Retrosternal Chest Pain Research Articles

TCTAP C-155 Primary Angioplasty of Left Main with Cardiogenic Shock & Pulmonary Oedema with Intra Aortic Balloon Pump & Ventilatory Support

### Patient Initials or Identifier Number LK ### Relevant Clinical History and Physical Exam His45-year-old gentleman- a known case of old AWMI (post-PTCA to LAD in 2011) presented to us with severe retrosternal chest pain & dyspnea a/w sweating for last 3 hours. The patient was in Killip class

Acute myocardial infarction as the first manifestation of Takayasu arteritis

Rationale:Takayasu arteritis (TA) is a chronic inflammatory disease involving the aorta and its major branches. Initial diagnosis is usually difficult due to the highly variable symptoms. Acute myocardial infarction (AMI) is a very rare presentation in patients with TA. Moreover, the choice of early management for these patients is not well established.Patient concerns:A 34-year-old woman was taken to the Emergency Department of our hospital, presenting with a sudden onset and persistent retrosternal chest pain radiating to both upper extremities for 2 hours. Blood pressures were different between 2 arms with 151/115 mm Hg on the right arm and 140/100 mm Hg on the left arm.Diagnoses:The patient was diagnosed with TA according to the medical history, physical examination, and vascular imaging.Interventions:Primary percutaneous coronary intervention (PPCI) was performed to restore the coronary flow of left anterior descending. Meanwhile, combination of oral glucocorticoids and immunosuppressive agents was administered to halt disease progression of TA.Outcomes:Chest pain was relieved without rest and exertional angina. The patient achieved long-term remission without symptom relapse during our follow-up.Lessons:Percutaneous coronary intervention was essential and effective in AMI of TA. Timely immunosuppressive therapy could improve the long-term outcome.

TCTAP C-203 Mother-and-child Catheter Induced Retrograde Dissection of the Left Main Coronary Artery During Optical Coherence Tomography Examination

### Patient Initials or Identifier Number CYD ### Relevant Clinical History and Physical Exam A 54-year-old man, a non-smoker or non-drinker, with good past health, presented severe retrosternal chest pain with a diagnosis of non-ST-elevation myocardial infarction. He is hemodynamically stable

TCTAP C-097 Recurrent Complete Heart Block Due to Left Circumflex Artery Stenosis

### Patient Initials or Identifier Number GP ### Relevant Clinical History and Physical Exam A 55-year-old female presented with acute inferior wall myocardial infarction (MI). The patient was diabetic and also presented with severe retrosternal chest pain for 3 days. On admission blood pressure

A cross sectional study on clinical profile of endoscopic proven gastroesophageal reflux disease

Background: Gastroesophageal reflux disease (GERD) is one of the main gastrointestinal diseases. It is due to the abnormal reflux of gastric contents into the esophagus or beyond. It has many symptoms and also many complications.Methods: Authors carried out this study to know the common symptoms, complications of GERD and the endoscopic study results regarding the same. 100 patients attending the surgery department at a tertiary care hospital were included in the study.Results: Mean age of participants was 54.09±14.75 years. Authors divided the 100 patients into two groups, GERD with complications (28 patients) and GERD without complications (72 patients). In the present study, out of 100 GERD patients, 73 patients were males (73%) and 27 patients were females (27%) with male to female ratio of 2.7:1. In this study, among 100 GERD patients, body mass index was <25 in 70 patients (70%) and ≥25 in 30 patients (30%). Heartburn was present in 72% patients, regurgitation in 71%, retrosternal chest pain was seen in 68% patients and dysphagia was seen in 29%. Out of 100 GERD patients, 16 patients (16%) had esophageal ulcers, 8 patients (8%) had Barrett’s esophagus, 4 patients (4%) had esophageal stricture and 72 patients (72%) didn’t have any complications.Conclusions: Age and BMI (both p <0.001) of the patients showed significant statistical difference between two groups. Some other studies also showed similar results with higher complications seen in increasing age and increased frequency of symptoms.

Study of inferior myocardial infarction extended to the right ventricle: Series of 100 cases

Ischemic heart disease is a common cause of morbidity and mortality worldwide. Acute inferior wall myocardial infarction accounts for 40% all acute myocardial infarctions. Acute coronary syndromes involving the right side of the heart are associated with increased mortality, a complex clinical course, and lengthy hospitalization, as well as with frequent mechanical and electrical complications. To study the incidence, clinical, therapeutic and angiographic profile of right ventricular (RV) infarction and inferior wall myocardial infarction. One hundred cases of inferior wall infarction were included in the study. Patients with history of previous infarction, bundle branch block, and suspected pulmonary embolism were excluded. Incidence of right ventricular infarction is about 25% in inferior wall myocardial infarction. Most patients presented with retrosternal chest pain associated with sweating. Male constituted 79.62% of the population studied. Smoking is the main cardiovascular risk factor found in 57.28% of cases. Diabetes and hypertension are present in 38% and 25% of cases respectively. Right ventricular failure was present in 23% of patients. The group with RV infarction has more conduction disorders (32% vs 6%). The right coronary artery (RCA) was responsible for the RV infarction in 100%. However, Acute inferior wall myocardial infarction is secondary of RCA in 56% and circumflex in 44%. RV infarction is common in patients with acute inferior wall myocardial infarction. Rapid detection of RV infarction and the early treatment even for patients without hypotension or cardiogenic shock is important to improve the prognosis.

Jackhammer Esophagus: From Manometric Diagnosis to Clinical Presentation.

Background Jackhammer esophagus is a hypercontractile esophageal disorder recently brought to light with the advent of high resolution manometry (HRM). As little is known about its clinical presentation, the aim of this study was to identify the clinical characteristics associated with this new gastrointestinal motility disorder. Methods A retrospective study was conducted on patients visiting the CHUM's Gastro-Intestinal Motility Center from January 2015 to December 2017. The HRM diagnoses were collated in a database along with age and sex of every individual. The latest Chicago classification (version 3.0) was used. Among all the patients subjected to HRM, those diagnosed with Jackhammer esophagus were included in the study. Patient charts were reviewed to collect relevant demographic and clinical data. Key Results A total of 36 patients with Jackhammer esophagus were included (62 ± 13 years age, 89% females). Their main symptoms were dysphagia (72%), pyrosis (42%), retrosternal chest pain (36%), and epigastralgia (33%). Other manometric findings were hypertonia (22%) and/or inadequate relaxation (19%) of the lower esophageal sphincter. Among the 26 patients who had esogastroduodenoscopy, hiatal hernia was seen in 3 patients. Pathological gastroesophageal reflux was found in 4 of the 10 patients investigated by pH-monitoring. Conclusions and Inferences Jackhammer esophagus represents 3% of the HRM diagnoses in this study, with a significant female preponderance. In more than two-thirds of cases, the clinical presentation of Jackhammer esophagus is dysphagia.

ATYPICAL PRESENTATION OF NON-ST ELEVATION MYOCARDIAL INFARCTION IN A YOUNG BENGALI WOMAN

Women presenting with atypical symptoms of Acute Coronary Syndrome (ACS) are more likely to be discharged without a diagnosis rather than be treated for ACS. A 25-year-old Bengali female with history of non-insulin dependent Diabetes Mellitus presented with non-exertional retrosternal chest pain

Right Aortic Arch, Kommerell Diverticulum, and Symptomatic Retro-Esophageal Vascular Ring in an Adult (Case Presentation and Review)

A 24 year-old Hispanic man presented with progressive retrosternal chest pain, shortness of breath, and dysphagia. Chest X-ray, computed tomography angiography, and magnetic resonance (MRA) studies were compatible with a right aortic arch and a 3.5-cm descending right aortic Kommerell diverticulum. Barium esophagogram and esophagoscopy demonstrated a constricting band crossing the esophagus at the level of the diverticulum. After discussion with other cardiothoracic surgeons, with a combined 300 years of experience, they reported only 1 other possible such case. Kommerell's diverticula are usually repaired in children and rarely are seen in the adult. Kommerell diverticular treatment options include endovascular stenting, cardiopulmonary bypass with resection and grafting, right thoracotomy, and a cervical approach. Because of the patient's findings of a right arch, a Kommerell diverticulum, and a constricting band causing esophageal compression and respiratory distress, it was felt stenting alone would not relieve his symptoms. Therefore, we used a left third posterior intercostal thoracotomy approach to resect the constricting esophageal band connecting the Kommerell diverticulum to the left subclavian artery and to perform the Kommerell diverticulectomy. Releasing the esophageal and tracheal compressing band and resection of the diverticulum provided complete symptom relief with elimination of the dysphagia, dyspnea, wheezing, and chest pain, using a single surgical procedure.

An Unusual Trigger for Stress Cardiomyopathy

Our patient is a 65-year-old male with a history of hypertension, hyperlipidemia, diabetes mellitus, alcohol abuse and paroxysmal atrial fibrillation, who presented to the emergency department with epigastric pain. On laboratory examination, his sodium level was found to be 127 meq/L (normal range: 136 - 145 meq/L). During his hospital course, he developed retrosternal chest pain. His electrocardiogram (ECG) during this episode showed deep symmetrical T wave inversions in the anterior, septal and apical leads. His symptoms of chest pain and ECG changes prompted a cardiac catheterization, which revealed, non-obstructive coronary disease with left ventriculogram significant for apical near akinesis and preserved basal wall motion, characteristic findings of Takotsubo cardiomyopathy, with an estimated left ventricle ejection fraction of 35-40%. J Med Cases. 2018;9(12):386-389 doi: https://doi.org/10.14740/jmc3132w

A Rare Case of Primary Herpes Esophagitis in an Immunocompetent Young Adult

Introduction Herpes Simplex Viral (HSV) esophagitis is an opportunistic infection that is seen in patients with impaired immunity. It is rarely seen in immunocompetent individuals. It may result from direct spread to the esophagus from an oro-pharyngeal infection or can occur in patients with latent HSV by reactivation of the virus and dissemination to the esophageal mucosa via the vagus nerve. A few cases of HSV in immunocompetent individuals have been reported. We present a case of primary HSV esophagitis in an immunocompetent young adult whose biopsy was positive for both HSV 1 & 2. Clinical Vignette A 21 y/o male presented to the ED with complaints of sore throat, odynophagia and chest pain. Symptoms started as low grade fevers and viral-like illness and then progressed to throat soreness followed by severe odynophagia. Other symptoms included nausea, vomiting, subjective fevers, abdominal pain with radiation to the back during swallowing. Patient had no known past medical history, no history of cold sores and endorsed heterosexual activity with approximately twenty lifetime sexual partners and denied use of barrier contraception or engaging in oral sex. Physical examination was remarkable tonsillar erythema and edema, with mild pharyngeal erythema & exudates on tonsils. Blood tests were remarkable for positive HSV 1 &2 IgM and negative for HIV, CMV & EBV. CT neck showed bilateral tonsillitis, thickening of the esophagus, no evidence for peritonsillar abscess. Upper endoscopy revealed esophagitis manifested as edema, erosion and friable mucosa with spontaneous bleed on contact. Biopsy and pathology results was positive for herpes virus 1 &2. Further work up for underlying immune deficiencies and autoimmune diseases was negative. Patient was treated with oral acyclovir for 7days with resolution of symptoms. Discussion Very few cases of HSV esophagitis in immunocompetent individuals have been reported. It is mostly seen in immunocompromised individuals such as HIV carriers, transplant recipients, people on immunosuppressive agents and those with cancer. Initial symptoms usually include a viral prodrome followed by sore throat with odynophagia. Other common manifestations are dysphagia, retrosternal chest pain, weight loss, fever, nausea and vomiting. It is diagnosed via endoscopic inspection and histopathology findings. Treatment is with acyclovir, famiciclovir or valaciclovir. Symptoms may resolve over time with symptomatic treatment.1709_A Figure 1. Endoscopic findings1709_B Figure 2. Histology of HSV infected cells1709_C Figure 3. Immunohistochemical staining showing HSV infected cells

Computed tomography coronary angiography in patients without known coronary artery disease can demonstrate possible non-cardiovascular causes of non-acute retrosternal chest pain

ObjectivesTo assess the computed tomography coronary angiography (CTCA) accuracy for demonstrating possible non-cardiovascular causes of non-acute retrosternal chest pain in patients without known coronary artery disease (CAD) and to correlate CTCA results with the patient management and relief from pain.MethodsThis prospective observational study was approved by the ethical committee. Consecutive patients suffering non-acute chest pain who underwent CTCA and with not known CAD were enrolled and classified as having coronary diseases (CD) or extracardiac diseases (ECD). Association between age, sex, body mass index (BMI), cardiovascular risk factors, and type of chest pain with CD or ECD was estimated. Correlation between BMI classes and each risk factor was also calculated.ResultsA total of 106 patients (60 males; age 62 ± 14 years [mean ± standard deviation]; mean BMI 27) were enrolled. Hypertension was found in 71/106 (67%); smoking was significantly more frequent among males (p = 0.003) and hypercholesterolemia among females (p = 0.017); hypertension and hypercholesterolemia significantly correlated with age, and hypertension also with BMI. Pain was atypical in 70/106 (66%) patients. The kind of pain did not correlate with disease or gender. CTCA showed possible causes of chest pain in 69/106 (65%) patients; 32/69 (47%) having only CD, 23/69 (33%) only ECD, and 14/69 (20%) both CD and ECD. Prevalence was: hiatal hernia 35/106 (33%); significant CAD 24/106 (23%); myocardial bridging 22/106 (21%). At follow-up of 94/106 (89%) patients, 71/94 (76%) were pain-free, 14/17 (82%) significant CAD had been treated, and only one patient with non-significant CAD was treated after CTCA.ConclusionCTCA suggested possible causes of non-acute pain in 65% of patients.Main messages• CTCA can either rule in or rule out possible causes of chest pain alternative to CAD.• Clinically relevant findings were detected in 65% of patients with non-acute chest pain.• Non-cardiovascular diseases potentially explained symptoms in 35% of patients.

Análise das alterações eletrocardiográficas em pacientes atendidos por serviço móvel de urgência

O estudo aqui apresentado teve como objetivo analisar a população atendida por meio de teleeletrocardiografia realizada por serviço público que pode ser referência para outros em matéria de atendimento pré-hospitalar móvel de urgência no município de Porto Alegre. Trata-se de estudo transversal retrospectivo. Foram analisados 1.338 eletrocardiogramas realizados de setembro 2013 a agosto 2014 pelo Samu/POA, com laudo a distância feito no Hospital do Coração (HCor) em São Paulo. Utilizou-se a metodologia embasada nas diretrizes STROBE (Strengthening the Reporting of Observational Studies in Epidemiology). Em 115 (8,6%) desses tele-eletrocardiogramas, os pacientes foram diagnosticados com supradesnivelamento do segmento ST. Esta alteração eletrocardiográfica prevaleceu no gênero masculino (p = 0,012) com idade acima de 60 anos (p = 0,014). Dor torácica típica retroesternal foi mencionada por 314 homens (54,3%) e 726 mulheres (56,3%). Síncope foi relatada por 94 homens (16,3%) e 107 mulheres (14,2%). A dispneia foi um sintoma apontado por 47 homens (8,1%) e 84 mulheres (11,1%). Os resultados do estudo revelaram que alterações eletrocardiográficas sugestivas de SCA (Síndrome coronariana aguda) predominam em homens idosos; embora as mulheres solicitem o serviço de atendimento com mais frequência, o supradesnivelamento do segmento ST mostrou-se preponderante no gênero masculino. A dor torácica ter sido mencionada como o sintoma mais referido está em concordância com a literatura atual. =O conhecimento de nossa realidade pode auxiliar a elaboração de protocolos de serviço.

Pinpoint Localized Odynophagia (PLO) as a Specific Symptom of Pill-induced Oesophagitis (PIO) in the Evaluation of Acute Retrosternal Chest Pain

36 out of 100 cases of retrosternal chest pains are due to oesophageal pathologies, and Pill-induced Oesophagitis (PIO) is one of them. PIO can present as retrosternal chest pain associated with various Gastrointestinal (GI) symptoms and require a high index of suspicion. PIO is a clinical diagnosis; and oesophagogastroscopy is required for confirmation of the diagnosis, to find out complications of PIO and to rule out other oesophageal disorders. Our aims of the present study were to study clinical profile, risk factors and endoscopic features of PIO. We have done a cross-sectional study of 1000 patients with acute retrosternal chest pain, and all patients of suspected upper gastrointestinal system involvement were subjected to oesophagogastroscopy. Patients having a history of pill ingestion followed by retrosternal chest pain with GI symptoms of less than 10 days duration and having typical endoscopy findings like kissing ulcer, multiple small discrete ulcers or erosion of esophagus were diagnosed as PIO after excluding other oesophageal pathologies. Among 1000 retrosternal chest pain patients, 450(45%) cardiovascular, 255(25.5%) respiratory, 248(24.85%) upper GI and 47(0.47%) had other system involvement. Among 248 GI patients, the frequency of symptoms was as follows: Pinpoint localized odynophagia (8.46%), non-localised odynophagia (12.09%), nausea (62.09%), vomiting (44.35%), dysphagia (3.62%), dyspepsia (13.70%) and hematemesis (0.8%). PLO, dysphagia, and hematemesis were significant symptoms of PIO (p<0.05). Endoscopic findings suggestive of PIO such as kissing ulcer, multiple small discrete ulcers, oesophageal erosions were observed in 91.30%, 47.83%, and 34.78% patients, respectively. Involvement of the middle third of esophagus was present in 74.19% and the lower third in 25.81% patients. Most of the patients with PLO had kissing oesophageal ulcer seen on endoscopy (pvalue =0.0002). The habit of consuming pill with less than 100 ml of water and consumption of night pill dose 10 minutes or less before sleeping were observed as significant risk factors for PIO (p value<0.05). PLO is a newly established and highly specific symptom of PIO of our study and it matches with kissing ulcer of the esophagus by endoscopy.

Comparison of spontaneous and secondary pneumomediastinum

Pneumomediastinum (PM) is an uncommon event defined as the presence of free air in the mediastinum. Its clinical picture includes retrosternal chest pain, subcutaneous emphysema, dyspnea, dysphagia, dysphonia and asthenia. PM is further divided into two groups of patients: spontaneous PM, without any obvious primary source, and secondary PM, with a specific responsible pathologic event, such as trauma, intrathoracic infections, violation of the aerodigestive track or others. We retrospectively examined and compared backgrounds, onset, treatments and outcomes of ten and 5 patients in spontaneous and secondary PM.

Cardiac Arrest With ST-Segment–Elevation in V1 and V2

A 58-year-old male patient arrived at the emergency department following out-of-hospital cardiac arrest. He had no known cardiovascular risk factors other than smoking. His relatives reported that he had developed oppressive retrosternal chest pain and sweating 3 hours prior to presentation. The first documented rhythm was ventricular fibrillation, requiring 4 electric shocks to restore sinus rhythm and return of spontaneous circulation. The postresuscitation ECG is shown in Figure 1. What is the most likely diagnosis? Figure 1. The 12-lead ECG at the emergency room. The 12-lead ECG at the emergency room, showing ST-segment–elevation in lead V1 and V2. Please turn the page to read the diagnosis. The ECG revealed sinus rhythm, narrow QRS complex, ST-segment–elevation in lead V1 and V2, with a slight elevation in leads III and aVF and 1-mm ST-segment–depression in leads I and aVL. Surprisingly, no pathological Q waves were evidenced after more than 3 hours of chest pain. These …

TCTAP C-030 Treatment of Near Occlusive Radial Artery Stenosis During Percutaneous Coronary Intervention

### Patient Initials or Identifier Number To avoid arterial spasm and discomfort to the patient, a 6F peripheral AXCER sheath (Arrow) was inserted. K V ### Relevant Clinical History and Physical Exam 75 years old female Diabetic, hypertensive H/O Retrosternal chest pain since 2 days -

TCTAP C-053 Primary Angioplasty of Left Main

### Patient Initials or Identifier Number L K ### Relevant Clinical History and Physical Exam This 45 year old gentleman- a known case of old AWMI (post PTCA to LAD in 2011) presented to us with severe retrosternal chest pain & dyspnea a/w sweating for last 3 hours. The patient was in Killip

An Uncommon Mass of the Esophagus: Esophageal Hemangioma

A 73-year-old woman complaining of retrosternal pain and swallow discomfort over the past 1 month was admitted to our hospital. She denied any dysphonia, regurgitation or weight loss. Physical examination was unremarkable. The hematological and biochemical profiles were normal. Barium meal studies revealed a smooth oval-shape mass with broad pedicle in the posterior wall of the upper esophagus (Figur 1). The patient refused to endoscopic investigation because of irregular heart rhythms. Further chest CT scan revealed a soft tissue mass with punctuate calcification and narrowing of the lumen to around 40% of the original size. The lesion showed moderately inhomogeneous enhancement after contrast injection (Figure 2 &amp; 3). There was no lymphatic node adenopathy in the mediastinum. Based on her symptoms and related radiological findings, the patient was firstly suspected with esophageal hemangioma and underwent thoracoscopic enucleating. Intraoperative photography showed deep-red lesion with smooth surface (Figure 4) and the mass was completely resected under the thoracoscopy. Histopathological findings were consistent with esophageal haemangioma (Figure 5). Post-operative course was uneventful and the patient’s symptom of retrosternal chest pain was completely resolved after surgery. She remained asymptomatic at 2-year follow-up.

CLOT TWIST: A RARE PRESENTATION OF THORACIC AORTIC THROMBUS IN A YOUNG FEMALE

A 21-year-old Caucasian female with no medical history presented with severe retrosternal chest pain, radiating to the back. Physical examination was unremarkable. Laboratory studies were notable for hemoglobin 11.1 (normal 12.0-15.5 g/dL) and CRP 84.2 (normal < 8.0 mg/L). CT angiogram of the chest