced computed tomography analysis of the chest revealed a solid tumor (5 cm in diameter) with an irregular enhancement effect close to the pericardium and pleural effusion in the left thoracic cavity. Pleural effusion was not detected in the previous imaging analysis. CT number of the pleural effusion was 40 HU, and the pleural effusion was suspected to be hematogenous. Therefore, rupture of the tumor with bleeding was suspected as the cause of the effusion because of the sudden onset. Preoperative diagnosis was a mediastinal tumor, such as a teratoma, because the tumor was close to the pericardium. Thoracoscopic surgery was performed with the patient in the right lateral decubitus position; bloody pleural effusion was observed and drained. The tumor originated from the visceral pleura of the left upper lobe of the lung and was resected with a surgical stapler. Macroscopic analyses of the resected tumor indicated that bleeding were caused by the rupture of the tumor at the defect of the capsule wall. The operation took 63 min. The postoperative pathological diagnosis was a benign SFT. Hemorrhage was observed just under the capsule wall of the tumor. The postoperative course of the patient was uneventful, and he was discharged 2 days after surgery.ConclusionsEven when an SFT is neither huge nor malignant, rupture can occur, and resection should be considered regardless of the size or malignant characteristics. After an SFT rupture, careful follow-up is needed to monitor for the intrathoracic recurrence or dissemination of the tumor.

Molecular testing in a patient with multiple alloantibodies and warm autoimmune hemolytic anemia: A case study

Abstract Introduction/Objective We present a case of RBC alloimmunization and warm autoimmune hemolytic anemia (WAIHA) in a patient with a recent RBC transfusion. Serological testing followed by molecular testing revealed a rare D+ C- E- partial c+ partial e+ VS+ V+ hrS+ hrB+vw/- predicted phenotype. Methods/Case Report A 75-year-old black male with secondary myelofibrosis presented with a sudden onset of chest pain, dyspnea and weakness during an RBC transfusion. The patient was subsequently admitted for further workup. Labs showed low hemoglobin, low haptoglobin, elevated LDH and a positive direct antiglobulin (DAT) test. The patient was started on intravenous immunoglobulin and steroids for suspected WAIHA. On immunohematology serologic testing, blood typed as B-positive and polyspecific DAT positive with anti-IgG positive and anti-C3 negative. Serum plasma studies showed probable warm autoimmune hemolytic anemia and allo anti-S, -E, and -C by previous history. Eluate studies showed panagglutinin and antibody with D-like specificity. Immucor PreciseTypeTM Human Erythrocyte Antigen (HEA) Molecular BeadChip test predicted a partial e antigen and potential hrB-. Genotyping for RHD variants was performed and revealed RHD*01 (homozygous or hemizygous). Targeted genomic testing did not detect variants associated with common partial or weak RhD antigens. Based on this testing, the patient was not predicted to be at risk of allo-anti-D. An RHCE genotype for C, c, E and e variants including hrB and hrS showed RHCE*ce48C,733G/RHCE*ce733G with predicated phenotype of D+ C- E- partial c+ partial e+ VS+ V+ hrS+ hrB+vw/-. Based on the RHCE testing, the patient was predicted to be at risk for allo-anti-c, -e, -f (ce) and possibly anti-hrB. Results (if a Case Study enter NA) NA Conclusion In this case, serologic testing alone did not reveal a precise diagnosis. Molecular testing aided in the diagnosis of WAIHA and will help guide future transfusions. Pathologists must consider molecular testing when faced with a challenging serologic diagnosis.

Diagnostic performance of quantitative perfusion cardiac magnetic resonance imaging in patients with prior coronary artery disease.

The diagnostic performance of quantitative perfusion cardiac magnetic resonance (QP-CMR) imaging has scarcely been evaluated in patients with a history of coronary artery disease (CAD) and new onset chest pain. The present study compared the diagnostic performance of automated QP-CMR for the detection of fractional flow reserve (FFR) defined hemodynamically significant CAD with visual assessment of first-pass stress perfusion CMR (v-CMR) and quantitative [15O]H2O positron emission tomography (PET) imaging in a true head-to-head fashion in patients with prior CAD. This PACIFIC-2 substudy included 145 symptomatic chronic coronary symptom patients with prior myocardial infarction and/or percutaneous coronary intervention. All patients underwent dual-sequence, single-bolus perfusion CMR, and [15O]H2O PET perfusion imaging followed by invasive coronary angiography with three-vessel FFR. Hemodynamically significant CAD was defined as an FFR ≤ 0.80. QP-CMR, v-CMR, and PET exhibited a sensitivity of 66, 67, and 80%, respectively, whereas specificity was 60, 62, and 63%. Sensitivity of QP-CMR was lower than that of PET (P = 0.015), whereas the specificity of QP-CMR and PET was comparable. Diagnostic accuracy and area under the curve of QP-CMR (64% and 0.66) was comparable to both v-CMR [66% (P = not significant [NS]) and 0.67 (P = NS)] and PET [74% (P = NS) and 0.78 (P = NS)]. In patients with prior myocardial infarction and/or percutaneous coronary intervention, the diagnostic performance of QP-CMR was comparable to visual assessment of first-pass stress perfusion CMR and quantitative [15O]H2O PET for the detection of hemodynamically significant CAD as defined by FFR.

A rare case of IgG4-related aortitis in the thoracic aorta mimicking an intramural hematoma: navigating the diagnostic labyrinth

A 54-year-old female presented with recurrent abdominal pain and new onset chest pain. Chest computed-tomography angiogram detected a thoracic aortic aneurysm with suspected Type A intramural hematoma (IMH) versus aortitis. Initially, conservative management was pursued while awaiting a definitive diagnosis. Differential workup was negative, while additional imaging modalities favored IMH, prompting expedited surgical intervention. During ascending aortic and hemiarch replacement, severe aortitis was unexpectedly discovered without evidence of IMH. Histopathological examination of the aortic specimens identified transmural aortic inflammation with lymphoplasmacytic infiltrate and irregular fibrosis. Numerous IgG4-positive plasma cells were present with IgG4/IgG ratio of 40–50% suggesting IgG4-related disease (IgG4-RD). Subsequent analysis revealed B cells positive for clonal IgH gene rearrangement, and bone marrow biopsy then revealed the same clonal B cells. She was ultimately diagnosed with CLL, the most common phenotype of monoclonal B-cell lymphocytosis, thought to account for the IgG4-predominant plasma cells causing aortitis. Although rare, this case highlights the importance of considering IgG4-related disease (IgG4-RD) as a cause of aortitis when assessing symptomatic patients with aortic pathologies, emphasizing the complexities involved in diagnosing due to a variety of imaging presentation, differentiating, and managing large-vessel vasculitides. Moreover, it underscores the importance of Multidisciplinary Aortic Team care and the use of multiple diagnostic modalities in evaluating ambiguous aortic pathologies.

Breaking Down SCAD: A Deep Dive into Spontaneous Coronary Artery Dissection (SCAD)

Spontaneous Coronary Artery Dissection (SCAD) is a rare, non-atherosclerotic cause of acute coronary syndrome, mainly seen in females with non-traditional cardiovascular risk factors. This case report follows a 44-year-old female who experienced a sudden onset of severe chest pain, which was attributed to SCAD following a coronary angiogram. This case emphasizes the importance of recognizing such presentations within the emergency department, particularly regarding differential diagnosis of chest pain following emotional or physical stressors. It also highlights the need for a multidisciplinary approach in terms of proper management with cardiology, emergency medicine, and mental health care to reduce the risk of reoccurrence. This case report aids in underscoring SCAD’s significance as a potential cause of ST Elevation Myocardial Infarction in what is noted as a low-risk population and the critical role of awareness and education in terms of its diagnosis and management.

Aneurisma aórtico roto associado com salmonelose difusa: Um relato de caso

Case report: A 63-year-old female patient, hypertensive and diabetic, reported a sudden onset of chest pain at night, which persisted continuously for 20 days. According to CT scans and computed tomography angiography, the diagnostic hypothesis of ruptured thoracic aortic aneurysm was considered. During the postoperative evolution, the patient presented difficulty in extubation and persistence of infectious symptoms, because of this, new tests were performed, which indicated a possible fistula with subsequent upper digestive endoscopy. During this period, the patient persisted with infectious symptoms and lack of improvement. Bronchoalveolar lavage fluid culture was performed at the same time, which identified bacterial growth of Salmonella spp. Discussion: A study that analyzed 129 cases of Salmonella in a hospital in Massachusetts showed that DM is one of the most common risk factors for Salmonella spp in adults. In a study carried out in China, it was evident that 28.9% of the cases were considered asymptomatic, that is: presence of the bacteria, but absence of diarrhea. In the scientific society, there is concern about the antimicrobial resistance of Salmonella spp. Because of this, treatment with antibiotics is indicated, especially in cases with a higher risk of complications. It is considered that the consequences of the bacterium on the body can lead the patient to septic shock and death. Final considerations: Thus, having knowledge about triggering factors, main symptoms, and appropriate treatment becomes essential for the best evolution of the clinical condition of infected patients.