Retrosternal Chest Pain Research Articles

Multiparametric assessment of myocarditis using simultaneous positron emission tomography/magnetic resonance imaging

A 19-year-old man presented with general malaise, retrosternal chest pain, and palpitations. ECG demonstrated a flattening of T-waves in pre-cordial leads. Laboratory measurements showed elevated troponin I (6.6 ng/mL) and creatine kinase (477 U/L). Histopathological analysis of three samples taken from the right ventricle (RV) via endomyocardial biopsy (EMB) was unsuspicious, but polymerase …

A case report of acute myocardial infarction concomitant with Standford type B aortic dissection

BackgroundAcute myocardial infarction (AMI) concomitant with aortic dissection (AD) is rare but a devastating situation if misdiagnosed as simply AMI, followed by anticoagulant or thrombolytic therapy. In such cases, Standford type B AD was extremely infrequent. ObjectivesTo present a case with apparent concordance with the patient's history, symptoms, cardiac enzymes that lead to diagnostic error. Case reportAn 85-year-old man with chronic hypertension and coronary atherosclerotic heart disease presented in our emergency department with squeezing retrosternal chest pain and dyspnea. Elevated cardiac enzymes and electrocardiography result suggested acute non-ST-segment elevation myocardial infarction. Emergency coronary angiography demonstrated a 50–90% diffuse stenosis of the proximal and mid right coronary artery also confirmed the diagnosis. Stents were deployed thereafter. However, the patient was found to be concomitant with Standford type B AD by computed tomography angiography due to unrelieved chest pain and new onset of abdominal pain after the operation. The patient refused to have endovascular operation and died of hemorrhagic shock one week later. ConclusionsAD may cause AMI due to some indirect mechanisms, and it is of utmost importance to search for the existence of AD before reperfusion therapy in AMI patients. Aortic dissection detection risk score, transthoracic echocardiography and D-dimer help early identification of AD.

Idiopathic acute myocarditis during treatment for controlled human malaria infection: a case report

A 23-year-old healthy male volunteer took part in a clinical trial in which the volunteer took chloroquine chemoprophylaxis and received three intradermal doses at four-week intervals of aseptic, purified Plasmodium falciparum sporozoites to induce protective immunity against malaria. Fifty-nine days after the last administration of sporozoites and 32 days after the last dose of chloroquine the volunteer underwent controlled human malaria infection (CHMI) by the bites of five P. falciparum-infected mosquitoes. Eleven days post-CHMI a thick blood smear was positive (6 P. falciparum/μL blood) and treatment was initiated with atovaquone/proguanil (Malarone®). On the second day of treatment, day 12 post-CHMI, troponin T, a marker for cardiac tissue damage, began to rise above normal, and reached a maximum of 1,115 ng/L (upper range of normal = 14 ng/L) on day 16 post-CHMI. The volunteer had one ~20 minute episode of retrosternal chest pain and heavy feeling in his left arm on day 14 post-CHMI. ECG at the time revealed minor repolarization disturbances, and cardiac MRI demonstrated focal areas of subepicardial and midwall delayed enhancement of the left ventricle with some oedema and hypokinesia. A diagnosis of myocarditis was made. Troponin T levels were normal within 16 days and the volunteer recovered without clinical sequelae. Follow-up cardiac MRI at almost five months showed normal function of both ventricles and disappearance of oedema. Delayed enhancement of subepicardial and midwall regions decreased, but was still present. With the exception of a throat swab that was positive for rhinovirus on day 14 post-CHMI, no other tests for potential aetiologies of the myocarditis were positive. A number of possible aetiological factors may explain or have contributed to this case of myocarditis including, i) P. falciparum infection, ii) rhinovirus infection, iii) unidentified pathogens, iv) hyper-immunization (the volunteer received six travel vaccines between the last immunization and the CHMI), v) atovaquone/proguanil treatment, or vi) a combination of these factors. Definitive aetiology and pathophysiological mechanism for the myocarditis have not been established.

Diagnosis and management of pheochromocytoma

Pheochromocytoma are neuroendocrine tumors that arise from sympathetic chromaffin cells within the adrenal medulla. They principally secrete catecholamines, potentially causing life-threatening cardiovascular complications. A myriad of symptomatology and clinical findings are associated with pheochromocytoma, including a catecholamine-induced dilated cardiomyopathy.A 50-year-old woman presented with retrosternal chest pain and underwent diagnostic evaluation for acute coronary syndrome. Cardiac catheterization demonstrated patent coronary arteries and a pattern of ventricular hypokinesis consistent with takotsubo cardiomyopathy, also known as broken heart syndrome. Further imaging with abdominal CT revealed an adrenal mass. Laboratory markers supported the clinical picture of pheochromocytoma. Right adrenalectomy was performed and our patient was symptom-free at discharge on post-operative day three.Alpha and beta adrenergic blockade are used in a critical care setting to prevent perioperative hemodynamic instability as well as catecholamine-induced heart failure in the setting of pheochromocytoma. Patients commonly require vasopressors in the postoperative period due to the rapid reduction in circulating catecholamines following resection. Discharge planning should include recommendations for genetic counseling to screen for syndromic causes of pheochromocytoma that increase the risk for other neoplasms.We present a case report of a rare adrenal tumor in a middle-aged woman that manifested as acute coronary syndrome. A presumptive diagnosis of takotsubo cardiomyopathy on cardiac catheterization led to further investigation. Abdominal imaging located an adrenal mass that correlated with laboratory studies positive for high levels of catecholamines and their metabolites. The tumor was excised and the patient recovered without complications.

Spontaneous pneumomediastinum with a rare presentation.

Spontaneous pneumomediastinum is an unusual and benign condition in which air is present in mediastinum. A 20-year-old male patient presented to ED with complaint of hoarseness and odynophagia from the day before, after weightlifting. The patient was nonsmoker and denied history of other diseases. On physical examination he had no dyspnea with normal vital signs. Throat examination and pulmonary auscultation were normal and no crepitation was palpable. We could not find subcutaneous emphysema in neck and chest examination. In neck and chest X-ray we found that air is present around the trachea. There was no apparent pneumothorax in CXR. In cervical and chest CT free air was present around trachea and in mediastinum. Subcutaneous emphysema was also evident. But there was no pneumothorax. The patient was admitted and went under close observation, oxygen therapy, and analgesic. The pneumomediastinum and subcutaneous emphysema gradually resolved within a week by conservative therapy and he was discharged without any complication. Many different conditions could be trigged because of pneumomediastinum but it is rarely seen in intense physical exertion such as weightlifting and bodybuilding. Two most common symptoms are retrosternal chest pain and dyspnea. But the patient here complained of hoarseness and odynophagia.

Spontaneous Pneumomediastinum Complicating with Asthma

Spontaneous pneumomediastinum is an uncommon disease that is defined as the presence of free air in the mediastinum in the absence of any obvious precipitating cause. This condition occurs as a rare complication of acute exacerbation of asthma. Classic symptoms include retrosternal chest pain, dyspnea and cough, but are not specific. Spontaneous pneumomediastinum complicated by asthma is usually self-limiting and well controlled with conservative management, but this condition can be potentially life threatening. We report a case of 18-year-old woman with asthma who presented with spontaneous pneumomediastinum. The patient was treated conservatively with oxygen and steroid therapy, and her clinical conditions were improved. Spontaneous

A novel method to remove an impacted sharp foreign body in the esophagus of an infant

Irregular and sharp foreign bodies in the esophagus are difficult to remove and carry a significantly high morbidity especially if a pointed object is lodged in the esophagus. Improper extraction technique may result in complications including bleeding and perforation. We describe a case of successful removal of an impacted earring where the earring post was lodged in the esophagus. A 19-month girl was noted by her parents that she cried on swallowing and complained of retrosternal chest pain and odynophagia on swallowing. She did not have any coughing, shortness of breath, or fever. Her mother reported that the baby had accidentally swallowed an earring some 15 hours earlier. The baby’s clinical condition was stable on admission. A chest X-ray revealed a metal foreign object (earring) in the esophagus and with the post seen lodged against the esophageal wall (Fig. 1). Computed tomography (CT) chest showed no mediastinal free air (Fig. 2). An upper endoscopy was performed under general anesthesia with endotracheal intubation. This revealed the presence of an earring in the upper esophagus with its post lodged and embedded in the esophageal wall at 19 cm from the incisor (Fig. 3). There was localized mucosal edema and punctate erosions in the esophagus. An attempt made to extract the earring using grasping forceps failed and there was concern over laceration of the esophageal wall because of the sharp post. We pushed the earring forward into the fundus of the stomach (Fig. 4) using a pair of forceps and the endoscope (GIF-Q260; Olympus, Tokyo, Japan). Repeated attempts at removal of the foreign body from the stomach using grasping forceps failed because of the size and the pointed post on the earring. Finally, a mechanical lithotripter (BML-V437QR-30; Olympus), normally used for fragmenting and removing biliary stones, was inserted into the stomach through scope. The basket was opened to engage the stopper on the post and the earring, and traction was applied to the basket wires to break off the post and stopper from the main body of the earring (Fig. 5). These were then removed separately using forceps. The main part of the earring measured 2.0 cm × 1.2 cm Figure 2. computed tomography (cT) chest showing no mediastinal free air

Migration of a fractured inferior vena cava filter strut to the right ventricle of the heart: a case report

A 23 year old woman presented with sudden onset retrosternal chest pain following an attempt to move a heavy object from her vehicle. Multiple fractured struts of an inferior vena cava filter were identified in the distal right and left pulmonary artery branches, and in the free wall of the right ventricle. A small pericardial effusion was noted. Because of the depth of penetration into the right ventricle, it was perceived not to be amenable to endovascular retrieval. Over several days of observation, she continued to have progressive retrosternal and left shoulder pain. She underwent exploratory sternotomy and extraction of a strut that was partially protruding from the right ventricle and abrading the diaphragmatic pericardium. The patient recovered quite well and was discharged on the third postoperative day.

A 19-year-old girl with ostial coronary lesions

A 19-year-old girl presented with retrosternal chest pain at rest associated with nausea and vomiting. She had excertional chest pain of three days’ duration. She had no past history of hypertension, diabetes or smoking. Her vital signs were stable. She weighed 53 kg and was 156 cm tall. Her body mass index was 21.7 kg/m2. On physical examination, she had extensive xanthomatosis on the extensor surfaces (knees and elbows), her buttocks and ankles, and swelling and erythema over her first and fifth metatarsophalangeal joints (Figs. 1, 2). There was a history of sudden death in her only sibling, an 18-year-old brother several years earlier. ECG showed diffuse and down-sloping ST segment depression in inferior and precordial leads along with ST segment elevation of 3 mm in avR (Fig. 3). Anti-ischaemic therapy was initiated and the patient was admitted to the Coronary Care Unit. Echocardiography showed global left ventricular ejection fraction of 45% with hypoplastic aortic root without aortic stenosis. Laboratory studies showed elevation of cardiac troponin I and creatinine kinase-MB. Lipid profile was total cholesterol of 570 mg/dL, HDL of 30 mg/dL, LDL of 522 mg/dL. Triglycerides levels were normal. She was scheduled for immediate coronary angiography. Non selective contrast injection in aortic root showed narrowing of aortic root and ostial lesion in the left main artery (Fig. 4). Right coronary injection showed ostial lesion in the right coronary artery. The patient had episodes of chest pain despite medical therapy and was scheduled for urgent coronary artery bypass grafting (CABG). During surgery, both coronary arteries had ostial lesions and CABG was performed. The patient was prescribed lipid-lowering therapy and referred for LDL aphresis on discharge. At six months follow-up, the patient remains well. Multiple xanthomas, high serum levels of LDL, and premature atherosclerosis are indicative of familial hypercholesterolaemia.

VALUE OF SPECIFIC PARAMETERS AND INTEGRATIVE INDICES OF TREADMILL TEST FOR THE ASSESSMENT OF CORONARY STENOSIS SEVERITY

Aim.To assess the value of specific parameters and integrated indices (II; such as Duke Index (DI), Centre for Preventive Medicine Index (CPMI), and modified CPMI) of the treadmill test in the diagnostics of coronary stenosis severity among patients with stable coronary heart disease (CHD).Material and methods.The study included all patients (260 permanent residents of Moscow City or Moscow Region) who were admitted to the State Research Centre for Preventive Medicine with the CHD diagnosis and who underwent coronary angiography (CAG) and treadmill test in the period between January 1st 2004 and December 31st 2007.Results.There were statistically significant associations between the main treadmill test parameters and the severity of coronary artery (CA) atherosclerosis. The larger number of stenosis-affected CA was associated with a higher prevalence of chest pain and treadmill tests with positive results and ST segment depression >1 mm, as well as with a decreased total duration of treadmill test. Similarly, the increased risk, as assessed by treadmill test indices (DI, CPMI, and modified CPMI), was linked to an increased number of stenosis-affected CA. Modified CPMI demonstrated the highest diagnostic value for the assessment of coronary atherosclerosis severity.Conclusion.The treadmill test parameters which demonstrated their diagnostic value for the assessment of CHD severity included the following: positive test results, retrosternal chest pain as the reason for test discontinuation, ST segment depression >1mm, and short total duration of the test. Overall, all II demonstrated their high value in CHD diagnostics. Modified CPMI was the most effective II in the assessment of CA atherosclerosis severity.

Primary Angioplasty in Patient with St-Segment Elevation Myocardial Infarction in the Setting of Intentional Carbon Monoxide Poisoning

BackgroundST-segment elevation myocardial infarction (STEMI) due to coronary artery occlusion in the setting of acute carbon monoxide (CO) poisoning is a very rare presentation. ObjectiveOur aim was to report on the use of primary angioplasty in a patient with STEMI in the setting of CO poisoning. Case ReportA 36-year-old man with retrosternal chest pain was admitted after exposure to CO. The initial electrocardiogram (ECG) showed ST depression in I, aVL, and V3−V4 with slight ST elevation in II, III, aVF leads. Toxic carboxyhemoglobin level of 22% and troponin I of 2.19 μg/L were confirmed. After oxygen therapy the chest pain diminished, but after about 15 h it returned. The repeat ECG revealed normalization of previous ST depression with persistent ST elevation in II, III, aVF leads. The troponin I concentration was 5.94 μg/L. An echocardiogram demonstrated an apex hypokinesia involving the adjacent segments of the anterior and lateral wall. On the coronary angiogram, an acute occlusion of the distal left anterior descending coronary artery was confirmed. Primary percutaneous coronary intervention (PCI) of the infarct-related artery was performed. After PCI, the patient was symptom free and had partial ST-segment elevation resolution. The patient was discharged home after 7 days, with persistent ST-T changes and mild hypokinesia of the apex suggesting myocardial injury. ConclusionsPatients with toxic CO exposure who have symptoms of STEMI should be carefully evaluated with serial ECG, cardiac necrosis marker measurements, and an echocardiogram. When there is evidence of myocardial injury, a wider use of coronary angiography can identify patients who could benefit from PCI.

Acute pleural effusion from aortic aneurysm rupture

A 78-year-old man was admitted to hospital with a urinary tract infection; on the second day of his hospital stay, he experienced a sudden onset of severe nonradiating pleuritic retrosternal chest pain, along with severe shortness of breath. An initial examination showed a blood pressure of 160/90

Endovascular Repair in Penetrating Aortoesophageal Foreign Body Injury

Foreign body ingestion in adults is not as common as in children. Sharp foreign body ingestion is even rarer; however, it may result in perforation, inflammation, or fistula formation at various gastrointestinal levels. In our case, the patient was unaware of the foreign body ingestion and presented with retrosternal chest pain, odynophagia, and occasional choking. Endoscopy and computed tomography thorax scan revealed a piece of chicken bone penetrating the aorta through the esophageal wall. No signs of mediastinitis were found. The foreign body was retrieved endoscopically with simultaneous endovascular stent repair of the aorta. Postoperative recovery was uneventful. There is an associated high morbidity and mortality in such cases, mandating long-term follow-up.

Nontraumatic Ascending Aortic Disruption

This report documents a case of completely spontaneous ascending aortic disruption. A 54-year-old African American male day laborer presented with severe retro-sternal chest and back pain and shortness of breath. He had no history of hypertension, smoking, or trauma and was taking no medications. The computed tomographic angiography scan performed to exclude pulmonary embolism instead demonstrated a hemorrhagic pericardial effusion and an ascending aortic pseudoaneurysm. He was taken emergently to the operating room for repair of his ascending aorta. The histopathology report was normal.

Aortic Dissection Presented as Paraparesis: A Case Report with Literature Review

One case of acute type B aortic dissection presented with paraparesis and retrosternal chest pain was treated conservatively with warfarin and blood pressure control with good recovery of symptoms. A literature review including 25 cases of aortic dissection presented with paraparesis/paraplegia from year 1980 to 2010 is also presented.

Pneumomediastinum, subcutaneous emphysema, and pneumothorax after a pulmonary function testing in a patient with bleomycin-induced interstitial pneumonitis

Spontaneous pneumomediastinum is an uncommon event, the clinical picture of which includes retrosternal chest pain, subcutaneous emphysema, dyspnea, and dysphonia. The pathophysiological mechanism involved is the emergence of a pressure gradient between the alveoli and surrounding structures, causing alveolar rupture with subsequent dissection of the peribronchovascular sheath and infiltration of the mediastinum and subcutaneous tissue with air. Known triggers include acute exacerbations of asthma and situations that require the Valsalva maneuver. We described and documented with HRCT scans the occurrence of pneumomediastinum after a patient with bleomycin-induced interstitial lung disease underwent pulmonary function testing. Although uncommon, the association between pulmonary function testing and air leak syndromes has been increasingly reported in the literature, and lung diseases, such as interstitial lung diseases, include structural changes that facilitate the occurrence of this complication.

Complicated Gastric Ulcer and Jejunal Hematoma with Concomitant Warfarin Use: Analytical and Biomedical Case Study Report

Intramural hematoma is commonly known as a hematoma that occurs in the wall of a structure, such as the bowel or bladder, usually resulting from trauma or, in rare situations, excessive anticoagulation. In particular, intramural gastrointestinal hematoma is part of a spectrum of gastrointestinal injuries. Vomiting and straining, endoscopic procedures, and bleeding disorders are essentially among the most common predisposing factors. However, it can also be an unusual complication of anticoagulation and/or thrombolysis therapy. The most common symptoms are retrosternal chest pain, dysphagia, and hematemesis. Intramural bowel wall hematoma is an often forgotten, rare clinical entity that may pose considerable diagnostic dilemma. Therefore, it is conspicuously imperative to diagnose this condition promptly and correctly in order to avoid unnecessary surgical intervention. In this rare presented case report, a 51-year-old woman having mitral valve prothesis and mild heart failure under warfarin wasadmitted to the renowned Sahel General Hospital in Beirut in November of 2006 with massive upper gastrointestinal bleeding that was subsequently controlled by endoscopic sclerotherapy and medical management. About 12 h later, the aforementioned patientsuffered a severe abdominal pain accompanied by a steep dropping in the hematocrit level. Moreover, an abdominal computed tomography scan showed thick jejunal hematoma of approximately 70 cm in length that was handled surgically. The patient had been incessantly observed for about 7 days,andsubsequently discharged with therapeutic international normalized ratio(INR).

Where Is the Acid Coming from? Esophago-Gastric Fistula Following Laparoscopic Nissen Fundoplication

A 61-year-old Caucasian female presented for evaluation of worsening retrosternal chest pain, heartburn, acid regurgitation, and dysphagia. She described a sensation of a bubble getting stuck in the bottom of her throat and chest after swallowing liquids. She also noted early satiety, belching, and nausea aggravated by greasy meals, weight loss, and frequent episodes of diarrhea. Three years prior, she had undergone a combined laparoscopic Nissen fundoplication, hiatal hernia repair, and cholecystectomy. Immediately after the operation, she experienced persistent nausea and vomiting, followed by recurrent reflux symptoms. Since a computed tomography scan obtained on the second post-operative day was unremarkable, she was reassured. She consulted a gastroenterologist due to progressive symptoms worsening over the ensuing 6 months. After a reportedly normal endoscopy, antisecretory drug therapy was started but failed to alleviate her symptoms. Over the next 30 months, her symptoms continued to worsen until she was evaluated in our unit. Her past medical and surgical histories were significant for overactive bladder, oral herpes, hypertension, hysterectomy, tubal ligation with subsequent reversal, carpal tunnel repair, and tendon repairs of both her hands. Having no known allergies, she was taking oxybutynin, acyclovir, lisinopril, and hydrochlorothiazide. Retired and living with her husband and daughter, she enjoyed gardening. She reported a 30-pack-year smoking history and denied alcohol and recreational drug use. Her family history was remarkable for Parkinson’s disease, breast cancer, and cholelithiasis. Further review of systems was unremarkable. Her physical exam was significant for a blood pressure 190/93 but was otherwise normal. Upper endoscopy revealed a fistula connecting her distal esophagus to her gastric cardia and a non-displaced but erythematous and tight fundoplication (Fig. 1a, b). The fistula was noted just proximal to the wrap, with an exit point at the level of the cardia, which was confirmed by a barium swallow that showed a 17-mm connection between the distal esophagus and the gastric fundus bypassing the lateral aspect of the wrap, consistent with an esophagogastric fistula (Fig. 1c). Esophageal manometry revealed a lower esophageal sphincter (LES) pressure of 23.3 mmHg (normal 10–30 mmHg) with a residual LES pressure of 17 mmHg and 40 % relaxation (normal [70 %) with swallowing, likely secondary to her prior fundoplication and consistent with an effective anti-reflux procedure. Nevertheless, an ambulatory pH study off anti-secretory medications revealed severe, mostly upright, pathologic acid reflux with a DeMeester score of 113.4 and a percentage fraction of time with a pH of \4.0 in the distal esophagus of 31.9 %. There was an excellent correlation between symptoms and acid events; the intra-gastric pH was normal when the patient was off protein-pump inhibitor therapy. C. L. Chun (&) Department of Internal Medicine, Oregon Health and Science University, Portland, OR, USA e-mail: chun@ohsu.edu

A case of pneumopericardium

A 77-year-old female with history of abdominal aortic aneurysm, COPD and Nissen fundoplication surgery for a hiatal hernia 10 years ago, was admitted with a one day history of sudden onset sharp retro-sternal chest pain radiating tothe back. She was hemodynamically stable. Chest X-ray and CT scan of the chest showed evidence of a significant pneumomediastinum and pneumopericardium with the greatest anterior depth of 3.8 cm. No pulmonary blebs were present on CT. Physical exam positive for Hamman’s crunch and pulsus paradoxus of 15 mmHg. Esophagram, bronchoscopy and EGD failed to show any evidence of fistulas. Trans-thoracic echocardiogram showed no evidence of cardiac tamponade. CT guided pericardial drainage was negative for gas-forming pathogens. She underwent thoracic exploratory surgery and intraoperative insufflation of the stomach revealing a gastro-pericardial fistula at the fundoplication wrap that was repaired. Pathology report showed thickened and inflamed pericardium. Patient’s pneumopericardium resolved and follow up imaging at six months showed no recurrence. The patient’s history of Nissen fundoplication predisposed her to gastric ulceration, which complicates almost 5% of cases with subsequent gastropericardial fistula formation. The most common risk factor for a gastropericardial fistula is history of gastro-esophageal surgery. While this is a rare finding to see in practice, one should be aware of the possibility of gastropericardial fistula in patients with previous history of gastric surgery who present with spontaneous pneumopericardium.

Chest Pain as a presenting complaint in patients with acute myocardial infarction (AMI)

To study various characteristics of chest pain in acute myocardial infarction patients. A total of 331 patients of AMI admitted at Cardiology unit Nishtar Hospital Multan and Chaudhry Pervez Elahi Institute of Cardiology Multan, irrespective of the age and gender, were included in this study. The study duration was one year starting from June 2011 to June 2012. Non-probability purposive sampling technique was used in this descriptive study. Informed consent to participate in this study was taken. Data were entered and analyzed using SPSS-11. A total number of 331 patients with AMI were included in the study. Mean age was 54.99±11.25 years with minimum age 20 years and maximum age 90 years. It included 264(79.8%) male and 67(20.2%) female patients with male to female ratio of 3.9:1. Out of these 331 patients 308 (93.1%) patients reported chest pain as the presenting complaint. Remaining 23(6.9%) presented with clinical features other than chest pain. There were 127(38.4%) patients with pre-cordial chest pain, 115(34.7%) had retrosternal chest pain, 58(17.5%) were having epigastric pain. Severe chest pain was seen in 281(84.9%) patients while 26(7.9%) had only mild chest discomfort. Radiation of the pain to shoulder, neck and jaw was seen in 75 (22.7%) patients. In 42(12.7%) patients, pain radiated to both sides of chest. Another 55(16.6%) patients had pain radiation to chest, shoulder, upper arm and ulnar side of left forearm. Chest pain radiation to interscapular region along with both sides of chest was present in 10(3.0%) patients. In 11(3.3%) patients' pain radiated only to left side of chest. Pain persisting for >20 minutes was reported by 298 (90%) patients while only 10(3.1%) had pain persisting for <20 minutes. There is considerable overlap in chest pain of cardiac as well as non cardiac causes. However, vigilant evaluation of characteristics of chest pain in history taking may help to overcome this dilemma. Severe and prolonged precordial chest pain in a male patient between the age of 41-70 years, with pain radiation to left shoulder, neck and jaw is highly suggestive of AMI.