Recurrent Chest Pain Research Articles

Extended radical resection and chest wall reconstruction for a pulmonary sarcomatoid carcinoma: a case report

BackgroundPulmonary sarcomatoid carcinoma (PSC) is a rare and highly malignant type of non-small cell lung cancer (NSCLC), for which the treatment of choice is surgery. For peripheral PSC growing outward and invading the chest wall, a complete resection of the affected lung lobes and the invaded chest wall can improve long-term prognosis. However, when the extent of the resected chest wall is large, reconstruction is often required to reduce the risk of postoperative complications. Here, we present a case of PSC invading the chest wall treated with successful extended radical resection for lung cancer and chest wall reconstruction.Case presentationA 58-year-old male patient with a nodule in the right upper lobe that had been identified on physical examination 2 years before presentation presented to our hospital with a recent cough, expectoration, and chest pain. Imaging revealed a mass in the right upper lobe that had invaded the chest wall. Preoperative puncture pathology revealed poorly differentiated NSCLC. We performed extended radical resection for lung cancer under open surgery and reconstructed the chest wall using stainless steel wire and polypropylene meshes. The procedure was uneventful, and the patient was discharged 7 days postoperatively. Furthermore, the final pathology revealed PSC.ConclusionsThis case underscores the feasibility of surgical R0 resection in patients with PSC with chest wall invasion and no lymph node metastasis, potentially enhancing long-term outcomes. The novel aspect of this case lies in the individualized chest wall reconstruction for a large defect, using cost-effective materials that offered satisfactory structural support and postoperative recovery, thereby providing a valuable reference for similar future surgical interventions.

Menstruation-Related Angina—The Wee Hours

AbstractLiterature reveals two kinds of menstruation-related anginas—cardiac syndrome X (CSX) and catamenial angina. CSX generally occurs in perimenopausal or postmenopausal women; catamenial angina affects females from puberty to menopause with existing/preexisting or predisposed to coronary artery disease. CSX involves recurring anginal-type retrosternal chest pains during exercise or rest with no significant findings on angiogram. Catamenial angina is menstruation-associated recurrent nonexertional left-sided chest pain alongside diaphoresis, hot flushes, and persistent lethargy. Pathophysiology of both anginas revolve around decreased levels of estrogen. Estrogen is known to act via genomic and nongenomic pathways on cardiomyocytes, endothelial cells, and smooth muscle cells to exert its cardioprotective effect. These cardioprotective effects could be lost during the postovulation phase and at the end of menstruation as well as during perimenopause or menopause owing to the decreased levels of estrogen. Evaluation should begin with a history and physical examination and focus on noninvasive tests such as exercise tolerance test, electrocardiogram, and echocardiogram. Reducing symptoms that cause discomfort and improving quality of life should be the main goal in management. Nitrates along with β blockers and analgesics for pain are the main pharmacologic modalities. Exercise training, smoking cessation, weight loss, and dietary changes are nonpharmacological modalities. Proper awareness and effective communication with patients or caregivers can lead to early diagnosis and treatment initiation.

Reasons for repeat urgent cardiac procedures within the same day.

With advances in technology and technique, the expectations are that patients undergoing procedures in the cardiac catheterization laboratory will not need to return for a repeat procedure within the same day. Report why subjects undergoing cardiac procedures return urgently to the catheterization laboratory for a repeat procedure during the same day. We retrospectively reviewed patients who were brought back to the cardiac catheterization laboratory within the same day for a repeat procedure. The reasons for index and repeat procedure were identified. Patients who were transferred from an outside center after an initial procedure at other centers were excluded. Between November 2013 and January 2022, 55,942 catheterization procedures were performed at our institution, of which 140 entries were included in our analysis. Common reasons for the index procedure were diagnostic angiography (35.0%), percutaneous coronary intervention (PCI, 29.2%), and transcatheter aortic valve replacement (15.0%). The most common reason for bringing these patients back to the cardiac catheterization laboratory within the same day was vascular complications (24.2%), followed by repeat PCI (20.7%), need for hemodynamic support (15.0%), heart team discussion and PCI (10%), and pacemaker implantation (10%). Acute limb ischemia was the most commonly identified vascular complication (7.1%), followed by pseudoaneurysm (5%). Our study demonstrates that a very small number of patients underwent repeat procedures within the same day. Special attention should be paid to vascular access and closure and assessment of recurrent chest pain postprocedure, as these are the main reasons for same-day repeat procedures.

Long-term prognostic factors for cardiovascular events in patients with chest pain without diabetes mellitus nor significant coronary stenosis.

Chest pain is the most common symptom of coronary artery disease (CAD) and diabetes mellitus (DM) is a well-known single strongest risk factor for cardiovascular diseases. Thus, the impact of CAD nor DM on long-term clinical effects is reported widely, but the prognostic factors of non-DM patients presenting with chest pain without significant CAD are limited. A total of 1,046 patients with chest pain without DM and significant CAD who underwent coronary angiography (CAG) and acetylcholine (ACH) provocation tests were finally enrolled. Propensity score matching and multivariate Cox-proportional hazard ratio analysis were performed to adjust for baseline potential confounders. Major adverse cardiac and cerebrovascular events (MACCE) were defined as the composite of total death, myocardial infarction (MI), revascularization, stroke, and recurrent angina. This study aimed to evaluate the long-term prognostic factors for MACCE in patients with chest pain without DM and CAD up to 5years. Coronary artery spasm (CAS) was the most common cause of chest pain. However, long-term MACCE of CAS was not worse than those of patients with chest pain without CAS when patients with CAS had subsequent optimal antianginal medication therapy. However, a recurrent chest pain remains a problem even with continuous antianginal medication therapy. Up to 5 years, the incidence of MACCE was in 7.3%, including recurrent angina 6.9%. Dyslipidemia (HR: 2.010, 95% CI 1.166-3.466, P = 0.012), mild-moderate (30-70%) coronary stenosis (HR: 2.369, 95% CI 1.118-5.018, P = 0.024), the use of aspirin (HR: 2.885, 95% CI 1.588-5.238, P < 0.001), and the use of nitrates (HR: 1.938, 95% CI 1.094-3.433, P = 0.023) were independent risk factors for MACCE. Among the patients with chest pain without DM and significant CAD, the incidence of MACE were rare, but recurrent angina was still a challenging problem who had treated with antianginal medications.

Lipoprotein (a) as a cause of premature coronary artery disease; a case report of a 34-year-old male patient presenting with ST elevation myocardial infarction.

Background&#x0D; Premature coronary artery disease (PCAD) is considered when coronary artery disease (CAD) occurs in the younger population, less than 45 years old in males. Modifiable risk factors are present in about 80% of patients with PCAD such as smoking, diabetes, high blood pressure and obesity. High serum lipoprotein (a) level has recently emerged as a risk factor for PCAD. However, it is not routinely investigated in young patients presenting with acute coronary syndromes.&#x0D; Case Presentation&#x0D; A 34-year-old African man presented to our hospital with 2 hours of worsening left sided chest pain. He gave a history of long-standing chest pain in the past that was being managed as peptic ulcer disease. He also complained of a slow heart rate. He had no traditional cardiovascular risk factors. The only significant history was a recent recovery from COVID-19 infection two months prior. His physical examination was only significant for a bradycardia, ECG revealed a hyper acute inferior STEMI without right ventricular involvement. Echo showed a normal left ventricle with reduced ejection fraction (EF: 50%), wall motion abnormalities consistent of an inferior MI. He immediately received streptokinase with good clinical and ECG response. His coronary angiogram showed a severe lesion and plaque rupture in the mid-distal segment of a dominant right coronary artery. Percutaneous coronary intervention (PCI) was successfully done, and one drug eluting stent was implanted. He was placed on guideline directed medical therapy for secondary prevention. The only significant possible aetiology found was an elevated Lipoprotein (a) (137mg/dl). Subsequent serum Lipoprotein (a) remained persistently elevated despite therapy with high dose niacin. He was recommended for a PCSK9 receptor blocker, but this medication is not available in the country and the patient could not meet the costs. He remains stable to current medications with no recurrence of chest pain, two years after the index event, the Lipoprotein (a) levels are still high.&#x0D; Conclusions:&#x0D; Lipoprotein (a) appears to be an important overlooked cardiovascular risk factor for premature coronary artery disease especially in the absence of traditional risk factors. It should always be considered in the screening of premature coronary cardiovascular disease. The acute presentation in this patient was probably triggered by SARS COV-2 infection.

МАГНИТНО-РЕЗОНАНСНАЯ ТОМОГРАФИЯ СЕРДЦА В ДИАГНОСТИКЕ МИКСОМЫ ЛЕВОГО ПРЕДСЕРДИЯ

Abstract. Introduction. Left atrial myxoma is one of the most common benign cardiac tumors. Myxomas occur most frequently in people aged 30-60 years. This tumor is one of the most difficult to diagnose due to the different density of its structure. Aim. To present our own clinical case report on choosing the strategy of managing a patient with left atrial myxoma. Materials and Methods. Female patient N., 66 years old, was admitted to the Department of Cardiology at City Clinical Hospital 7, Kazan on a referral from the polyclinic with complaints of recurrent burning chest pain radiating to the left arm and occurring during physical exertion (walking up to 50-100 m), accompanied by dyspnea; increase in blood pressure up to 180/100 mm Hg, heart performance disorders, heart palpitations, dizziness, and high-blood- pressure-associated headaches. When writing this article, the authors used the patient’s source documents (her case history). The article details the current disease history, clinical manifestations, examination findings, and the approaches to choosing the patient management considering her age and clinical manifestations. Results and Discussion. Clinical manifestations of the disease set on in January 2023 with dyspnea occurring during accelerated walking and burning chest pain. Before her admission to City Clinical Hospital 7, heart pain syndrome had recurred. In view of the clinical manifestations of acute coronary syndrome, the patient was prescribed coronary angiography that detected multivessel coronary artery disease. Echocardiography detected congenital heart disease: Secondary atrial septal defect. Thrombus? Myxoma? in the left atrium cavity. Magnetic resonance imaging of the heart was performed to verify the diagnosis. This technique allowed us to determine her accurate diagnosis: Left atrium myxoma; atrial septal defect. Conclusions. Practitioners will need these data to choose the strategy of managing patients with left atrial myxoma

Syntropy - gastroesophageal reflux disease and ischemic heart disease - diagnostic methods and treatment tactics

Introduction. Studies describe chest pain as the common symptom for the association of gastroesophageal reflux disease (GERD) and coronary artery disease (ICD). Among the patients evaluated at the emergency department for chest pain &gt;50% do not show signs of coronary ischemia and require further investigation. Materials and methods. The study was carried out by searching the articles that were published in the period 2016-2023, using the PubMed, NCIB, Medscape, Mendeley databases, using the keywords: „GERD”, „coronary artery disease”, „diagnosis” , „treatment”, as well as their association. Results. Both nosologies are clinically manifested by chest pain caused by gastrointestinal acid irritation, which activates the vagal reflex, and endothelial dysfunction, which causes ischemia and coronary vasoconstriction. Paraclinical findings are characterized by increased levels of IL1,6,8 and NO metabolites involved in disease pathogenesis. ECG and pH measurement for 24 h are sufficient at the first stage to determine the cause of attacks of recurrent chest pain. PPIs are the first line of treatment for chest pain relief in these patients. Conclusions. GERD and BCI represent diseases with a global impact, and the interdisciplinary therapeutic approach of these diseases, culminating in a targeted treatment program, determines the improvement of symptoms with an improvement of the patient’s quality of life.

Concomitant percutaneous coronary intervention and transcatheter aortic valve replacement for aortic stenosis complicated with acute STEMI: a case report and literature review

Aortic stenosis (AS) complicated with acute ST-segment elevation myocardial infarction (STEMI) is a life-threatening emergency with high mortality. A 75-year-old male patient attended the emergency department of Wuhan Asia Heart Hospital in December 2021 with chest pain for 2 days and exacerbation for 1 h. The electrocardiogram (ECG) indicated atrial fibrillation with rapid ventricular response and ST-segment depression. Echocardiography showed severe AS and mild/moderate aortic insufficiency. The patient refused coronary angiography and further invasive procedures and then requested discharge, but he had recurrent chest pain on the third day. The ECG showed an extensive anterior wall STEMI. During preoperative preparation, he suffered from cardiogenic shock (CS). Concomitant percutaneous coronary intervention (PCI) and transcatheter aortic valve replacement (TAVR) was performed, but he died of CS and multiple organ failure 4 days after surgery. Patients with AS and STEMI might be susceptible to CS during perioperative period of concomitant PCI and TAVR, which requires proactive prevention.

Navigating the Challenges of Takayasu Arteritis in a 26-Year-Old Female With Recurrent Chest Pain and a Complex Medical History

Navigating the Challenges of Takayasu Arteritis in a 26-Year-Old Female With Recurrent Chest Pain and a Complex Medical History

Long-term efficacy of tailored prolonged immunosuppressive therapy in biopsy-proven virus- negative myocarditis: a single center propensity weighted study

Abstract Background The efficacy of immunosuppressive therapy (IT) in biopsy-proven (BP) myocarditis was proved by small trials in lymphocytic myocarditis with heart failure (HF) presentation. Aim To evaluate the efficacy of IT in a single center cohort of BP myocarditis patients, irrespective of histological type and clinical presentation. Methods Consecutive BP myocarditis patients were included and, in the absence of contraindications, were treated with IT according to current guidelines on top of standard care. IT patients were compared with a propensity score-weighted control group of non-IT patients, considering age, gender, ejection fraction (EF), NYHA class and histological type (Fig. 1A). The primary outcome was a composite of death or heart transplant (HTx), and the secondary outcome a composite of variation of biventricular function, NYHA class and myocarditis relapse. Results 87 IT patients were compared with 265 without IT. IT patients were older (44 vs 39 years, p=0.035), and more frequently had a systemic immune-mediated disease (34% vs 10%, p&amp;lt;0.001), and HF (59% vs 46%, p=0.048) or fulminant presentation (9% vs 2 %, p=0.002). IT patients had lower baseline left ventricular (LV) EF both on echocardiography (35±15% vs 43±15%, p=0.001) and cardiac magnetic resonance (26±16 % vs 45.5±15 %, p=0.0013), lower right ventricular (RV) fractional area change (FAC: 34±11 % vs 41±11 %, p&amp;lt;0.001) and higher frequency of lymphocytic, eosinophilic and giant cell myocarditis (71% vs 58%, 11% vs 1 %, and 7% vs 2%, p&amp;lt;0.001 respectively) compared to non IT patients. IT was indicated because of unremitting HF (62%) and recurrent chest pain (14%), and mainly involved prednisone (PDN) and azathioprine as first-line (61%) and PDN and mycophenolate mofetil as second-line therapy (62%). IT lasted on average 24 months. No difference was observed in the primary outcome between the two groups (5 years survival 88% in IT vs 91% in non-IT patients, p=0.8, Fig. 1B), while relapse incidence was higher in IT patients (p&amp;lt;0.001, Fig.2B). At long-term follow up (54 months, IQR 21.4-96.45), LVEF and RV FAC were within the normal range in both groups, and propensity score weighting analysis showed that IT patients presented LVEF values of only 3% lower than non-IT (p=0.013, Fig. 2). In addition, IT patients had a similar probability of presenting the same NYHA class as non-IT patients at last follow up (p=0.46). Conclusions Our study shows for the first time the efficacy of prolonged tailored IT in BP lymphocytic and non lymphocytic autoimmune myocarditis, with or without HF and with or without RV dysfunction. IT patients, despite having lower biventricular function and a higher risk profile at baseline as well as a higher frequency of relapses, at long-term follow up showed normalized biventricular function and a similar survival compared to their propensity-score weighted controls. Thus, autoimmune myocarditis responds to IT, even when the disease relapses.Figure 1.Figure 2.

Abstract 18714: Myocardial Infarction With Non-Obstructive Coronary Artery Disease in a Young Woman - The Cardinal Role of Coronary Reactivity Testing in Unveiling the Underlying Etiology

43-year old female presented to the emergency department with substernal chest pain. She had similar symptoms years ago without obstructive CAD on coronary angiogram and was diagnosed with myocarditis. Presenting ECG revealed new anterolateral T wave inversions (Fig 1), and high-sensitivity troponins peaked at 322 ng/L consistent with NSTEMI. TTE was significant for global hypokinesis of the left ventricle with a reduced ejection fraction of 35 to 40%. Invasive coronary angiogram showed no obstructive CAD or spontaneous coronary artery dissection however there was reduced flow in the mid to distal LAD raising suspicion for endothelial and microvascular dysfunction. Contrast-enhanced cardiac MRI showed myocardial edema in the anterior and anteroseptal walls with elevated myocardial T1 and T2 values, and early enhancement post gadolinium administration showed an acute LAD territorial infarct (Fig 2). Findings were consistent with myocardial infarction with non-obstructive coronary artery disease (MINOCA). She was started on carvedilol for empiric treatment of coronary artery spasm and microvascular dysfunction, along with aspirin and atorvastatin. Losartan was added for heart failure management. Outpatient invasive coronary reactivity testing showed severe epicardial (70% vasoconstriction) and microvascular (80% decrease in coronary blood flow) endothelial dysfunction in response to acetylcholine (Fig 3 and Fig 4) as underlying etiology of recent MINOCA. CFR was normal. L-arginine (NO precursor) was added to the medical regimen. Patient has not had recurrence of chest pain or ACS at 1 year follow-up and LVEF normalized on repeat echocardiogram. This case shows the importance of cardiac MRI in confirming the diagnosis of MINOCA in patients with no obstructive CAD, and the crucial role of coronary reactivity testing in diagnosing and treating severe coronary endothelial dysfunction, which is aligned with the AHA/ACC MINOCA consensus document.

Abstract 16706: Women With Coronary Vascular Dysfunction Have Heightened Emotional Responses to Mental Stress With Attenuated Recovery

Introduction: Coronary vascular dysfunction (CVaD) is associated with major adverse outcomes, recurrent chest pain, and can be triggered by mental stress. Hypothesis: We hypothesized that women with CVaD have heightened emotional response and attenuated recovery compared to reference control (RC) women. Methods: Women diagnosed with CVaD (cases, n=57, age: 57±1 years) by abnormal adenosine or acetylcholine response during invasive coronary function testing were enrolled in Cardiac Autonomic Nervous System Study and compared to age-matched, asymptomatic RCs women (n=25, age: 56±3 years), free of cardiac or risk factor history. All underwent two 4-minute standardized mental stress tests - anger recall and mental arithmetic - followed by 15 minutes of recovery. Emotional arousal (tension, anxious, depressed) and chest pain were assessed via self-reported Likert scale at baseline, after stress, and after recovery. The difference between post-stress or post-recovery and baseline scores was used to evaluate stress provocation and recovery. Increased differences indicate more provocation or recovery attenuation. We utilized multivariate models adjusted for anti-anginal medications, statins, and aspirin or traditional cardiovascular risk factors and chest pain to assess associations between CVaD and chest pain or emotional arousal, respectively. Results: The two groups did not differ in hemodynamic response to mental stress (p&gt;0.05). In multivariate models, CVaD status was associated with more stress-provoked chest pain (β 1.24 [0.1, 2.4], p=0.03) and more attenuated chest pain recovery (β 1.5 [0.6, 2.3], p=0.001) than RC. Similarly, after adjustment, cases were associated with more stress-provoked anxiety (β 1.2 [0.2, 2.2], p=0.02) and tension (β 1.2 [0.001, 2.4], p=0.05) while having more attenuated recovery of anxiety (β 1.1 [0.1, 2.0], p=0.02) and tension (β 1.1 [0.2, 2.0], p=0.02) compared to RC. There were no differences in feelings of depression between the two groups. Conclusions: Response to mental stress is heightened with attenuated recovery in women with CVaD. An improved understanding of mechanisms in stress response and CVaD is needed for potential therapeutic targets that may improve angina and quality of life.

Abstract 15838: To Tear Again: Recurrent and Complicated Spontaneous Coronary Artery Dissection

Background: SCAD is as an infrequent cause of ACS with a predominance affecting a mean age of 42.6 years and 82% of patients being female. SCAD can be classified as primary or secondary, where primary dissections occur spontaneously, and secondary causes involve the aortic root and are a direct consequence of coronary interventions, surgery, or trauma. Case: 26-year-old female with no previous cardiac or significant family history presented with severe mid-sternal chest pain, radiating to both arms and back, and associated with nausea and cold sweats. Cardiovascular exam was unremarkable. Troponins were elevated at 0.18 and 0.59. Echo showed anteroseptal wall hypokinesis, consistent with Takotsubo cardiomyopathy. ECG showed anterolateral ST elevations. The patient went for cardiac catheterization and had spontaneous dissection of the left main into the LAD/diagonal with 100% occlusion of the LAD and 99% occlusion of the ramus/circumflex. Impella device was implanted due to persistent shock, V. fib., and cardiac arrest. Stents were placed in the proximal, mid, and distal LAD, ramus/circumflex, and LCA. The patient had an LVEF of 25%. Follow-up echo showed an LVEF of 30%, with subsequent Impella removal. Following week, LVEF increased to 45-50%. The patient began aspirin 81 mg, atorvastatin 10 mg, bisoprolol 5 mg, prasugrel 10 mg, and rivaroxaban 10 mg. Over the next few years, she had recurrent chest pain, syncope, palpitations, and a non-viable pregnancy at 12 weeks of gestation due to premature bleeding complications. 3 years after the initial SCAD, the patient presented with spiral dissection of the RCA, requiring three stents. LVEF was 30%. She is being managed with aspirin 81 mg, atorvastatin 20 mg, bisoprolol 10 mg, and prasugrel 10 mg. Discussion: The initial age of presentation of this patient makes this case unique. Risk of recurrent SCAD was present in 17% of patients at a median age of 2.8 years after the initial episode. Triggers for recurrent SCAD include extreme emotional/physical stress and pregnancy. Pregnancy it is not recommended in this patient population. Beta-blockade and adequate BP control are mainstay in medical management and reduce the reoccurrence of SCAD.

Abstract 17846: Successful Treatment of Recurrent Pericarditis With Rilonacept in the Setting Of ATRA/ATO Use in Acute Promyelocytic Leukemia

Case Presentation: A 40-year-old female was admitted for a 4-day history of recurrent left-sided pleuritic chest pain. Physical examination was pertinent for tachycardia and presence of a pericardial friction rub. Past medical history included recently diagnosed Acute Promyelocytic Leukemia undergoing active chemotherapy. Complete blood count showed leukopenia. Brain natriuretic peptide was slightly elevated at 241 pg/mL. Electrocardiogram demonstrated sinus tachycardia with diffuse ST-segment elevation and PR-segment depression (Figure 1. A). Echocardiogram showed normal biventricular function with a small posterior and lateral pericardial effusion and small pericardial effusion adjacent to the right ventricle (Figure 1. B). Cardiac magnetic resonance (CMR) imaging showed a moderate circumferential pericardial effusion and increased pericardial signal on T2 STIR imaging and late gadolinium enhancement (LGE) (Figure 1. C, D). Given the constellation of symptoms and findings, the patient was diagnosed with acute pericarditis secondary to differentiation syndrome (DS) suspected to be due to her underlying malignancy and anti-cancer treatments. She was started on aspirin and colchicine. Steroids and rilonacept were later added for incomplete treatment response. On follow-up, she was doing well. Repeat CMR demonstrated mild to moderate pericardial delayed enhancement with no edema and no pericardial effusion (Figure 1. E,F). Discussion: The presentation of DS can vary, and consensus diagnostic criteria are lacking. Cases of myopericarditis with concurrent pericardial effusions have been reported in the setting of patients undergoing chemotherapeutic treatment with differentiating agents. Management is complicated and requires multi-disciplinary care. Our case illustrates that rilonacept may be considered as an alternative to corticosteroids in the treatment of recurrent pericarditis in a patient with a hematologic malignancy.

Abstract 14382: Discovery of Magnetocardiography for Monitoring of Myocardial Injury Following Radiotherapy: A Case Report

Introduction: Radiotherapy, as one of the important management approaches for cancer, could induce the cardiomyocyte injury and increase the risk for cardiovascular diseases. However, early detection and identification of myocardial damage during radiotherapy is still challenging with routine methods. Magnetocardiography (MCG), a novel way to detect feeble magnetic fields formed by electrical activity of cardiomyocytes, is highly sensitive to the diagnosis of myocardial ischemia. Here, we present a case for whom the MCG changes observed during radiotherapy for thymoma. Case: The patient received radiotherapy for the tumor bed in the second month after transthoracoscope enlarged thymectomy and resection of the adherent tissues, with a total radiation dose of 50Gy/20F. The mean heart dose was 20.62Gy, and the volume of heart receiving greater than or equal to 30Gy is 31.77%. Comprehensive clinical biochemistry, ECG and echocardiography were taken before radiotherapy and presented without any abnormalities in cardiac structure and function. The magnetic field angle, character of positive and negative pole at T peak were also normal in magnetic field map before radiotherapy(Figure 1A). MCG and ECG were collected every week during radiotherapy. Nevertheless, during the whole 4 weeks, no significant abnormalities were found but the shape of positive and negative pole in magnetic field map became distorted gradually compared with the initial standard ellipse in MCG(Figure1B-D). Recurrent chest pain influenced the patient in the last two weeks either, which indicates the possibility of myocardial injury. Conclusions: Our case showed the possible minimal myocardial injury detected by MCG in the early stage of radiotherapy, while ECG is normal throughout the therapy. Therefore, our case may provide interesting insights into the potential of MCG for early detection of radiotherapy-induced myocardial damage, which deserves further validation study in the future.

Abstract 17755: Post-Cardiac Injury Syndrome From Robotic Atrial Septal Defect Closure: A Case of Recurrent Pericarditis

Case Presentation: A 23-year-old female rugby player presented for recurrent chest pain. She has a history of atrial septal defect (ASD) repaired with robotic ASD closure. She developed acute pericarditis postoperatively and was treated with naproxen and colchicine inpatient. Her subsequent recurrences occurred with playing rugby and were treated with ibuprofen, colchicine, and prednisone. Electrocardiogram showed sinus bradycardia at 59 beats per minute but without ST segment changes. Cardiac magnetic resonance (CMR) imaging showed mild-to-moderate circumferential pericardial late gadolinium enhancement (LGE) without signal hyperintensity on T2 STIR imaging. She was diagnosed with chronic recurrent pericarditis secondary to post-cardiac injury syndrome (PCIS) and was started on rilonacept. On follow-up after 1 year, the patient remained symptom-free. She gradually increased her activity level to walking 3 miles per day and weaned down to rilonacept monotherapy. Repeat CMR showed mild pericardial LGE that was improved from before. Discussion: PCIS is a known cause of pericarditis due to local and systemic inflammatory responses to cardiothoracic surgery. Robotic ASD closure is a minimally invasive endoscopic procedure that has a favorable safety profile; PCIS is not a previously documented complication. Treatment of pericarditis secondary to PCIS includes NSAIDs plus 3 months of colchicine for acute pericarditis, NSAIDs plus 6 months of colchicine for a first recurrence, with corticosteroids or interleukin-1 inhibitors added for further recurrences. Incomplete treatment of acute pericarditis, as in this patient's case, is a risk factor for recurrent pericarditis. The risk of recurrences with physical activity is debated and current guidelines recommend restriction from physical activity until there is no evidence of active disease, though the data is not robust. In clinical practice, a gradual return-to-play program is frequently utilized.

Abstract 16620: Long-Term Prognostic Factors for Cardiovascular Events in Patients With Chest Pain Without Diabetes Mellitus and Significant Coronary Stenosis

Background: Chest pain is the most common symptom of coronary artery disease (CAD) and diabetes mellitus (DM) is a well-known single strongest risk factor for cardiovascular diseases. Thus, the impact of CAD and DM on long-term clinical effects is reported widely, but the prognostic factors of non-DM patients presenting with chest pain without significant CAD are limited. Methods: A total of 1,046 patients with chest pain without DM and significant CAD who underwent coronary angiography (CAG) and acetylcholine (ACH) provocation tests were finally enrolled. Propensity score matching and multivariate Cox-proportional hazard ratio analysis were performed to adjust for baseline potential confounders. Major adverse cardiovascular events (MACE) were defined as the composite of total death, myocardial infarction (MI), and revascularization. Major adverse cardiac and cerebrovascular events (MACCE) were defined as the composite of MACE, stroke, and recurrent angina. This study aimed to evaluate the long-term prognostic factors for MACCE in patients with chest pain without DM and CAD up to 5 years. Results: Coronary artery spasm (CAS) was the most common cause of chest pain. However, long-term MACCE of CAS was not worse than those of patients with chest pain without CAS when patients with CAS had subsequent optimal anti-anginal medication therapy. However, a recurrent chest pain remains a problem even with continuous anti-anginal medication therapy. Up to 5-year, the incidence of MACCE was in 7.3%, including recurrent angina 6.9%. Dyslipidemia, ICS, the use of aspirin and nitrates were associated with long-term MACCE. Conclusions: Among the patients with chest pain without DM and significant CAD, the incidence of MACE were rare, but recurrent angina was still a challenging problem who had treated with anti-anginal medications.

A dominant pathogenic MEFV mutation causes atypical pyrin-associated periodic syndromes.

Pyrin, a protein encoded by the MEFV gene, plays a vital role in innate immunity by sensing modifications in Rho GTPase and assembling the pyrin inflammasome, which in turn activates downstream immune responses. We identified a novel and de novo MEFV p.E583A dominant variant in 3 patients from the same family; the variant was distinct from the previously reported S242 and E244 sites. These patients exhibited a phenotype that diverged from those resulting from classical MEFV gene mutations, characterized by the absence of recurrent fever but the presence of recurrent chest and abdominal pain. Colchicine effectively controlled the phenotype, and the mutation was found to induce pyrin inflammasome assembly and activation in patients' peripheral blood mononuclear cells (PBMCs) and cell lines. Mechanistically, truncation experiments revealed that the E583A variant affected the autoinhibitory structure of pyrin. Our study offers insights into the mechanisms underlying pyrin inflammasome activation.

S2317 Chilaiditi Syndrome: A Rare Case of Recurrent Chest Pain Due to Colonic Interposition

S2317 Chilaiditi Syndrome: A Rare Case of Recurrent Chest Pain Due to Colonic Interposition

Exploring the ECG "6+2" Phenomenon in Coronary Artery Disease and Coronary Artery Spasm: A Case Report Analysis and Treatment Implications.

BACKGROUND Although coronary artery disease and coronary artery spasm (CAS) can lead to acute myocardial infarction, there are clear differences in treatment between coronary heart disease and CAS, and the therapeutic schedule should not be confused. Furthermore, electrocardiogram (ECG) "6+2" phenomenon is recommend as a specific ECG indicator for lesions in the left main coronary artery or multiple vessels. Currently, no reports of this phenomenon in CAS exist. CASE REPORT A 72-year-old man had history of recurrent chest pain for over 6 years, with episodes lasting about 10 min and resolving with rest. He experienced symptom recurrence and exacerbation due to substance abuse. He was admitted to our Emergency Department for chest pain at rest. His emergency ECG revealed a 6+2 phenomenon, accompanied by troponin levels exceeding 18 times the reference value. Promptly, we conducted coronary angiography, with unexpected normal findings. Following thorough assessment, we postulated the patient could have CAS. Subsequent to medical team intervention, the patient's ECG normalized, leading to his discharge upon condition stabilization. CONCLUSIONS We report a case of CAS in a patient with ECG 6+2 phenomenon, without significant coronary artery stenosis. This differs from transient ST-segment elevation on ECG, a well-recognized hallmark of CAS; however, such a presentation has not been documented before. Additionally, treatment strategies for myocardial ischemic conditions stemming from coronary atherosclerosis diverge from those employed for CAS. Therefore, clinicians should advocate for coronary angiography whenever feasible. This approach serves to elucidate the underlying disease etiology and facilitates the administration of precision-targeted interventions for patients.