Retrosternal Chest Pain Research Articles

BN SO30 - One hundred consecutive Laparoscopic Heller's Cardiomyotomy & Fundoplication – a personal series

Abstract Background Oesophageal Achalasia (OA) is an uncommon primary oesophageal motility disorder, characterised by the loss of inhibitory neurons in the oesophageal myenteric plexus. The primary goal of treating OA is to alleviate dysphagia caused by the functional obstruction of the distal oesophagus due to the inability of the lower oesophageal sphincter (LOS) to relax appropriately after swallowing. Heller's cardiomyotomy (HCM) remains a standard treatment for OA. The aim of this study was to assess the symptomatic improvement and post-operative outcomes following HCM with fundoplication at our centre. Method All patients underwent HCM through laparoscopic blunt muscle separation technique, between January 2005 and March 2024, by a single surgeon. Retrospective review of electronic and compiled paper patient records were analysed to assess patient demographics, preoperative symptoms, operative details, length of stay (LOS), complications, post-operative symptoms, gastroscopy and pneumatic dilation (PD) as well as revisional surgery. Primary outcomes assessed were binary changes in key symptoms of weight loss, dysphagia, retrosternal pain and regurgitation. Comparison of pre and post-operative outcomes were performed using paired t-test. A p-value of <0.05 was considered statistically significant. Results 100 procedures involving 99 patients (average age 50 years, 43% female), 1 conversion to open and 1 revision at 3 years. ASA grades were 1 (27%), 2 (58%), and 3 (15%). Median LOS was one day, median follow-up 99 months. Post-operatively; weight loss persisted in 11% of patients from 48%, dysphagia reduced from 98% to 42%, retrosternal chest pain from 39% to 20% and regurgitation from 57% to 24% (all p<0.05). 2 patients required (PD) ≤30 days (CD≥3). 36 patients underwent PD at median of 13 months, 20 needed repeat PD. None of the patients developed cancer. Conclusion As demonstrated in this large series of 100 consecutive patients, HCM remains one of the best treatment modalities for OA. Key symptoms of OA significantly reduced following HCM. Our technique avoided the use of energy devices, ensured a short hospital stay and durable symptom improvement, lends support to its continued application in managing this condition.

Abstract 4145822: The Enigma of Chest Pain: Rare Presentation of ALCAPA Syndrome in a Young Adult

Introduction: Anomalous Left Coronary Artery Arising from the Pulmonary Artery (ALCAPA), also known as Bland-White-Garland syndrome, is a rare congenital anomaly(incidence:1 in 300,000 live births) typically presenting during infancy. Adult presentations are even rarer due to a high mortality rate of nearly 90% in the first year of life without surgical intervention. This report examines an adult patient with exercise-induced chest pain who received a delayed diagnosis of ALCAPA via multimodal imaging. Case Summary: A 21-year-old male presented to the emergency department(ED) with severe retrosternal chest pain radiating to both shoulders and arms, which began during exercise 30 minutes prior. He had a history of similar, milder episodes during exercise, previously treated as musculoskeletal pain and gastroesophageal reflux disease in the ED. His medical, social, and family histories were unremarkable. Physical examination revealed a soft, continuous murmur along the left sternal border. During this visit, An EKG done showed sinus tachycardia at 110 bpm and deep T-wave inversions in the anterolateral leads, a dynamic ST-T changes from his baseline.Serial Cardiac biomarkers and a lipid profile were within normal ranges. Initially managed for acute coronary syndrome-unstable angina with antithrombotic therapy, beta-blockers, and nitrates, he underwent urgent coronary angiography. This revealed a dilated right coronary artery (RCA) with retrograde flow to the left coronary artery (LCA) into the main pulmonary artery (PA) via collaterals, with no evidence of atherosclerosis (Figure 1).Echocardiography (Figure 2) and coronary CT angiography (Figure 3) confirmed the diagnosis of ALCAPA. The patient underwent successful surgical repair with aortic reimplantation of the LCA and was discharged in good health. Discussion: In adult ALCAPA patients, good collateral circulation may develop; however, myocardial ischemia can occur due to the "coronary steal phenomenon" and poor collateral flow regulation, leading to angina, arrhythmias, and sudden cardiac death. ALCAPA should be considered a differential diagnosis in adults presenting with exercise intolerance, as most sudden cardiac death cases occur by the fourth decade. A high index of clinical suspicion and a multimodality imaging approach is essential for the early diagnosis of this rare coronary anomaly, underscoring the critical role of early surgical intervention in preventing catastrophic, life-threatening events.

Sickle Cell Disease Revealed by Simultaneous Occurrence of Acute Coronary Syndrome and Pulmonary Embolism: A Case Report

The simultaneous occurrence of acute coronary syndrome (ACS) and pulmonary embolism (PE) in patients with sickle cell disease (SCD) presents notable diagnostic and management challenges. This case report describes a 25-year-old woman with SCD who, after an uncomplicated laparoscopic cholecystectomy, developed acute retrosternal chest pain, severe dyspnea, and tachycardia. Diagnostic workup included several key methods: thoracic CT angiography was performed, revealing massive bilateral pulmonary embolism and a pulmonary infarct. Echocardiography demonstrated myocardial abnormalities, such as wall motion defects and a mildly reduced ejection fraction. Electrocardiography showed ST-segment depression and T-wave inversions in the anteroseptal leads. To confirm the presence of coronary artery disease, coronary angiography identified significant thrombotic stenosis in the proximal left anterior descending artery. Sickle cell disease was confirmed through a positive sickle cell test, which identified the characteristic hemoglobin S. Despite aggressive treatment, the patient’s condition rapidly deteriorated, leading to death within 24 hours. This case underscores the critical role of a comprehensive diagnostic approach, including specific tests for SCD, in managing severe cardiovascular complications and highlights the need for tailored treatment strategies to improve patient outcomes.

Relationship between Ocular Manifestations and Chest pain: A frequency based analysis of Systemic and Ocular Signs in COVID-19 Patients

Objective: To find the frequencies of systemic and ocular signs in confirmed polymerase chain reaction (PCR) positive COVID-19 cases and to find association between ocular manifestation and systemic signs in Covid-19 patients. Study Design: A prospective cross-sectional study. Place and Duration: Department of Medicine and Ophthalmology, KRL Hospital Islamabad. The research lasted six months, from 1st January 2021 to 31st August 2021. Methodology: A total of 416 PCR-confirmed COVID-19 positive patients were included. As a sample strategy, purposive sampling was adopted. SPSS version 21 was used for statistical analysis. Descriptive statistics was calculated for continuous variables. Chi square test was applied to find association among systemic and ocular signs. Results: The study included 73% men, and 27% women. Patients presented with body aches 67%, sudden onset retrosternal chest pain 21.9%, abdominal pain 14.4%, ocular symptoms 10.3%, loss of taste 67%, and loss of smell 66.7%, loose motion 1.1% and shortness of breath in 1%. The patients' mean platelet counts were 230.30 ±65.63, mean lymphocyte counts were 3702 ±176, t mean total leucocyte counts (TLCs) were 7.524 ±5, and mean c-reactive protein (CRP) level was 21.816 with SD of ±25.992.Assessing the relation between ocular symptoms and other systemic symptoms, the Chi-square test revealed an insignificant relationship. However, it showed a significant association between chest pain and ocular symptoms with a p-Value 0.001. Conclusion: This study found a significant association between chest pain and conjunctivitis in COVID-19 patients, attributing chest pain to respiratory issues, inflammation, and blood clotting. Conjunctivitis was prevalent, especially in healthy, young individuals. Keywords: COVID-19, Chest Pain, Conjunctivitis, Ocular Symptoms.

MEDIASTINITIS, WHAT SHOULD WE KNOW: A CASE REPORT OF PNEUMOPYOTHORAX WITH SUSPECTED MEDIASTINITIS IN A 67-YEAR-OLD MALE

Mediastinal disease consists of various diagnoses that have different characteristics, and the severity is not the same. The mediastinal disease diagnosis is often delayed because of the non-specific and sometimes vague presentation and clinical symptoms. One of the commonly missed diagnoses is acute mediastinitis, which is usually presented with fever, pleuritic or retrosternal chest pain, and an inflammatory syndrome. Careful clinical evaluation and radiological correlation are essential when diagnosing mediastinitis, as well as the need to differentiate it from mediastinal infiltration due to malignancy. In this case report, we describe a 67-year-old male, who was referred with pyothorax, cough, and 10 kg of weight loss in the last 1 month. The patient then underwent a CT examination with contrast to establish the diagnosis. Finally, the patient was diagnosed with pneumopyothorax with suspicion of mediastinitis and abscess formation. The lessons learned from this case include the need for recognizing features of mediastinitis, such as fat stranding and fluid collection, which may contain gas locules, in the mediastinal region. The aim of this case report is to increase awareness of early signs of mediastinitis so that prompt management can be initiated as early as possible. Keywords: Mediastinitis, pneumopyothorax, CT thorax

Chest pain in pediatric patients in the emergency department- Presentation, risk factors and outcomes-A systematic review and meta-analysis.

This study aimed to assess and determine the presentation, risk factors, and outcomes of pediatric patients who were admitted for cardiac-related chest pain. Although chest pain is common in children, most cases are due to non-cardiac etiology. The risk of misdiagnosis and the pressure of potentially adverse outcomes can lead to unnecessary diagnostic testing and overall poorer patient experiences. Additionally, this can lead to a depletion of resources that could be better allocated towards patients who are truly suffering from cardiac-related pathology. This review was conducted per PRISMA guidelines. This systematic review used several databases including MEDLINE, Embase, Scopus, and Web of Science to obtain its articles for review. A total of 6,520 articles were identified, and 11 articles were included in the study. 2.5% of our study population was found to have cardiac-related chest pain (prevalence = 0.025, 95% CI [0.013, 0.038]). The most commonly reported location of pain was retrosternal chest pain. 97.5% of the study population had a non-cardiac cause of chest pain, with musculoskeletal pain being identified as the most common cause (prevalence = 0.357, 95% CI [0.202, 0.512]), followed by idiopathic (prevalence = 0.352, 95% CI [0.258, 0.446]) and then gastrointestinal causes (prevalence = 0.053, 95% CI [0.039, 0.067]). The overwhelming majority of pediatric chest pain cases stem from benign origins. This comprehensive analysis found musculoskeletal pain as the predominant culprit behind chest discomfort in children. Scrutinizing our study cohort revealed that retrosternal chest pain stands as the unequivocal epicenter of this affliction. Thorough evaluation of pediatric patients manifesting with chest pain is paramount for the delivery of unparalleled care, especially in the context of potential cardiac risks in the emergency department.

Heterogeneity of coronary vascular function and myocardial oxygenation in women with angina and non-obstructive coronary artery disease.

Women with angina and non-obstructive coronary artery disease (ANOCA) have a heightened risk for cardiovascular events, and the pathophysiology for ischaemic symptoms may be related to alterations in microvascular structure and function. We examined the use of breathing-enhanced oxygenation-sensitive cardiac magnetic resonance imaging (OS-CMR) using vasoactive breathing manoeuvres to assess myocardial oxygenation in women with ANOCA. We recruited women (aged 40-65 years) from two sites in Canada who presented to healthcare with persistent retrosternal chest pain and found to have ANOCA, or without a history of cardiovascular disease. All participants were scanned using a clinical 3T MRI scanner, and OS-CMR images were acquired over a breath hold following paced hyperventilation to measure global and regional measurements of heterogeneity. Fifty-four women with ANOCA (age: 55 ± 6.2 years) and 48 healthy controls (age: 51.2 ± 4.8 years) were recruited. There was no significant difference in volume, function, mass, or global myocardial oxygenation between the two groups [mean %Δ in signal intensity (SI): 4.9 (±7.3) vs. 4.5 (±10.1), P = 0.82]. Women with ANOCA had higher regional variations in myocardial oxygenation in circumferential [median %Δ in SI: 5.1 (2.0-7.6) vs. 2.2 (1.4-3.5), P = 0.0004] and longitudinal directions [median %Δ in SI: 11.4 (5.4-16.7) vs. 6.0 (3.0-7.0), P = 0.001], which remained present in a multivariate model. Heterogeneous myocardial oxygenation may explain ischaemic symptoms without any associated epicardial obstructive coronary artery disease. Regional variations in myocardial oxygenation on OS-CMR could serve as an important diagnostic marker for microvascular dysfunction in women with ANOCA.

Type A Aortic Dissection: A Call for Vigilance in Chest Pain Diagnosis

Introduction: Acute aortic dissection (AD) is a rare and life-threatening condition associated with high mortality rates in the absence of prompt intervention. This article provides an in-depth examination of the clinical presentation, diagnostic approach, and management of Stanford type A AD in a 62-year-old hypertensive female patient with atypical symptoms.
 Case Report: The patient presented with retrosternal chest pain and rapidly worsening dyspnea, demonstrating a 3/6 diastolic murmur over the aortic area. Diagnostic findings included negative T-waves on ECG, significant mediastinal widening on chest X-ray, and transthoracic echocardiography revealing an intimal flap, ascending aorta dilation, and acute aortic insufficiency. Computed tomography confirmed a Stanford type A aortic dissection.
 Discussion: Acute AD poses a diagnostic challenge, as atypical presentations can lead to misdiagnoses. The case emphasizes the importance of considering AD in the differential diagnosis of chest pain and conducting thorough investigations, especially when faced with unusual symptoms. Management strategies, encompassing both pharmacological and surgical interventions, are crucial for addressing AD promptly.
 Conclusion: This case underscores the significance of recognizing both typical and atypical presentations of AD to ensure timely intervention and avoid potentially catastrophic outcomes. A comprehensive understanding of diagnostic approaches and management protocols is essential in the emergency setting. Overall, this article contributes to the growing body of knowledge surrounding acute aortic dissection and emphasizes the critical need for awareness and rapid intervention in clinical practice.

COVID-19 vaccine-associated myocarditis in an adolescent after the third vaccine dose. Case report with follow-up

We report on the case of a 16-year-old boy with myocarditis developing after the third dose of COVID-19 mRNA vaccine. The patient presented with fever and retrosternal chest pain two days after immunisation. On admission, the boy was in good condition, with stable vitals. Elevated serum troponins and electrocardiographic repolarisation abnormalities with normal echocardiographic contractility were noted. Cardiac magnetic resonance imaging revealed active myocarditis in form of oedema with late gadolinium enhancement in five segments of the left ventricle myocardium. During further hospitalisation, rapid improvement in the patient’s general condition with normalisation of troponin level, and regression of electrocardiographic abnormalities were observed. In follow-up reassessments at three and nine months, cardiac magnetic resonance revealed residual myocardial lesions. No symptoms and abnormalities in laboratory tests, electrocardiography, or echocardiography were found. It is imperative to exercise full vigilance for COVID-19 vaccine-associated myocarditis when chest pain appears following vaccination, even in the absence of alarming symptoms after previous vaccine doses.

Abstract 12538: Myocardial Bridge Induced Cardiomyopathy

Introduction: A myocardial bridge(MB) is a condition in which the epicardial coronary artery traverses through the myocardium, has an intra-myocardial course of varying length, and then exits the myocardium and appears on the surface of the heart. Clinical Presentation: A 54-year-old male with no significant past medical history except tobacco abuse and anxiety presented to the hospital with retrosternal chest pain radiating to the back and shoulder and associated with nausea and diaphoresis. His SBP was 100/60, and his heart rate 46. His EKG showed ST elevation in inferior leads, and he was given a nitro tablet, which improved the chest pain to 5/10. He was emergently taken to the Cath lab and found to have proximal left circumflex artery occlusion and underwent PCI with a 2.25x23 Xience Drug-eluting stent. Troponin was elevated to 2.35. His cath also showed a significant mid-LAD myocardial bridge. His echocardiogram showed mid and apical anterior, anterior septal, apical wall, and inferior wall hypokinesis. His EF has been reduced to 30%. Coronary CTA showed mid-LAD has myocardial bridging, which is more than 2 cm long and 5 mm deep in the muscle. The patient has persistently low HR in 40-45, beta-blocker was not started. Due to significant cardiomyopathy induced by a myocardial bridge, unroofing of LAD was done off-pump. His EF improved to 55% after three months of surgery. Discussion: CABG or myotomy is the treatment of choice for patients with symptomatic myocardial bridging refractory to medical therapy, evidence of myocardial ischemia or infarction, or >75% systolic coronary compression on angiography. Incidental myocardial bridging finding without ischemia or symptoms does not require any treatment. Symptomatic patients with ischemia on stress tests can be offered beta or calcium channel blockers. Medical therapy is superior to revascularization with percutaneous intervention.

Non-cardiac Chest Pain in Japan: Prevalence, Impact, and Consultation Behavior - A Population-based Study.

Non-cardiac chest pain (NCCP) is defined as recurring angina-like retrosternal chest pain of non-cardiac origin. Information about the epidemiology of NCCP in Japan is lacking. We aim to determine the prevalence and characteristics of NCCP in the Japanese general population. Two internet-based surveys were conducted among the general population in March 2017. Questions investigated the characteristics of symptoms associated with chest pain and consultation behavior. Quality of life, anxiety, depression, and gastroesophageal reflux disease were analyzed. Five percent of the survey respondents reported chest pain. Subjects with chest pain showed higher frequencies of anxiety and depression and lower quality of life. Among subjects with chest pain, approximately 30% had sought medical attention for their symptoms. Among all consulters, 70% were diagnosed with NCCP. Females were less likely to seek consultations for chest pain than males. Further, severity and frequency of chest pain, lower physical health component summary score, and more frequent gastroesophageal reflux disease were associated with consultation behavior. Subjects with NCCP and cardiac chest pain experienced similar impacts on quality of life, anxiety, and depression. Among subjects with NCCP, 82% visited a primary-care physician and 15% were diagnosed with reflux esophagitis. The prevalence of chest pain in this sample of a Japanese general population was 5%. Among all subjects with chest pain, less than one-third consulted physicians, approximately 70% of whom were diagnosed with NCCP. Sex and both the severity and frequency of chest pain were associated with consultation behavior.

Endovascular treatment of chronic type b dissection at dong nai general hospital: A case report

Introduction: Chronic type B aortic dissection is a disease that can lead to false lumaen dilatation, which carries a risk of aortic rupture and sudden death. Endovascular intervention to treat this disease has been carried out at major centers in Vietnam. We report 1 case of endovascular intervention for chronic type B aortic dissection at Dong Nai General Hospital.[1]
 Case report: A 76-year-old male patient was admitted to the hospital because of incidentally finding of mediastinum dilatation on chest x ray. The patient had a history of severe retrosternal chest pain radiating to the back 3 months before admission. Computed tomography showed chronic type B dissection, primary entry point diameter of 16.3 mm, maximum aortic diameter of 46.6 x 47.7 mm. The patient underwent endovascular intervention, a 40 x 36 x 150 mm Medtronic Valiant Captivia graft was used, half of the left subclavian artery was covered. The results were good, the false lumen was partially thrombosed. The patient was discharged from the hospital in a stable condition 4 days after the intervention.
 Conclusion: Endovascular intervention for chronic aortic dissection at Dong Nai General Hospital can be applied safely. The implementation of this technique would benefit local patients and promote the development of the hospital.

SAT153 A Case Of Hypoglycemia-induced Chest Pain Secondary To Adult Nesidioblastosis: A Case Report

Abstract Disclosure: O.L. Medina Espitia: None. A. Quintero Altare: None. V.A. Clavijo: None. L.C. Martínez Delgado: None. The report of the present case in the medical literature is important in itself because of the infrequency of Nesidioblastosis. Additionally, it allows us to show unusual forms of presentation such as chest pain, and dynamic electrocardiographic changes in the ST segment with negative troponin, which coincide with episodes of hypoglycemia. At admission, the patient consulted the emergency department for a clinical presentation consisting of progressive retrosternal chest pain radiating to the left cervical region associated with dyspnea for medium exertion, palpitations, and dysautonomic symptoms, given by nausea. Due to episodes of chest pain, a coronary arteriography had been performed six months before admission without evidence of obstructive lesions. During hospitalization, episodes of hypoglycemia were observed. Remarkably, it was possible to document Dynamic ST changes in all EKG leads during episodes of hypoglycemia, as shown in Figure 1. Among the differential diagnoses, hypoglycemia secondary to adrenal or thyroid dysfunction was considered a first possibility, which was ruled out in the presence of normal paraclinical tests and medications that could generate hypoglycemia (negative sulfonylurea tests) were ruled out. A fasting test was performed with results showing endogenous hyperinsulinemic hyperinsulinemia with levels of insulin in 35.5 mg/dL, C-peptide 9.34 ng/dL and blood glucose 34 mm/dL. MRI of the abdomen without lesions. Due to a history of gastric bypass, endoscopic ultrasonography was not performed, therefore pancreatic calcium stimulation test was performed with evidence of a significant delta over the territory of the splenic artery. A distal pancreatectomy was obtained. Pathology report with findings suggestive of Nesidioblastosis (Figure 2.). There was a complete resolution of episodes of hypoglycemia and chest pain for two weeks. The recurrence of hypoglycemia episodes led to ambulatory treatment, with diazoxide with complete resolution of events. Presentation: Saturday, June 17, 2023

A comparison of different symptomatic reflux esophagitis treatments: A real-world study.

Proton pump inhibitors (PPIs) are currently the reference drugs for gastroesophageal reflux disease (GERD), but symptoms often recur after their withdrawal. Moreover, whether prokinetics or barrier drugs used alongside PPIs are more effective remains under debate. The aim of the study was to assess the efficacy of different therapeutic approaches to GERD treatment. We enrolled 211 grade A reflux esophagitis patients who consented to participate in this non-randomized, open-label trial. The study consisted of 6 sequentially administered medical treatments for GERD, lasting 2 months, with a 3-week washout period between each drug schedule: Group A: PPI (esomeprazole 40 mg/day before breakfast); Group B: mucosal protective drugs (a combination of hyaluronic acid, chondroitin sulfate and poloxamer 407, or a combination of hyaluronic acid, chondroitin sulfate and aluminum, 3 times daily after a meal); Group C: prokinetics (levosulpiride 25 mg or domperidone 10 mg, 3 times daily before a meal); Group D: barrier drug (alginate 3 times daily after a meal); Group E: PPI (esomeprazole 40 mg/day before breakfast) and mucosal protective drugs (a combination of hyaluronic acid, chondroitin sulfate and poloxamer 407, or a combination of hyaluronic acid, chondroitin sulfate and aluminum, before sleep); Group F: PPI (esomeprazole 40 mg/day before breakfast) and prokinetics (levosulpiride 25 mg or domperidone 10 mg before lunch and dinner). Symptoms were evaluated using the visual analogue scale (VAS) and global symptomatic score (GSS), as follows: heartburn: 0-3; retrosternal chest pain: 0-3; regurgitation: 0-3. All but 2 treatments (groups C and D) significantly improved VAS and GSS, with group E showing the most significant GSS improvement. Group C had the highest number of dropouts due to treatment failure and reported more side effects. Using PPIs and mucosal protective drugs resulted in significant symptom alleviation. However, the administration of prokinetics caused higher dropouts due to treatment failure.

Hypocalcemic tetany associated with simultaneous administration of cimetidine and nifedipine: a case report

BackgroundAcute hypocalcemia is generally caused by a sudden drop in serum calcium ion and presents with a mild or severe form of tetany. Even though the occurrence of hypocalcemia is well documented with certain drugs such as calcium chelators, bisphosphonates, and cisplatin, it is a very unusual and poorly documented adverse event with cimetidine and nifedipine. Here, we present a case of severe hypocalcemic tetany during simultaneous administration of cimetidine and nifedipine in a hypertensive patient with dyspepsia.Case presentationA 46-year-old known human immunodeficiency virus patient from Ethiopia on antiretroviral therapy over the past 14 years presented to the emergency department with acute exacerbation of dyspepsia and hypertensive urgency. She was given intravenous cimetidine (400 mg) and oral nifedipine (30 mg) simultaneously. One hour after the administration of these two drugs, she developed severe hypocalcemic tetany with carpopedal spasm, involuntary plantar flexion, and muscle spasms. She also had severe retrosternal chest pain and shortness of breath. Her blood pressure was 160/110 mmHg during the attack and she had no skin changes, such as urticaria. She was immediately given 1 g of calcium gluconate intravenously over 30 minutes. The carpopedal spasm progressively decreased during calcium gluconate administration. An hour later, she completely regained voluntary movement of her fingers and feet. The chest pain persisted, but resolved over the next 12 hours. The patient was discharged home after 2 days of observation. This is an unusual adverse effect that needs caution during concomitant administration of these drugs.ConclusionsSevere hypocalcemic tetany can occur with concomitant administration of cimetidine and nifedipine. Immediate treatment with calcium gluconate quickly reverses this adverse event. Concomitant administration of these drugs should be done with caution or be avoided if possible.

Spontaneous Pneumomediastinum Secondary to Undiagnosed Asthma inMilitary Adult.

Spontaneous pneumomediastinum (SPM) is a rare but described complication of exercise-induced bronchoconstriction (EIB), more commonly observed in children with asthma. We present a 23-year-old active duty military male and avid distance runner who developed progressive radiating retrosternal chest pain preceded by wheezing and coughing paroxysm. A chest computed tomography revealed extensive pneumomediastinum. SPM results from increased intrathoracic pressure with alveolar rupture and subsequent tracking of air between fascial planes. Like most cases of SPM, our patient remained hemodynamically stable and responded well to conservative therapies with complete resolution. After thorough evaluation, undiagnosed asthma was determined to be the inciting etiology. The patient is now well controlled and symptom free on a daily low-dose inhaled corticosteroid without SPM reoccurrence. In young adult patients presenting with SPM, EIB and asthma should be considered on the differential diagnosis as appropriate medical therapy will improve symptoms and reduce risk of reoccurrence.

C55 A GIANT PSEUDOANEURYSM OF MITRAL–AORTIC INTERVALVULAR FIBROSA PRESENTING AS RECENT–ONSET ANGINA AND CARDIAC ARREST DUE TO VENTRICULAR FIBRILLATION

Abstract A 66–year–old man was suddenly referred to the emergency department (ED) for an extra–hospital cardiac arrest due to ventricular fibrillation, promptly treated by a single DC shock. Four months prior, he had undergone aortic valve replacement with a biological valve prosthesis (BVP, Perimount Magna n. 23) for severe aortic stenosis. One month after cardiac surgery the patient was hospitalized for acute cholecystitis requiring antibiotics and percutaneous cholecystostomy. On arrival to the ED the patient was awake and completely asymptomatic; no fever during days before the episode. He had been complaining of constricting retrosternal chest pain during physical exertion for ten days. However, no signs of ischemia were seen on the EKG. TT echo showed a very large pulsatile anaechogenic area posteriorly to BVP. Transesophageal echocardiography (TEE 2D, Traditional 3D and TrueVue) highlighted a very large pseudoaneurysm of mitral–aortic interventricular fibrosa (P–MAIVF; Figures 1 and 2, long axis and short–axis views). TEE features included: 1) a very large cavity with thickened walls, extended for more than two–thirds of the prosthetic circumference and with multiple septa; 2) a large communication between the left ventricular outflow tract (LVOT) and P–MAIVF (see yellow dotted line in Fig.1A) with a to–and–fro flow into the cavity and a prominent systolic pulsation; 3) no paraprosthetic leak and absence of any attached mass or intraprosthetic aortic regurgitation. These findings suggested a prosthetic aortic valve endocarditis with an extensive periannular involvement. Moreover, the P–MAIVF may have led to “ab extrinseco” compression of the left coronary artery, with a potential role in the genesis of chest pain and ventricular arrhythmia (in absence of significant CAD at preoperative coronary angiography). An empiric antibiotic therapy with daptomycin and piperacillin–tazobactam was started. The patients subsequently underwent Bentall surgery with a subannular implantation technique (Perimount valvular prosthesis n.23 and Gelweave vascular prosthesis n.28). Figure 3 shows an intraoperative image and postoperative TEE. In conclusion, P–MAIVF is an ominous complication of prosthetic valve endocarditis. Presentation with exertional angina and cardiac arrest is unusual. TEE is sensitive for diagnosis and 3D echo provides better insights into the anatomy helping formulate an appropriate surgical strategy.

COVID-19 a Possible Cause of Myocarditis and Pericarditis: About A Case

Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) is an unparalleled challenge for the healthcare community across the globe. Angiotensin-2 converting enzyme receptors play a central role in the pathogenesis of the virus. Disruption of this receptor results in cardiomyopathy, cardiac dysfunction, and heart failure. Pericarditis is described as another cause of morbidity in patients with COVID-19. The exact mechanisms of how SARS-CoV-2 can cause myocardial damage are not clearly understood. We report the case of a 72-year-old man presenting for 17 days with retrosternal chest pain suggestive of pericarditis associated with a dry cough and a decline in general condition. He has had exertional asthma and active smoking as a history. He is taken care of in the emergency room. His clinical examination found a patient hemodynamically and respiratory stable, afebrile with a normal somatic examination apart from crackling rales. The biological assessment shows an inflammatory syndrome with slightly increased troponins HS. The scan performed in the emergency room notes typical pulmonary involvement moderate to COVID-19 and low-abundance pericardial effusion confirmed by echocardiography. The COVID-19 nasopharyngeal smear was positive. We conclude in an acute peri-myocarditis with COVID-19. The clinical and biological outcome is rapidly favorable with colchicine.

MEDIASTINAL PSEUDOCYST: A RARE ASYLUM FOR A COMMON DISEASE

Pseudocyst is one of the commonest complications following pancreatitis. However, a mediastinal pseudocyst is a rare entity which demands a high index of suspicion for diagnosis. We report a case of a 42 years old male who presented to the emergency with cough, retro-sternal chest pain, progressive dysphagia and vomiting. He was a chronic alcoholic with multiple hospitalisations in past 4 years for recurrent episodes of severe acute pancreatitis. There was left sided pleural effusion on chest radiograph and extrinsic compression of distal oesophagus and proximal stomach from posterior aspect on endoscopy. Abdominal computed tomography (CT) revealed a large pseudocyst abutting the body of pancreas and extending superiorly into the mediastinum. Patient was treated conservatively and given total parenteral nutrition followed by Ryle's tube feeding. He improved, started accepting orally and was discharged. Patient was asymptomatic on follow up and repeat CT scan after 6 weeks showed signicant decrease in the size of collection

Focused Chest Pain Assessment for Early Detection of Acute Coronary Syndrome: Development of a Cardiovascular Digital Health Intervention.

Chest pain misinterpretation is the leading cause of pre-hospital delay in acute coronary syndrome (ACS). This study aims to identify and differentiate the chest pain characteristics associated with ACS. A total of 164 patients with a primary complaint of chest pain in the ER were included in the study. ACS diagnosis was made by a cardiologist based on the WHO criteria, and the patients were interviewed 48 hours after their admission. Furthermore, every question was analysed using the crosstabs method to obtain the odds ratio, and logistic regression analysis was applied to identify the model of focused questions on chest pain assessment. Among the samples, 50% of them had an ACS. Four questions fitted the final model of ACS chest pain focused questions: 1) Did the chest pain occur at the left/middle chest? 2) Did the chest pain radiate to the back? 3) Was the chest pain provoked by activity and relieved by rest? 4) Was the chest pain provoked by food ingestion, positional changes, or breathing? This model has 92.7% sensitivity, 84.1% specificity, 85% positive predictive value (PPV), 86% negative predictive value (NPV), and 86% accuracy. After adjusting for gender and diabetes mellitus (DM), the final model has a significant increase in Nagelkerke R-square to 0.737 and Hosmer and Lemeshow test statistic of 0.639. Focused questions on 1) left/middle chest pain, 2) retrosternal chest pain, 3) exertional chest pain that is relieved by rest, and 4) chest pain from food ingestion, positional changes, or breathing triggering can be used to rule out ACS with high predictive value. The findings from this study can be used in health promotion materials and campaigns to improve public awareness regarding ACS symptoms. Additionally, digital health interventions to triage patients' suffering with chest pain can also be developed.