Typical Exertional Chest Pain Research Articles

270 PARTICULAR MISDIAGNOSED ACS-NSTEMI IN A YOUNG ADULT WITH HISTORY OF HODGKIN'S LYMPHOMA IN THE ERA OF FREQUENT SARS-COV2 RELATED MYOCARDITIS: NOTHING SHOULD EVER BE LEFT TO CHANCE.

Abstract Background Radiotherapy plays a key role in the multimodality treatment of thoracic tumors. Radiotherapy-induced heart disease (RIHD) has become an increasingly recognized adverse reaction contributing to major radiation-associated toxicities, including nonmalignant death. Especially patients with diseases with excellent prognosis, such as breast cancer or Hodgkin's lymphoma, may suffer from delayed side effects 2-6 including RIHD in a dose-dependent manner. The pathological spectrum of RIHD includes conduction abnormalities, valvular disease, coronary artery disease, pericarditis and pericardial constriction or effusion, cardiomyopathy, and myocardial fibrosis. Here we describe the case of a young man cured of Hodgkin's lymphoma who presented to our laboratory with the diagnosis of suspected myocarditis in the Sars-COV 2 era, but the presenting clinical picture confused the clinicians and complex coronary artery disease was behind it. Method-Clinical Case A young 33-years-old man presented to the emergency room with typical exertional chest pain. Clinical history: smoker patient who denied familiarity for cardiovascular diseases, dyslipidemic, 10 years previously underwent chemotherapy and radiotherapy for Hodgkin's Lymphoma in complete remission. A nasopharyngeal molecular swab for Sars-COV 2 was performed, which was negative. The presentation electrocardiogram (EKG) documented nonspecific repolarization abnormalities; the myocardionecrosis enzyme curve performed at three times was frankly positive with elevated PCR values ​​(102 pg/ml). Color Doppler echocardiography documented a left ventricular ejection fraction at the lower limits of normal, hypokinesia of the mid-basal segments of the infer-posterolateral wall with moderate mitral valve regurgitation. On suspicion of acute myocarditis, the patient was transferred to the Coronary Care Unit and, during admission, underwent MRI, which showed a slightly enlarged left ventricle (DTD 58 mm, EDV 147 ml), slightly depressed systolic function (LVEF 46%), akinesia of the proximal lateral and mid-proximal wall. In delayed enhancement sequences late persistence of gadolinium in the endomesocardium (60%), proximal lateral and mid-proximal wall with involvement of areas adjacent to the base of implantation of both papillary muscles. In light of the instrumental picture, the patient underwent coronarography, which showed an unexpected nightmare picture, given his young age. Circumflex branch (lcx-lesion culprit) suboccluded to the middle segment with TIMI I downstream flow at the bifurcation with a prominent obtuse marginal branch (OM) with a delayed reperfusion (Medina 1,1,1); diffusely atheromatous left anterior descending artery (LAD), showing 70% complex critical disease in the proximal segment at the bifurcation with a first diagonal branch of good caliber and good distribution area (Medina 1,1,1). Clinical resolution/Results Therefore, in a patient with misdiagnosed ACS-NSTEMI, two complex coronary bifurcation angioplasties according to TAP technique (Fig 3-4) were performed through left radial access with Slender 7 in 6 introducer at one time. The following drugs were administered in the cath-lab: Cangrelor bolus/kg followed by continuous infusion for 2 hours and Prasugrel 60 mg, initially UFH 5000 IU and anticoagulation control according to ACT during the procedure. The procedure ended with complete revascularization and asymptomatic patient. During the following days of hospitalization, no late electrical or mechanical complications occurred. Conclusions The one just described represents a complex and unexpected scenario for a young adult. The literature available has analyzed the pathophysiology of myocardial damage resulting from exposure to high amounts of radiation in patients undergoing curative radiotherapy for Hodgkin's lymphoma. It is now generally accepted that the most common clinical syndromes after irradiation are pericarditis in acute and chronic forms,. However, coronary vessel lesions have been considered exceptionally rare, so the true pathophysiological triggering mechanism is still poorly understood. The most widely accepted hypothesis on the onset of RICHD is a dual pathway of vascular damage ("two-hit combined hypothesis"). The most important preventive measure regarding RICHD is dose minimization. Few data are available in the literature on outcomes according to the revascularization strategy adopted in patients with RICHD (PCI vs. CABG). Morbidity and mortality from post-radiotherapy cardiovascular complications in patients with Hodgkin's lymphoma must be reduced through close cardiological surveillance in primary prevention and a close collaboration between oncologists and cardiologists in order to minimize any deleterious complications, especially in the young. Further research is needed to elucidate profibrotic mechanisms, identify promising therapies that can be implemented early during the course of treatment and to compare revascularization strategies with longer-term mortality in such patients, in order to guide the physicians in the decision-making.

Apical Hypertrophic Cardiomyopathy in a Case with Chest Pain and Family History of Sudden Cardiac Death: A Case Report

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiovascular disease, which is caused by a multitude of mutations in genes encoding proteins of the cardiac sarcomere (1). Apical hypertrophic cardiomyopathy (AHCM) is an uncommon type of HCM. The sudden cardiac death is less likely to occur in the patients inflicted with AHCM (2). Herein, we presented the case of a 29-year-old man with AHCM, who had typical exertional chest pain without any cardiovascular risk factors, except for a sudden cardiac death in his older brother at the age of 28 years. After performing complete clinical and paraclinical evaluations, the patient underwent optimal medical treatment with beta-blocker agents without any symptoms.

Fragmented QRS frequency in patients with cardiac syndrome X.

Objective:Cardiac syndrome X (CSX) is characterised by typical exertional chest pain, a positive response to exercise testing, and a normal coronary angiography. The relationship of CSX with myocardial fibrosis and ischemia has been clearly demonstrated in previous studies. In addition, fragmented QRS (fQRS) has been reported in the literature as an indicator of myocardial fibrosis. The aim of this study was to investigate the frequency of fQRS in patients with CSX.Methods:This prospective case-control study included 37 patients (CSX group) with typical complaints of angina, ischemia on an exercise test, and normal coronary arteries as detected by angiography and 47 patients (control group) with normal coronary arteries. Echocardiographic examinations were performed according to the recommendations of the American Society of Echocardiography. Continuous variables were expressed as mean±standard deviation (SD), and the qualitative variables were expressed as a percentage or ratio. Data were compared statistically with Shapiro–Wilk test, Student’s t-test, Mann-Whitney U, chi-square and Fisher exact test.Results:There was no significant difference between the CRX and control groups with respect to basic characteristics such as age and sex. fQRS and the frequency of its presentation with stable angina pectoris at the clinic were significantly higher in the CSX group than in the control group (p values: 0.001 and <0.001, respectively).Conclusion:A close follow-up would be useful in CSX patients in whom fQRS is detected in an electrocardiogram (ECG) because of the association between fQRS and poor prognosis with respect to the prevention of late complications. We believe that the presence of fQRS in the ECG aids in the diagnosis of CSX in clinical practice and in the recognition of this group of patients. (Anatol J Cardiol 2016; 16: 616-20)

Medical management of chronic stable angina.

Stable angina pectoris is characterised by typical exertional chest pain that is relieved by rest or nitrates. Risk stratification of patients is important to define prognosis, to guide medical management and to select patients suitable for revascularisation. Medical treatment aims to relieve angina and prevent cardiovascular events. Beta blockers and calcium channel antagonists are first-line options for treatment. Short-acting nitrates can be used for symptom relief. Low-dose aspirin and statins are prescribed to prevent cardiovascular events.

OP-336 Low Adiponectin and High Lipoprotein (A) in Cardiac Syndrome X: Are they the Origin of Pathophysiology?

Cardiac syndrome X (CSX) is usually defined by normal-appearing coronary angiogram associated with typical exertional chest pain, ST-segment changes on the exercise stress test and no evidence of epicardial coronary vasospasm. The cause of CSX is not correctly understood. Lipoprotein a and adiponectin have been accepted the new confounders of the coronary heart disease. We studied the contribution of lipoprotein a ve adiponectin in CSX physiopathology.

24 HOUR STABLE ANTI-ANGINAL EFFECT OF RETARD VERAPAMIL, DILTIAZEM & NIFEDIPINE

maintain anti anginal effect throughout 24 hours. However the duration of effect and antianginal effect of retard form of calcium antagonists has not been widely investigated. Objective: The objective of this study was to asses the duration of effect, antianginal effect and tolerability of retard forms of nifedipine, verapamil and diltiazem. Methods: Patients with typical exertional chest pain and atleast 1mm ST-segment depression on ECG were included in this study. Each patient under went control ETT. Then ETT was done after giving drugs at 4, 12 and 18 hours with each drug in all patients after an interval of 3-4 days. Mean ST-segment depression of all leads was calculated and Δ% ST-segment depression was derived. The drug was considered effective if Δ% ST-segment depression was more than 30%. Result: With 20mg retard nifedipine, the Δ% ST-segment depression after 4 hours was 35.8% and after 12 hours was 45.2% with 120 mg retard verapamit, it was 36.4% after 4 hours 31.4% after 12 hours 25% after 18 hours with 240 mg of retard verapmit, it was 58.6% after 4 hours, 58.1% after 12 hours and 46.5% after 18 hours, with 90mg retard diltiazem it was 65.1% after 4 hours 49.9% after 12 hours and 16.4% after 18 hours. Conclusion: All calcium antagonists in retard form have shown good anti ischemic and anti anginal effect throughout 24 hours.

All That Glitters is not Gold: Apical Hypertrophic Cardiomyopathy Mimicking Acute Coronary Syndrome

Hypertrophic cardiomyopathy is characterized by the idiopathic hypertrophy of the left ventricle (and occasionally right ventricle). HCM is an autosomal dominant disease, with variable penetration. In Asian population, apical hypertrophic cardiomyopathy is relatively common (25%). However, this is relatively rare in Caucasian population (0.2%). Patients with HCM, often presents with typical exertional chest pain and shortness of breath. Apical HCM patients tend to have milder symptoms. However, the clinical presentation and electrocardiographic features of Apical HCM often mimic acute coronary syndrome and high index of suspicion is warranted in differentiating this condition. Patients with apical HCM have relatively better prognosis when compare to the other varieties. Here, we are presenting a patient who presented with typical exertional chest pain whose electrocardiographic changes are concerning for acute ischemic changes.

Cardiac syndrome X

Cardiac syndrome X (CSX) is a clinical condition characterized by the presence of typical exertional chest pain, a positive response to exercise stress testing, and normal coronary angiograms. The exact mechanism of CSX is not known and multiple pathophysiologic abnormalities have been reported in patients with CSX, including abnormal coronary flow reserve, insulin resistance, abnormal autonomic control, enhanced sodium–hydrogen exchange activity, abnormal cardiac sensitivity, and microvascular spasm [1].

Cardiac syndrome X in women: the role of oestrogen deficiency

Cardiac syndrome X (CSX), defined as typical exertional chest pain, a positive response to stress testing, and normal coronary arteriograms, encompasses different pathogenic subgroups. Both cardiac and non-cardiac mechanisms have...

Usefulness of the blood lymphocyte count in predicting recurrent instability and death in patients with unstable angina pectoris

S case-control and prospective studies have reported that increased white blood cell (WBC) count is an independent risk factor for coronary heart disease, cardiovascular events, and mortality.1–4 An elevated WBC count has been associated with both a higher risk of developing myocardial infarction and worse outcome in post–myocardial infarction patients.5–7 It has been also reported that relative lymphocyte count may have prognostic significance in patients with known or suspected coronary heart disease.8,9 However, the relation between WBC count and prognosis in patients with unstable angina has not been investigated systematically. In acute coronary syndromes, markers of increased risk, such as cardiac troponin-I exist, which have been shown to be useful for patient risk stratification.10,11 This study assesses the prognostic value of total and differential WBC counts in patients presenting with unstable angina. • • • We studied 71 consecutive patients (44 men) who were admitted to our coronary care unit between September 1996 and June 1997 with the diagnosis of unstable angina (class II-B and III-B according to the Braunwald classification).12 As a control group for baseline WBC measurements, we examined 118 patients (84 men) with chronic stable angina who were admitted for routine coronary arteriography. Patients with unstable angina received conventional treatment with nitrates, heparin, b-adrenergic blockers, calcium antagonists, and aspirin. Clinical decisions were left to the discretion of the managing cardiologist. All patients with unstable angina were followed up for 1 year, or up to the time of elective coronary revascularization in patients who were put on a waiting list for this purpose before hospital discharge. The following were considered to represent study end points: (1) new admission to coronary care unit with unstable angina (Braunwald III-B)12 requiring intravenous drug administration and/or revascularization, (2) myocardial infarction diagnosed according to World Health Organization criteria, and (c) cardiac death. Stable angina was defined as typical exertional chest pain relieved by rest and/or nitrate administration. In all patients with exertional angina, symptoms were stable for at least 3 months before study entry. Exclusion criteria that applied to both groups of patients were: recent (,12 weeks) myocardial infarction, evidence of active infectious disease, inflammatory or immunologic disorders, recent major surgery or trauma, known or suspected neoplastic diseases, treatment with anti-inflammatory or immunosuppressive drugs, renal failure, significant valvular heart disease, and severe heart failure. All patients gave written informed consent before study entry and the study was approved by the local ethics committee. In patients with unstable angina, total and differential WBC counts were measured in morning fasting blood samples withdrawn within the first 24 hours after admission. In those with stable angina, measurements were obtained in fasting blood samples drawn in the morning before coronary angiography. Total and differential WBC counts were determined by a commercially available automated system (STKS Coulter, Beckman Coulters, High Wycombe, United Kingdom) that uses a sample size of up to 8,000 cells. In patients with unstable angina, cardiac troponin-I was measured using a commercially available high-sensitivity immunoassay (AxSYM system, Abbott Laboratories, Abbott Park, Illinois). The value of 0.4 mg/L demonstrating a 95th percentile value of troponin-I measurement in serum from 52 healthy blood donors was subsequently used as the threshold for the analysis. Variables are expressed as mean 6 SD. Odds ratio are expressed with their 95% confidence interval. Proportions have been compared using the chi-square test or 2-tailed Fisher’s exact test. Continuous variables were analyzed using unpaired t tests and Mann-Whitney U tests when appropriate. Logistic regression was used to calculate odds ratio between lymphocyte quartiles. The Cox regression model was used to assess adjusted time-to-event rate curves, where the dependent variable was a risk marker (defined as abnormal cardiac troponin-I and lymphocyte count ,2.40 3 10 lymphocytes/L) and the independent variables were those with p ,0.20 in the univariate analysis. A probability ,0.05 was considered statistically significant. The baseline characteristics of patients with stable and unstable angina are presented in Table I. Unstable angina patients had both higher neutrophil and relative monocyte counts than patients with chronic stable angina. These differences, however, were not statistically significant when adjusted for gender, history of diabetes, past history of myocardial infarction, hypertension, and cholesterol levels (p 5 0.10 and p 5 0.35, respectively). The mean duration of follow-up for unstable angina patients was 13 6 2 months. During that period, 22 unstable angina patients had cardiac events: 18 were readmitted with a new episode of From the Department of Cardiological Sciences, St George’s Hospital Medical School, London, United Kingdom. Prof. Kaski’s address is: Department of Cardiological Sciences, St. George’s Hospital Medical School, Cranmer Terrace, London SW17 0RE, United Kingdom. E-mail: jkaski@sghms.ac.uk. Manuscript received November 22, 1999; revised manuscript received and accepted February 29, 2000.

Heart rate-independent prolongation of QTc interval in women with syndrome X

Cardiac syndrome X is usually diagnosed in the presence of typical exertional chest pain, a positive response to exercise testing, and normal coronary angiograms. The underlying pathogenic mechanisms are speculative, but myocardial ischemia and increased sympathetic activity have been implicated. The present study examined whether QTc interval is prolonged in women with syndrome X when confounding factors such as heart rate, gender, and environmental conditions are accounted for. Maximum QTc interval and its relationship to clinical and exercise variables were evaluated in 32 women with syndrome X (exertional chest pain, positive exercise testing, and completely normal coronary arteries) and 34 normal controls. Patients with syndrome X had significantly longer QTc interval (440 +/- 24 ms) than normal subjects (410 +/- 26 ms, p < 0.004). However, this QTc prolongation appears to be heart rate-independent as patients with syndrome X showed longer QT and QTc intervals than controls despite an identical heart rate. No relation was found between QTc prolongation and clinical or exercise test variables in patients with syndrome X. Although increased sympathetic drive is present in syndrome X, and this variable is likely to modulate QTc duration, the mechanism and clinical implications of QTc interval prolongation in syndrome X remain speculative.

925-41 Coronary Sinus pH During Dipyridamole Infusion in Patients with Angina and Hypertrophic Cardiomyopathy

Typical angina pectoris and myocardial scarring suggestive of ischemia are common in patients with hypertrophic cardiomyopathy (HCM). However, the clinical evaluation of myocardial ischemia in HCM remains problematic as baseline ECG abnormalities are frequent and thallium-201 perfusion abnormalities correlate poorly with anginal symptoms. Similarly, coronary sinus lactate studies are subject to sampling errors. Coronary sinus pH measurement using a catheter mounted pH electrode is a validated, sensitive technique for the detection of myocardial ischemia. The change in coronary sinus pH during i.v. dipyridamole was determined in 10 patients with HCM and typical exertional chest pain (7 male, mean age 35 ± 11 years, range 19–53). Eight patients had ST segment depression of ≥ 1 mm in 2 or more leads of the baseline ECG at rest and 4 had reversible perfusion defects during stress thallium-201 scintigraphy. The pH electrode was introduced into the coronary sinus via the subclavian vein and dipyridamole (0.5 mg/kg) administered by slow i.v. injection. All patients experienced typical chest pain associated with a fall in coronary sinus pH (mean 0.08 ± 0.04, range: 0.020.15 units). Eight patients had changes ≥ 0.04 units. ST depression ( ≥ 1 mm from baseline) occurred in 3 patients. Peak heart rate Imean 95.5 ± 12 bpm, range 80 – 115) correlated with the maximal pH change (r = 0.7, P = 0.02). There was no association between maximum pH change and left ventricular dimensions or outflow tract gradient. Chest pain during dipyridamole infusion in patients with HCM is caused by myocardial ischemia. Coronary sinus pH electrodes can be used successfully in the evaluation of myocardial ischemia risk in patients with HCM.