Patients Reported Chest Pain Research Articles

A systematic assessment of myocardial involvement and cardiovascular events up to six months in patients hospitalised with COVID-19

Abstract Background Retrospective cohort studies indicate that myocardial injury occurs in approximately 25% of patients hospitalised with COVID-19. However, prospective studies with a systematic assessment of myocardial involvement and major adverse cardiovascular events (MACE) after COVID-19 are scarce. Purpose The primary objective was to determine the incidence of MACE within six months of hospitalisation. MACE was defined as a composite of cardiac death, sudden death, life-threatening ventricular arrhythmia's, heart failure, non-fatal myocardial infarction, and/or non-fatal stroke. The main secondary objective was to determine the frequency of other cardiac complications not covered by this definition. Methods We conducted a prospective multicenter cohort study in 13 Dutch medical centers. Adult patients hospitalised with COVID-19 were consecutively recruited (May 2021-April 2023). Exclusion criteria were age ≥70 years, a history of new cardiac disease in the past six months, or dependency in the activities of daily living. Cardiac involvement was evaluated by a standardised healthcare pathway that was implemented in participating hospitals. All patients received an electrocardiogram, transthoracic echocardiogram, and troponin measurement at admission and at six months follow-up. Furthermore, a questionnaire was distributed at three and six months after admission to collect information on post-COVID symptomatology. Results In total 190 patients were included, median age of 57 years [IQR 48; 64], mostly male (n=110, 60%) and white (n=136, 72%). Cardiovascular risk factors were present in 116 (61.1%) patients and 33 (17.4%) had a history of cardiac disease. At admission, troponin was above the upper limit of normal in 68 (35.8%) patients. Seven (3.7%) patients died during follow-up. The cumulative incidence of MACE was 2.6% at discharge with no additional events during follow-up. Other cardiac complications were detected in 18 (9.5%) patients during admission with 3 (1.6%) additional events at six months follow-up. Supraventricular tachycardias (n=8, 4.2%) were the most common cardiac complication. Other complications were myocarditis (n=2, 1.1%), pericarditis (n=1, 0.5%), non-sustained ventricular tachycardia (n=1, 0.5%), and other arrhythmias or conduction disorders (n=5, 2.6%). At six months follow-up, three (2.3%) patients reported chest pain, with one requiring a percutaneous coronary intervention. Palpitations and dizziness were experienced by 88.9% and 83.3% of patients three months after admission but the prevalence of these symptoms decreased to 9.8% and 11.8% at six months. Conclusion With a systematic assessment, one in three patients hospitalized with COVID-19 have elevated troponin levels at admission. However, the overall incidence of MACE within six months is low. Palpitations and dizziness are commonly reported after discharge but these symptoms disappeared for most participants within six months.

Transcatheter patent foramen ovale closure in patients with and without documented nickel hypersensitivity

Abstract Background Transcatheter PFO closure has been established as a safe and feasible approach for secondary prevention in appropriately selected patients with previous cryptogenic stroke. The two FDA-approved devices, widely used, consist of a nitinol frame; a nickel-titanium alloy. Although nickel is recognized as the primary metal causing hypersensitivity reactions worldwide, the potential occurrence of nickel hypersensitivity following PFO closure remains a subject of debate. Purpose The aim of this study is to investigate whether patients with nickel hypersensitivity are more susceptible to experiencing adverse events after PFO closure and to explore the potential role of device selection. Methods We prospectively enrolled patients undergoing PFO closure at our tertiary hospital. Before the procedure, all patients underwent nickel skin patch tests, considered the gold standard for diagnosing nickel hypersensitivity. Subsequently, patients were randomized to receive one of the two FDA-approved devices. During a three-month follow-up period, we evaluated the primary endpoint, a composite outcome including patient-reported chest pain, palpitations, headaches, and rash. Blinding was maintained for the patients, the operator, and the assessor of endpoints regarding the results of the nickel skin patch tests. The chi-squared test was utilized to evaluate the primary endpoint. Results for continuous variables are expressed as mean ± standard deviation or, for non-normally distributed variables, as median (interquartile range). Results Between January 2021 and November 2023, a total of 63 patients were included in our analysis. The majority were men (n=33, 52.4%) with a mean age of 46.1 ± 10.1 years. The median RoPE score was 7 (6-8). Nickel hypersensitivity was documented in 30.8% of the patients. The primary endpoint was met in 37.7% (n=23) of the total sample, with a significantly higher incidence in patients with nickel hypersensitivity than in those without (61.1% versus 27.9%, p=0.015, OR: 4.060, 95% CI: 1.275 – 12.930). No significant difference was observed when analyzing the two devices separately (p=0.096 and p=0.078, respectively). No recurrent ischemic stroke, severe anaphylactic reaction, or requirement for device surgical removal was observed in any patient. Conclusions Our findings indicate that patients with documented nickel hypersensitivity are more likely to develop symptoms such as chest pain, palpitations, headaches, and rash following the procedure. However, these findings do not raise major safety concerns. The completion of our study is necessary to acquire more reliable and conclusive results.

Downsloping TP Segment in the Precordial Leads on a Standard 12-lead Electrocardiogram: Suspected Cardiac Impulse-tapping Artifact.

We herein report an 80-year-old man showing a downsloping TP segment together with an increase in the height of the T wave in the precordial leads on a standard 12-lead electrocardiogram (ECG). Separately, an 87-year-old woman showed only a downsloping TP segment in the precordial leads on a standard 12-lead ECG. Neither patient reported chest pain or dyspnea when ECGs was obtained. This downsloping TP segment in the precordial leads on the standard 12-lead ECG is thought to be due to a cardiac impulse-tapping artifact. Differential diagnoses are also discussed.

Abstract 13272: Acute Effects of Enhanced External Counterpulsation in Adults With Fontan Circulation

Background: Patients who have undergone Fontan palliation for single ventricle CHD exhibit reduced cardiac output. Aims: To study the safety and acute hemodynamic effects of enhanced external counterpulsation (EECP) in a cohort of Fontan patients. Methods: Pilot study of adult Fontan patients recruited through the ambulatory clinic at a single, large-volume ACHD center. Patients underwent TTE and measurement of pulmonary blood flow (PBF), a surrogate for cardiac output, followed by 1 hour of EECP divided into 20-minute stages (80 mmHg, 160 mmHg, 240 mmHg). TTE and PBF measurement were repeated at each stage and 15-30 minutes after completion of EECP. Patients were monitored for symptoms throughout the visit. A repeated measures linear-mixed-model (robust to non-normality) was used to estimate the mean at each time point and to test for differences across time points. Results: There were 23 patients enrolled (52% male, 91% cis-gender, 74% White). Mean age at enrollment and at Fontan completion was 33.0 ± 7.8 years and 5.1 ± 4.1 years, respectively. Six patients (26%) had a pacemaker. Twenty-two (96%) completed a full hour of EECP. Pressure was reduced in the third stage for 3 patients due to discomfort. No patients reported chest pain or increased dyspnea during EECP. PBF was increased at each stage of EECP compared to baseline and returned to baseline post-EECP (Fig. 1). There was a small qualitative improvement in ventricular systolic function in the second and third stages of EECP compared to baseline (160 mmHg: p=0.048; 240 mmHg: p=0.024). O 2 saturation was increased at each stage of EECP compared to baseline (baseline: 93.0%, 80 mmHg: 94.3% [p=0.008], 160 mmHg: 94.6% [p=<0.001], 240 mmHg: 94.6% [p=<0.001]). Mean arterial pressure and heart rate did not change. Conclusions: EECP is well-tolerated in adult Fontan patients and acutely improves PBF at pressures as low as 80 mmHg. Further study is warranted to explore long-term therapeutic effects of EECP in these patients.

Abstract 14453: Patent Foramen Ovale Closure in Patients With and Without Nickel Hypersensitivity Using Two Different Devices

Background: Transcatheter PFO closure has been established as a safe and effective approach for secondary prevention in patients with ESUS. The Amplatzer® PFO occluder and Gore Helex® septal occluder are two FDA-approved devices, which consist of a nickel-titanium alloy frame. While nickel is the first cause of hypersensitivity reaction worldwide, the potential occurrence of nickel hypersensitivity following PFO closure is still under investigation. Aim: Our aim is to investigate whether patients with nickel allergy are more susceptible to experiencing adverse events after device implantation and to explore the potential role of device selection. Methods: We prospectively enrolled patients undergoing PFO closure. Before the procedure, nickel skin patch tests were performed in all the patients. The patients were randomized to receive either Amplatzer® or Gore® device. During a three-month follow-up period, we evaluated the primary endpoint, which was a composite outcome including patient-reported chest pain, palpitations, headaches, and rash. We used the chi-squared test to evaluate the primary endpoint and performed multivariate binary logistic regression analysis to assess the effect of device selection on the primary endpoint. Results: A total of 50 patients (50% female, 45.4±10.3 years old) completed the follow-up and were included in the present analysis. Among them, 29 patients received the Gore device, while the remaining 21 patients received the Amplatzer device. Fourteen patients were diagnosed with nickel hypersensitivity. The primary endpoint was reached in 40% of the analyzed patients. The occurrence of the primary endpoint was significantly higher in patients with nickel hypersensitivity compared to those without (50% vs. 13.3%, p=0.005). Additionally, multivariate binary logistic regression analysis demonstrated no association between device selection and the composite outcome (p=0.892). Conclusions: Our preliminary results indicate that patients with nickel hypersensitivity are more likely to develop symptoms such as chest pain, palpitations, headaches, and rash following the procedure. However, the completion of our study is necessary to obtain more reliable and conclusive results.

Clinical Profile of Patients with Hypertensive Crisis Presenting to an Emergency Department of a Tertiary Care Hospital in Western India

Objectives: A hospital-based retrospective study was undertaken among the adult patients presenting to document the incidence of hypertensive urgency (HTN-U) and emergency while the secondary objectives included clinical presentations, disposition from emergency room, and inhospital mortality. Materials and Methods: All patients were evaluated by vital signs, clinical examination as well as relevant laboratory tests and radiological tests. Patients with target organ damage were grouped under the hypertensive emergency (HTN-E) group ( n = 104) and patients without target organ damage were included under the HTN-U group ( n = 52). The data were analyzed using GraphPad Prism (vs. 9.4.1) and MedCalc (vs. 20.118). Results: The incidence of HTN-E and HTN-U was 68.4% and 31.6%, respectively. The most common symptom observed in patients with HTN-E was breathlessness (53.8%), followed by chest pain (34.6%) and headache (27.9%). While, in HTN-U patients, most patients reported chest pain (43.8%), headache (39.6%), and epistaxis (22.9%). Majority of the patients in both the groups presented with signs of tachycardia, tachypnea, and hypoxia. The mortality in HTN-E and HTN-U patients was 15.4% and 2.1%, respectively. Among 104 patients with HTN-E, 53.8% each of the patients had acute heart failure and acute pulmonary edema. While, in HTN-U patients, acute pulmonary edema and acute coronary syndrome were observed in 2.1% each of the study subjects. Conclusion: Patients at high risk or end-organ damage should be immediately referred to the emergency department from the outpatient settings, as a rapid reduction in blood pressure is essential over minutes to hours, to prevent further organ damage.

A retrospective study of the clinical characteristics of 9 children with pulmonary embolism associated with Mycoplasma pneumoniae pneumonia

ObjectiveThe aim of this study was to analyze the clinical characteristics and treatment of children with Mycoplasma pneumoniae pneumonia (MPP) who also present with pulmonary embolism (PE).MethodsThis retrospective analysis examined the demographic data, clinical manifestations, laboratory tests, imaging characteristics, therapy, and prognosis of nine cases of children with Mycoplasma pneumoniae pneumonia (MPP) complicated by pulmonary embolism (PE). The study focused on patients admitted to the respiratory department of Tianjin Children’s Hospital between January 2018 and December 2021.ResultsThe age range of the patients was 3 to 8 years old, with a median age of 7.5 years. The median number of days from pulmonary infection to the diagnosis of embolism was 14 days. All patients had refractory Mycoplasma pneumoniae pneumonia (RMPP). Among them, three patients reported chest pain, one of whom had hemoptysis, while five patients had dyspnea, and six patients experienced radiating pain at unusual sites. Five out of the nine children tested positive for lupus anticoagulant (LA), five for anticardiolipin antibody (ACA), three for anti-2-glycoprotein antibody IgM, four for reduced protein S or protein C activity, and three for elevated coagulation factor VIII. Moreover, six out of the nine children tested positive for antinuclear antibodies. All the children underwent CT pulmonary angiograms, which revealed filling defects. After sequential low-molecular heparin anticoagulation with rivaroxaban, nine children in this study showed a good prognosis, with two of them receiving thrombolytic therapy for combined cardiac embolism. Follow-up at 0.5-9 months showed the gradual resolution of the emboli in all 9 children, with no thrombotic recurrences and normalized autoantibodies and thrombophilia markers.ConclusionsThe majority of cases involving Mycoplasma pneumoniae pneumonia (MPP) combined with pulmonary embolism (PE) were diagnosed with refractory MPP (RMPP). However, PE did not always occur in the advanced stages of the disease. Most patients presented with transient autoantibody positivity, abnormal coagulation, and fibrinolytic balance. With timely treatment, the prognosis of MPP combined with PE is generally good. Additionally, rivaroxaban treatment has been shown to be safe and effective.

Congenital absence of the left pericardium: a case report

BackgroundCongenital absence of the pericardium (CAP) is rare in clinical practice, the symptoms vary among patients, and most doctors do not have enough knowledge of the condition. Most reported CAP cases are incidental findings. Therefore, this case report aimed to present a rare case of left partial CAP that presented with non-specific, possibly cardiac-related symptoms.Case presentationThe patient, male, 56 years old, Asian, was admitted on March 2, 2021. The patient complained of occasional dizziness in the past week. The patient was suffering from hyperlipidemia and hypertension (stage 2), both untreated. The patient reported chest pain, palpitations, discomfort in the precordium, and dyspnea in the lateral recumbent position after strenuous activities, all of which started when he was about 15 years old. ECG showed sinus rhythm, 76 bpm, premature ventricular beats, incomplete right bundle branch block, and clockwise rotation of the electrical axis. Most of the ascending aorta could be detected in the parasternal intercostal space 2–4 by transthoracic echocardiography in the left lateral position. Chest computed tomography revealed the absence of pericardium between the aorta and the pulmonary artery, and part of the left lung was extending into the space. No changes in his condition have been reported up to now (March 2023).ConclusionsCAP should be considered when multiple examinations suggest heart rotation and a large moving range of the heart in the thoracic cavity.

Cardiac Involvement in Monkeypox Outbreak.

Unusual presentations and uncommon clinical manifestations of Monkeypox (Mpox) in the current outbreak highlight the need to focus on cardiac symptoms of the virus. Owing to limited discussion regarding cardiac involvement in recent cases of Mpox, we conducted a scoping review to determine the range of existing research and provide a descriptive overview of the current literature on these manifestations. This review was conducted using a previously developed six-stage methodological approach and keeping in view the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR). Records retrieved from PubMed, ScienceDirect and Google Scholar, using a two-step search strategy, were subjected to title and abstract screening, followed by full text screening of remaining articles against specified eligibility criteria. Relevant information was extracted and summarized. Our search yielded 707 records. Following title and abstract screening, 23 articles were retrieved for full text screening. Finally, a total of nine articles were included in this review (three case series and six case reports discussing a total of 13 patients). Myocarditis was identified as the most frequently reported cardiac manifestation of Mpox. Novel clinical presentations included pharyngitis, sore throat, proctalgia, and perianal irritation. Most patients reported chest pain as the primary symptom of cardiac system involvement. Elevated troponin was the most commonly reported investigation finding followed by an elevated C- Reactive Protein. There exists a lack of high-quality studies investigating cardiac system involvement in the current outbreak of Mpox. More information is needed regarding risk factors for cardiac complications, disease progression, and cardio tropism and immunological response to improve preventive/therapeutic strategies. We highlight the paucity of relevant data and call for further discussion to improve the understanding of cardiac manifestations of Mpox. This scoping review sheds light on the underexplored cardiac manifestations of Mpox and highlights the need for heightened awareness of cardiac symptoms in the current outbreak.

Side effects and major adverse cardiac events caused by fractional flow reserve measurement: a systematic review and meta-analysis of 12,215 patients

Abstract Background Current guidelines recommend revascularization based on fractional flow reserve (FFR) in angiographically intermediate coronary stenoses. Side effects of FFR caused by adenosine administration are usually transient with little relevance. However, major adverse cardiac events (MACE), such as coronary artery occlusion, may infrequently occur as a consequence of intracoronary wire manipulation and little is known about their incidence. This systematic review aims to analyze the rate of side effects including MACE caused by FFR measurement as reported in large multicenter studies. Methods A PubMed database query for “fractional flow reserve” of the type “multicenter study” identified 348 records. Subsequently, one retracted record was excluded, another record was excluded as it contained no digital object identifier, 52 records were excluded since access could not be obtained, and one was a duplicate. Of the 293 records screened, only 15 contained relevant information on adverse effects or events due to FFR measurement and had included at least 100 patients. To systematically report the frequency of adverse events, the micro average for each event type was calculated across all studies where it was described. Results This systematic review includes data from 15 studies with a total of 12,215 patients. Measurement of FFR was successful in 99.1% (5,163 of 5,210). Hyperemia for FFR measurement was usually induced by adenosine, in most cases administered intravenously. Adverse effects are summarized in Figure 1. With 34.5% (778 of 2,257) of patients reporting chest pain or discomfort, this was the most common side effect of adenosine administration. Dyspnea was noted by 20.0% (250 of 1,250) of patients. Heart-rhythm disturbances occurred in 3.3% (185 of 5,646) of patients. More specifically, a transient atrioventricular block was reported in 2.6% (115 of 4,396) of patients, whereas ventricular arrhythmia was considerably less frequent with 0.2% (11 of 5,864). Hypotension was described by 0.9% (14 of 1,574) of patients, vomiting or nausea by 0.9% (11 of 1,250), and bronchospasm by 0.2% (11 of 4,836). MACE were infrequent, but not negligible: the pressure wire used for FFR measurement was reported to cause coronary artery dissection in 0.2% (8 of 4,158) of patients, coronary artery occlusion in 0.2% (4 of 2,381) of patients, and coronary artery perforation in 0.1% (2 of 3,228) of patients. Conclusions Chest pain, dyspnea, and transient arrhythmias are commonly experienced by patients in the context of adenosine but bear limited clinical relevance. The analysis of a large patient cohort revealed that MACE caused by vessel injury, while infrequent, occur at a rate of approximately 0.5% and should hence be considered relevant. Funding Acknowledgement Type of funding sources: None.

Cardiac arrest in non-ST segment elevation myocardial infarction: what to expect

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Ischemic heart disease is the leading cause of cardiac arrest (CA). While in ST segment elevation myocardial infarction its approach is well defined, in non-ST segment elevation myocardial infarction (NSTEMI) it is still a matter of debate. This study aimed to characterize patients with NSTEMI and out-of-hospital CA and to evaluate its prognosis. Methods This was a national multicenter retrospective study of patients hospitalized for NSTEMI undergoing coronary angiography (ANG) between October 2010 and September 2019. Results Out of a total of 9544 patients, 96 were admitted after CA. The baseline characteristics of both groups were similar, with the exception of more past history of heart failure (10,5% vs 5,6%, p=0,038) and peripheral artery disease (11,5% vs 5,9%, p=0,023) in patients with CA. In the peri-arrest period, 64,6% of the patients reported chest pain. Patients with CA had worse left ventricular ejection fraction (49±13% vs 53±12%, p=0,006), ended up reaching higher Killip classes more often and needing more inotropic and mechanical support. The median time from admission to ANG was similar in both groups (0 (0;3) vs 1 (0;2) days, p=0,796). CA patients had more multivessel coronary disease (66% vs 55,5%, p=0,043) and left main artery involvement (25,3% vs 11,2%, p<0,001). The proportion of revascularization procedures was similar. During hospitalization, patients with CA were less treated with beta-blockers (77,9% vs 85,2%, p=0,046) and ACE inhibitors (77,7% vs 86,1%, p=0,018), a difference that disappeared at discharge. However, statin prescription at discharge was lower in CA patients (88,3% vs 94,4%, p=0,040). In a multivariate analysis for events occurred during hospitalization, CA was associated with a significant increase in myocardial reinfarction (adjusted OR 5,42 (95% CI 2,10-1,98)), stroke (adjusted OR 5,38 (95% CI 1,24-2,32)) and death (adjusted OR 13,86 (95% CI 5,98-32,17)). After excluding patients with indication for an immediate invasive strategy, we verified that mortality was higher in CA patients who underwent ANG in the first 24 hours. CA was not associated with a significant increase in the 1-year mortality rate (adjusted HR 0,67 (95% CI 0,10-4,90)). Conclusions In this study, NSTEMI patients surviving CA had more severe coronary events. CA was independently associated with a significant increase in in-hospital major adverse events. However, during the 1-year follow-up there was no significant increase in mortality.

Three-dimensional mapping systems for radiofrequency catheter ablation of slow pathway for the treatment of atrioventricular nodal reentrant tachycardia: About 2 cases

Radiofrequency ablation (RFA) of the atrioventricular nodal reentrant tachycardia (AVNRT) is associated with the risk of complete atrioventricular (AV) block. This risk is majored by some anatomic conditions and remains a serious complication in young patients. Herein, we would like to report 2 cases of 3D mapping system use to guide RF ablation of AVNRT. This is a case of a 57-year-old man with a long medical history of atrial fibrillation (AF). He presented with palpitation and dyspnea. Physical examination was normal. On ECG, supraventricular tachycardia (SVT) with a heart rate of 144 beats per minute was noted. RFA was indicated because of the recurrence of this symptomatic tachycardia. CARTO 3D system mapping was used as the patient has a medical history of multiple ablated AF. RF delivery below the Coronary sinus (CS) ostium showed an accelerated junctional rhythm. No SVT was reproducible at the end of the procedure. A 50-year-old patient reported chest pain and dyspnea related to SVT. Physical examination and tranthoracic echocardiography were unremarkable. On ECG, a supraventricular tachycardia with long RP’ with ST depression was noted. Blood tests showed troponin elevation. Coronary angiography was normal. This patient had a long medical history of tachycardia that often starts and ends suddenly, not improved by beta-blockers treatment. RFA was indicated. RHYTHMIA Mapping system was used. The EP study reproduced the clinical tachycardia, which was a slow-slow AVNRT. RF delivery for 90 minutes below the CS ostium and 12 mm under the His bundle eliminated completely the slow pathway. The 3D mapping systems is an interesting tool for AVRNT RF ablation. It is correlated with lower radiation exposure and shorter procedure time. It may offer more security in young patient and those with a short distance between His bundle and CS ostium.

Abstract 11847: Acute Myocarditis Following COVID-19 mRNA Vaccination

Introduction: Acute myocarditis after coronavirus disease 2019 (COVID-19) mRNA vaccination is not well described. Recent public reports have signaled that this is an entity that requires ongoing surveillance. The goal of this study is to investigate myocarditis incidence following COVID-19 mRNA vaccination, and to report the clinical course and outcomes. Methods: This is a retrospective population-based cohort study performed at Kaiser Permanente Southern California (KPSC), an integrated health care system in California. Patients who received at least one dose of BNT162b2 (Pfizer) or mRNA-1273 (Moderna) mRNA vaccine were included. Clinically significant cases of acute myocarditis within 10 days of COVID-19 mRNA vaccination were identified between 12/14/2020 and 5/31/2021. Key demographic, clinical, laboratory, diagnostic data, and clinical course were obtained from medical record review. Results: Of 1,776,608 KPSC members who received at least one dose of COVID-19 mRNA vaccines, 12 developed acute myocarditis within 10 days following vaccination, for an estimated incidence of 6.6 cases per 1 million patients. All patients were relatively healthy White or Hispanic men between the ages of 18 and 40 years. Patients reported chest pain two to eight days after vaccine administration (Moderna N=5; Pfizer N=7). Eleven patients developed myocarditis after the second dose, and one after the first dose. Troponin I elevations ranged from 1.53-32.30 ng/mL. All cases were self-limited, with troponin peaking within 24-48 hours of admission and symptom resolution prior to discharge. None of the patients had evidence of decompensated heart failure. Length of stay was 1-4 days, with all patients discharged home and no recurrence, readmission, or major adverse cardiac events. Conclusions: Acute myocarditis after COVID-19 mRNA vaccination is a rare and self-limited event that warrants further description and investigation.

Clinical outcomes vary between the Shuttle Walk Test and Stress Test in patients with coronary artery disease

PurposeThe purpose of this study was to determine if the Incremental Shuttle Walk Test (ISWT) can elicit similar patient responses as a treadmill stress test in patients with coronary artery disease (CAD). MethodsBoth the stress test and the ISWT were performed by 172 participants, aged 60.67±10.23 years. We screened participants for unstable angina, severe aortic stenosis, uncontrolled hypertension, and excluded if unable to walk on a treadmill. Outcome measures (signs and symptoms) included: i) patient-reported chest pain; ii) patient-reported breathlessness/exhaustion and not being able to keep up with test protocol; and iii) able to reach target HRmax. Additionally, EKG changes during the stress test were monitored for ST changes or arrhythmias. ResultsDuring the stress test, 15 participants reported chest pain, 23 participants reached target HRmax. No participants reported chest pain and 2 participants reached target HRmax during the ISWT. Participants reporting chest pain had a higher mean BMI and significant difference in METS (p < 0.001) during the stress test and walking distance (p = 0.03) when compared with patients who did not report chest pain during the stress test. Breathlessness and not being able to keep up with protocol were the most commonly reported in both tests. Changes in EKG were observed in 38 participants in the stress test. ConclusionA maximal effort stress test is better at eliciting ischemic signs and symptoms and a superior tool for diagnosis of progression or severity of CAD than the ISWT. Appropriate selection of exercise tests is important in the clinical setting.

Abstract 14896: Air Embolism and St Elevation Myocardial Infarction: A Systematic Review

Introduction: Air embolism has rarely been associated with ST- elevation myocardial infarction (STEMI). Limited data exists on the risks, management and outcomes of this phenotype of STEMI to guide clinicians. Method: We queried EMbase, PubMed and Cochrane database for cases of air embolism associated with STEMI to better understand this association, its complications and outcomes. Results: We identified thirty-six cases of systemic air embolism events associated with STEMI. A mean age of fifty-nine with male predominance was identified. Patent foramen ovale was identified in 22%. Periprocedural air emboli occurred 66% (24/36) and miscellaneous causes including scuba diving and positive pressure ventilation accounted for 33% (12/36). Six patients reported chest pain, eleven developed shock and four suffered cardiac arrest. Neurological symptoms were reported in eighteen patients (50%). ST elevations were noted in all cases. CT angiography detected air bubbles in ten patients and seven were detected via cardiac catheterization. Transthoracic echocardiography detected air bubbles in a ventricular cavity in seven patients, and thirteen had air bubbles demonstrated on CT brain. Hyperbaric oxygen was delivered to eleven patients, nine of whom also received high flow oxygen. Seven were placed in Trendelenburg position and two had catheter aspiration of air bubbles. All patients received supportive treatment. Thirteen (36%) patients died. Conclusion: Patients with periprocedural STEMI and unexplained neurological symptoms should have air embolism considered in the differential. If identified, patients should be treated as per STEMI guidelines along with early delivery of 100% oxygen, in hyperbaric setting if available. If patient is hemodynamically unstable for catheterization, CT and echocardiographic imaging are reasonable alternatives to establish the diagnosis.

Symptom presentation of acute myocardial infarction – can we correctly identify patients with atypical symptoms of myocardial infarctions over the phone?

Abstract Introduction Acute myocardial infarction (AMI) can manifest itself with a variety of symptoms which can hinder early recognition of the disease, particularly when diagnosis is performed over the phone. It is currently unknown to what extent AMI patients are correctly recognized and quickly referred to treatment when calling for help at the emergency medical services (EMS) and out-of-hours service (OOHS). Therefore, we investigated how the symptom presentation of AMI patients affected their chances of being recognized. Purpose This study aimed to describe the symptoms reported by AMI patients when calling the EMS and OOHS and investigate to what extent these patients were correctly recognized and lastly, how the symptom presentation affected the survival. Methods All calls to the EMS and OOHS in the Capital Region of Denmark from 1st January 2014 to 31st December 2017 are included in this study resulting in 4,905,318 calls made by 1,313,980 people. A total of 5,526 people were identified with either a hospital admission with an AMI or an AMI as cause of death maximum 72 hours after a call to the EMS or OOHS. The main symptoms were registered by the EMS and OOHS personnel and we grouped the symptoms into symptom categories. Finally, a patient was defined as recognized if an emergency ambulance were dispatched. The unrecognized patients were separated into one group which were not referred to any treatment and another group that received none-urgent treatment. Results 72% of all AMI patients reported chest pain as their main symptom followed by breathing problems (7%) and unknown problems (5%). A total of 76% of all AMI patients were correctly recognized and received an emergency ambulance. The proportion of recognized AMIs was 88% at the EMS, but only 55% at the OOHS. The symptom presentation was highly associated with the help provided to the patient and less than 14% of patients reporting musculoskeletal pain, infection/fever or pain in stomach/back/intestine received an emergency ambulance. In comparison, 87% of patients with chest pain and 96% of unconscious patients received an emergency ambulance (Figure 1). Results from a multiple logistic regression showed that chest pain patients had the lowest risk of death at 30-days follow-up compared to all other symptom presentation. Conclusion 24% of AMI patients were not correctly recognized with an acute life-threatening disease when calling for help. Patients presenting without chest pain and unconsciousness had a much lower chance of being recognized. Similarly, patients calling the OOHS were less likely to be recognized compared to patients calling the EMS. Symptom presentations without chest pain had a dramatically increased 30-day mortality indicating that AMI patients with atypical symptoms truly are a high-risk patient group. Figure 1 Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): The Danish Heart Association

Coronary spastic angina after the administration of intravenous immunoglobulin in myasthenia gravis: a case report

BackgroundMyasthenia gravis (MG) is an autoimmune disease caused by antibodies that block or destroy nicotinic acetylcholine receptors at the neuromuscular junction. Most of MG patients need immunosuppression agents in addition to treatments that alleviate the symptoms. Intravenous immunoglobulin (IVIg) and plasma exchange are specific treatments given to patients with severe MG and myasthenia gravis crisis. IVIg therapy can cause an increase in serum viscosity; therefore, the risk for thromboembolic events, such as stroke, myocardial infarction, and pulmonary embolism, are reported after IVIg therapy.Case presentationAn MG patient was treated with pyridostigmine bromide and prednisolone. The patient’s symptoms worsened 26 days after the commencement of treatment and was presented with head drop and dyspnea. The patient was diagnosed with MG crisis and IVIg was initiated. However, the patient reported chest pain and dyspnea 3 days after IVIg had started. An electrocardiogram (ECG) revealed ST elevations in leads II, III, and aVF. A cardiac catheterization was performed and stenosis, obstruction, and sclerosis were ruled out. Glyceryl trinitrate relieved the patient’s symptoms, suggesting coronary spastic angina (CSA).ConclusionsWe report the first case of CSA after IVIg. Practitioners should be aware of the potential risks of CSA when administering IVIg for MG patients, in particular in old patients with vascular risk factors.

Myocarditis in a 16-year-old boy positive for SARS-CoV-2

A 16-year-old boy was admitted to our emergency department, in Lombardy, complaining of intense pain in his chest—radiating to his left arm—which had started 1 h earlier. The day before he had a fever of 38·3°C that decreased after 100 mg of nimesulide. He reported no other symptoms, no medical history, and no contact with anyone with confirmed COVID-19. We found his vital signs to be normal apart from his temperature which was raised at 38·5°C. On auscultation of the patient's chest, we heard normal heart sounds, no pericardial rub, and no abnormal respiratory signs. We found no lymphadenopathy, no rash, and no areas of localised tenderness on the chest wall. An electrocardiogram (ECG) showed inferolateral ST-segment elevation (figure) and a transthoracic echocardiography showed hypokinesia of the inferior and inferolateral segments of the left ventricle, with a preserved ejection fraction of 52%; no pericardial effusion was seen. Investigations showed raised high-sensitivity cardiac troponin I (9449 ng/L), creatine phosphokinase (671·0 U/L), C-reactive protein (32·5 mg/L), and lactate dehydrogenase (276·0 U/L) concentrations (appendix). The leucocyte count was 12·75 × 109 per L, the neutrophil count was 10·04 × 109 per L, and the lymphocyte count was 0·78 × 109 per L. We gave the boy aspirin to relieve his pain and transferred him to the coronary care unit with a working diagnosis of acute myocarditis. The patient's pain gradually improved and after 2 h had completely resolved. However, during the first night, he reported further chest pain; the ECG was repeated but no significant changes were seen (appendix). We started him on intravenous ibuprofen 600 mg three times a day and both his symptoms and raised temperature resolved. Tests for autoantibodies and cardiotropic viruses were negative (appendix). On day 3, a nasopharyngeal swab test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was positive, so we started hydroxychloroquine and antiviral therapy. Serial measurements of the patient's troponin concentration showed a gradual reduction from a peak of 16 862 ng/L on day 1, to 39 ng/L on day 8. The inflammatory markers also returned to normal and the ST-segment elevation on ECG resolved (appendix). On day 11—after nasopharyngeal swabs taken on 2 consecutive days were negative—MRI T2-weighted short-tau inversion recovery sequences showed changes supporting the diagnosis of acute myocarditis (figure; appendix). On day 12, he was well, asymptomatic, and allowed home. Notably, throughout the entire time he was in hospital, our patient did not have any of the signs or symptoms—apart from a fever—typically reported in COVID-19; his peripheral oxygen saturation levels remained within normal limits and two chest x-rays, on days 3 and 6, were clear (appendix). Paediatric patients reporting chest pain and other features suggestive of acute myocarditis—with or without respiratory symptoms—should, we believe, also be tested for SARS-CoV-2 (video). Contributors We were all involved in the care and management of the patient, and the writing and editing the manuscript. Written consent for publication was obtained from the patient and his parents. Download .pdf (1.67 MB) Help with pdf files Supplementary appendix eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIyZDRhMGZkNzJlNjBlMjUzMjE1Y2U0NjJiOGFjM2FkYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc0ODYxODkwfQ.jsi0EXkWppwei0D6Vj5VR619I_5i4O7xMhA9zHn_79yPDpo5FaLU1HSwJaoFLueT8SLN62sboN9uykXTu0mWTwxQrmTNSzFBTT3kyv_kUU52agHxApICwa6T6uGQX80JX78fpJpEWIrFaX3dn51lWcLJ16G01bfnMnHyNmqkc_fmXBw62qoKGsoHBl_RYLjU_aSKNaslY5AVn4kE7rGnSQ-MURic7OBrZMnRTWdEPx-rrgNLbIILQLCBWRcUGP28GOBqYVc14IGTst58n-P81h8rYXLkytDhTaaq8d290T06r-IqLxz-LXwRXriFUwZvcE3Meqk2dWwIpDOhyTEofQ Download .mp4 (30.68 MB) Help with .mp4 files Supplementary videoChest pain and fever in a teenage with SARS-CoV-2 positive nasopharyngeal swabChest pain and fever: myocarditis with Covid-19https://youtu.be/HtTB9mZkIDo

577 What Proportion of Ambulance Calls for Chest Pain Receive an Acute Coronary Syndrome Diagnosis?

The Medical Priority Dispatch System (MPDS) is a standardised system of protocols that assists ambulance dispatchers to identify chief complaints and assigning an appropriate emergency response. Callers reporting non-traumatic chest pain are allocated a protocol 10, the majority receive a Code-1(lights-and-sirens) response, and includes a tool that may result in self-administration of aspirin. However, the accuracy of protocol 10 correctly identifying acute coronary syndrome (ACS) is not well understood. We linked adult Victorian patients allocated a Protocol 10 between 2008 and 2015 to diagnoses from paramedics (in patients not transported), the Victorian Emergency Minimum Dataset (VEMD–in patients discharged from public ED), and the Victorian Admitted Episodes Dataset (VAED–in all patients admitted). Over this 8-year study, there were 350,169 Protocol 10 patients attended: 92% received a Code-1 response; 98% were transported to hospital; and 15% had a diagnosis of ACS. Among non-ACS cases there were 4492 different diagnoses, the most common being unspecified chest pain (37%), and 60% were admitted to hospital. Diagnoses where aspirin could be potentially harmful were rare but present (e.g. ruptured AAA, haemorrhage, SAH, GI bleeds). Chest pain is a broad presenting complaint, with many possible causes and ACS making up a small percentage. A significant proportion of patients reporting chest pain do not require a lights-and-sirens response, and for some aspirin may be harmful. Improving ambulance triage and the benefit/safety of aspirin administration in this group needs to be explored further.

Young patient with hantavirus-induced myocarditis detected by comprehensive cardiac magnetic resonance assessment

BackgroundWe report a case of hantavirus-induced myocarditis in a young adult. Hantavirus showed a rapid increase of infections in the year 2017. Only scarce data is available about potential myocardial involvement in hantavirus infections. With ECG and echocardiography providing often inconclusive results, a multiparametric cardiac magnetic resonance protocol with distinct myocardial tissue characterization seems to be the adequate tool for detecting even slight myocardial alterations.Case presentationThis case started with the presentation of young adult suffering from headache and abdominal pain. Thrombocytes were decreased, creatinine was elevated, and there was massive proteinuria. Puumala virus IgG ELISA turned out to be positive, and specific antibodies (IgG and IgM) could be detected in the serum, and confirmed by immunoassay. The patient was admitted to the nephrology department for supportive therapy. Few days later, the patient reported chest pain and dyspnea. High sensitivity troponin I rose up to 0.32 μg/l (normal range below 0.04 μg/l) with an increase of the creatinkinase to 319 U/l (normal max. 190 U/l), no dynamic ECG changes could be observed. Echocardiography revealed a normal left ventricular function without regional wall motion abnormalities, no pericardial effusion or valve abnormalities, coronary artery disease could be excluded by computed tomography. A multiparametric cardiac magnetic resonance protocol including recent mapping techniques confirmed myocardial involvement induced by acute hantavirus infection. In the next few weeks, the patient’s state of health rapidly improved and symptoms of chest pain and dyspnea disappeared. Follow up multiparametric CMR exam showed substantial decrease of the previously observed myocardial alterations during acute hantavirus infection suggesting myocardial healing.ConclusionsThis case demonstrates that a CMR protocol including recent mapping techniques and established late gadolinium enhancement technique is an adequate non-invasive tool for both 1) initial detection, and 2) follow up of patients with hantavirus-induced myocarditis, which might be more common than previously known.