A 43 year old woman with a 40 year history of exertional chest pain

BMJ ◽  
2012 ◽  
Vol 344 (feb02 2) ◽  
pp. e628-e628
Author(s):  
P. D. Morris ◽  
K. J. Trevest ◽  
A. Y. Butt ◽  
E. D. Grech
Keyword(s):  
Chest Pain ◽  
History Of

scholarly journals Diagnostic markers for discriminating between acute aortic dissection and acute myocardial infarction during the pre-hospital phase: analysis of 3,195 cases

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
K Watanabe ◽  
H Yoshino ◽  
T Takahashi ◽  
M Usui ◽  
K Akutsu ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Back Pain ◽  
Chest Pain ◽  
Aortic Dissection ◽  
Acute Aortic Dissection ◽  
Diagnostic Markers ◽  
Network Database ◽  
History Of ◽  
First Contact

Abstract   Both acute aortic dissection (AAD) and acute myocardial infarction (AMI) present with chest pain and are life-threatening diseases that require early diagnosis and treatment for better clinical outcome. However, two critical diseases in the very acute phase are sometimes difficult to differentiate, especially prior to arrival at the hospital for urgent diagnosis and selection of specific treatment. The aim of our study was to clarify the diagnostic markers acquired from the information gathered from medical history taking and physical examination for discriminating AAD from AMI by using data from the Tokyo Cardiovascular Care Unit (CCU) Network database. We examined the clinical features and laboratory data of patients with AAD and AMI who were admitted to the hospital in Tokyo between January 2013 and December 2015 by using the Tokyo CCU Network database. The Tokyo CCU Network consists of >60 hospitals that fulfil certain clinical criteria and receive patients from ambulance units coordinated by the Tokyo Fire Department. Of 15,061 patients diagnosed as having AAD and AMI, 3,195 with chest pain within 2 hours after symptom onset (537 AAD and 2,658 AMI) were examined. The patients with out-of-hospital cardiac arrest were excluded. We compared the clinical data of the patients with chest pain who were diagnosed as having AAD and AMI. The following indicators were more frequent or had higher values among those with AAD: female sex (38% vs. 20%, P<0.001), systolic blood pressures (SBPs) at the time of first contact by the emergency crew (142 mmHg vs. 127 mmHg), back pain in addition to chest pain (54% vs. 5%, P<0.001), history of hypertension (73% vs. 58%, P<0.001), SBP ≥150 mmHg (39% vs. 22%, P<0.001), back pain combined with SBP ≥150 mmHg (23% vs. 0.8%, P<0.001), and back pain with SBP <90 mmHg (4.5% vs. 0.1%, P<0.001). The following data were less frequently observed among those with AAD: diabetes mellitus (7% vs. 28%, P<0.001), dyslipidaemia (17% vs. 42%, P<0.001), and history of smoking (48% vs. 61%, P<0.001). The multivariate regression analysis suggested that back pain with SBP ≥150 mmHg (odds ratio [OR] 47; 95% confidence interval [CI] 28–77; P<0.001), back pain with SBP <90 mmHg (OR 68, 95% CI 16–297, P<0.001), and history of smoking (OR 0.49, 95% CI 0.38–0.63, P<0.001) were the independent markers of AAD. The sensitivity and specificity of back pain with SBPs of ≥150 mmHg and back pain with SBPs <90 mmHg for detecting AAD were 23% and 99%, and 4% and 99%, respectively. In patients with chest pain suspicious of AAD and AMI, “back pain accompanied by chest pain with SBP ≥150 mmHg” or “back pain accompanied by chest pain with SBP <90 mmH” is a reliable diagnostic marker of AAD with high specificity, although the sensitivity was low. The two SBP values with back pain are markers that may be useful for the ambulance crew at their first contact with patients with chest pain. Funding Acknowledgement Type of funding source: None

scholarly journals Clinical judgement in chest pain: a case report 

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Mishita Goel ◽  
Shubhkarman Dhillon ◽  
Sarwan Kumar ◽  
Vesna Tegeltija
Keyword(s):  
Chest Pain ◽  
Coronary Artery ◽  
Tobacco Use ◽  
Stress Test ◽  
Artery Bypass ◽  
Pretest Probability ◽  
Clinical Judgement ◽  
Test Results ◽  
Cardiac Stress ◽  
History Of

Abstract Background Cardiac stress testing is a validated diagnostic tool to assess symptomatic patients with intermediate pretest probability of coronary artery disease (CAD). However, in some cases, the cardiac stress test may provide inconclusive results and the decision for further workup typically depends on the clinical judgement of the physician. These decisions can greatly affect patient outcomes. Case presentation We present an interesting case of a 54-year-old Caucasian male with history of tobacco use and gastroesophageal reflux disease (GERD) who presented with atypical chest pain. He had an asymptomatic electrocardiogram (EKG) stress test with intermediate probability of ischemia. Further workup with coronary computed tomography angiography (CCTA) and cardiac catheterization revealed multivessel CAD requiring a bypass surgery. In this case, the patient only had a history of tobacco use but no other significant comorbidities. He was clinically stable during his hospital stay and his testing was anticipated to be negative. However to complete workup, cardiology recommended anatomical testing with CCTA given the indeterminate EKG stress test results but the results of significant stenosis were surprising with the patient eventually requiring coronary artery bypass grafting (CABG). Conclusion As a result of the availability of multiple noninvasive diagnostic tests with almost similar sensitivities for CAD, physicians often face this dilemma of choosing the right test for optimal evaluation of chest pain in patients with intermediate pretest probability of CAD. Optimal test selection requires an individualized patient approach. Our experience with this case emphasizes the role of history taking, clinical judgement, and the risk/benefit ratio in deciding further workup when faced with inconclusive stress test results. Physicians should have a lower threshold for further workup of patients with inconclusive or even negative stress test results because of the diagnostic limitations of the test. Instead, utilizing a different, anatomical test may be more valuable. Specifically, the case established the usefulness of CCTA in cases such as this where other CAD diagnostic testing is indeterminate.

A palpable chest wall mass in a 4-year-old boy

2021 ◽  
pp. e20200053
Author(s):  
Jakob M Domm ◽  
Joanne M Langley
Keyword(s):  
Chest Pain ◽  
Tract Infection ◽  
Respiratory Tract ◽  
Chest Wall ◽  
Respiratory Infection ◽  
Lower Respiratory Tract ◽  
Atypical Presentation ◽  
History Of ◽  
Wall Mass ◽  
Chest Wall Mass

Empyema necessitans (EN) is a rare but dangerous complication of a lower respiratory tract infection. The diagnosis can be difficult to make and therefore delayed. We describe a case of a child with an atypical presentation of EN. He was afebrile and without chest pain and presented with a palpable chest wall mass after a history of recent respiratory infection. The threshold of suspicion for EN should be low, and it must be suspected in all children with a chest wall mass and recent history of respiratory infection.

Abstract 115: Predictors Of A Positive Stress Test Among Patient Presenting To The Emergency Department With Chest Pain

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Taraka V Gadiraju ◽  
Jahnavi Sagi ◽  
Dev Basu ◽  
Srikanth Penumetsa ◽  
Michael Rothberg
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Stress Test ◽  
Tertiary Care ◽  
Face Validity ◽  
Pseudorandom Number Generator ◽  
Multivariable Model ◽  
Final Multivariable Model ◽  
Significant Difference ◽  
History Of

Objectives: Patients frequently present to the hospital with chest pain. Once myocardial infarction is ruled out based on EKG and cardiac enzymes, most patients undergo stress testing, but only few patients have a positive test. In ambulatory practice, age, sex and symptomatology can establish pretest probability of the coronary disease. However, there are no studies evaluating the predictors of a positive stress test in the emergency department (ED). We assessed predictors for a positive stress test in patients presenting to our hospital with chest pain. Methods: This is a case-control study conducted on a subset of patients admitted to our tertiary care center with chest pain between 2007 and 2009, and who had an inpatient stress test (n=1474). Using chart review, we identified 87 patients, whose stress tests were positive (abnormals), defined as presence of ischemia on EKG and/or imaging modalities. We then used a pseudorandom number generator to select 194 patients whose stress test results were normal (normals) for comparison. Clinical features of chest pain and CAD risk factors were abstracted from the medical record for comparison. A bivariable screening process was used to identify characteristics for inclusion in a multivariable predictive model. Sex and age were maintained in the model for face validity, and remaining covariates were removed in ascending order of their z-statistics until only those with a two-sided p-value of <0.10 remained. Stata 12.1 (Copyright 2011, StataCorp LP) was used for all analyses. Results: Patients with an abnormal stress test were older and more likely to be male and to have a history of vascular disease. Although patients with abnormal stress test were more likely to have history of hypertension, hyperlipidemia and current or ex-smoking, this difference was not statistically significant. Over half of the patients presented with non-cardiac chest pain and there was no significant difference in the chest pain characteristics between patients who had a normal and an abnormal stress test result. In the final multivariable model, when compared to the normals, abnormals were four times as likely to have a history of revascularization (OR 4.13, 95% CI 2.11, 8.09) and twice as likely to have a history of hyperlipidemia (OR 2.1, 95% CI 1.18, 3.79). They were also more likely to have an EKG suggestive of ischemia at presentation (OR 1.90, 95% CI 1.03, 3.53). Specificity of the model was 89%; sensitivity was 43%, and the c-statistic for the final multivariable model was 0.76, suggesting fair to good discrimination. Conclusions: Among patients presenting to the ED with chest pain, a past history of revascularization and hyperlipidemia and an EKG suggestive of ischemia may independently predict the likelihood of an abnormal stress test. Further validation of this model on an external dataset is necessary.

A rare case of spontaneous haemothorax in patient with haemophilia A

2021 ◽  
Vol 14 (4) ◽  
pp. e242412
Author(s):  
Suthaphong Tripoppoom ◽  
Nophol Leelayuwatanakul
Keyword(s):  
Chest Pain ◽  
Rare Case ◽  
Rare Event ◽  
Haemophilia A ◽  
Minor Trauma ◽  
Conservative Approach ◽  
Pleuritic Chest Pain ◽  
Good Clinical Outcome ◽  
History Of

Haemorrhage in patients with haemophilia is common after minor trauma but may occur spontaneously. Despite the diversity of bleeding sites, spontaneous haemothorax, on a non-traumatic basis, is an exceedingly rare event and only a few cases had been reported. We present a case of a 43-year-old man with a history of haemophilia A who had pleuritic chest pain for 1 day without significant history of trauma. Diagnostic thoracentesis showed bloody pleural fluid in which neither abnormal cell nor organism was found. He was treated by cryoprecipitate replacement and therapeutic thoracentesis for releasing haemothorax. After discharge, the patient returned for follow-up with complete radiological resolution. Regarding the consequences of retained haemothorax from conservative approach and the procedure-related bleeding of given therapeutic intervention in haemothorax making its management in patients with haemophilia to be more challenging. Our case illustrates a conservative treatment of spontaneous haemothorax in patient with haemophilia resulting in a good clinical outcome.

scholarly journals Chest Pain and Exercise Induced Ischemia with Angiographically Insignificant Coronary Arterial Disease: Clinical Presentation and Follow-Up

1970 ◽  
Vol 6 (1) ◽  
pp. 27-31
Author(s):  
Md Khurshed Ahmed ◽  
Mohammad Salman ◽  
Md Ashraf Uddin Sultan ◽  
Md Abu Siddique ◽  
KMHS Sirajul Haque ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cardiovascular Risk ◽  
Chest Pain ◽  
Stress Test ◽  
Exercise Stress Test ◽  
Exercise Stress ◽  
Coronary Angiogram ◽  
Ecg Changes ◽  
History Of

Angiography of patients with typical chest pain reveals normal epicardial coronary arteries in about 15-20%. ECG changes suggestive of myocardial ischemia during exercise also can be demonstrated in this subset of the patients. Total 58 patients (42 females) with mean age 42±7 years who were undergoing coronary angiogram in the Department of Cardiology, University Cardiac Center, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from January 2005 to December 2009 were evaluated. The patients were recruited on the basis of presence of history of chest pain, with normal resting ECG and ischemia like ECG changes during exercise stress test. 32.8% patients had hypertension and 15.5% were diabetics, 19.0% had dyslipidemia and 6.9% had family history of ischemic heart disease. All the patients were having positive exercise stress test. Angiographic findings showed luminal irregularities in 29.3% patients, 15.5% patients had luminal stenosis less than 30% and rest had normal coronary angiogram. Follow up of the patients after one and six months of angiogram was done. After one month 63.8% patients remained symptomatic and after six months 63.3% patients remained symptomatic despite maximum medical management. The pathophysiology and appropriate management of this subset of the patients still remained a challenge for physicians. Optimum management of cardiovascular risk factors is very important issue in this group of patients.Key words: Angiography; Epicardial coronary arteries; Exercise stress test; Cardiovascular risk factors. DOI: 10.3329/uhj.v6i1.7187University Heart Journal Vol.6(1) 2010 pp.27-31

scholarly journals Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome

CJEM ◽  
2010 ◽  
Vol 12 (02) ◽  
pp. 128-134 ◽  
Author(s):  
Erik P. Hess ◽  
Jeffrey J. Perry ◽  
Pam Ladouceur ◽  
George A. Wells ◽  
Ian G. Stiell
Keyword(s):  
Heart Failure ◽  
Emergency Department ◽  
Congestive Heart Failure ◽  
Chest Pain ◽  
Chest Radiography ◽  
Clinical Decision ◽  
Chest Radiographs ◽  
Clinical Decision Rule ◽  
Coronary Syndrome ◽  
History Of

ABSTRACTObjective:We derived a clinical decision rule to determine which emergency department (ED) patients with chest pain and possible acute coronary syndrome (ACS) require chest radiography.Methods:We prospectively enrolled patients over 24 years of age with a primary complaint of chest pain and possible ACS over a 6-month period. Emergency physicians completed standardized clinical assessments and ordered chest radiographs as appropriate. Two blinded investigators independently classified chest radiographs as “normal,” “abnormal not requiring intervention” and “abnormal requiring intervention,” based on review of the radiology report and the medical record. The primary outcome was abnormality of chest radiographs requiring acute intervention. Analyses included interrater reliability assessment (with κ statistics), univariate analyses and recursive partitioning.Results:We enrolled 529 patients during the study period between Jul. 1, 2007, and Dec. 31, 2007. Patients had a mean age of 59.9 years, 60.3% were male, 4.0% had a history of congestive heart failure and 21.9% had a history of acute myocardial infarction. Only 2.1% (95% confidence interval [CI] 1.1%–3.8%) of patients had radiographic abnormality of the chest requiring acute intervention. The κ statistic for chest radiograph classification was 0.81 (95% CI 0.66–0.95). We derived the following rule: patients can forgo chest radiography if they have no history of congestive heart failure, no history of smoking and no abnormalities on lung auscultation. The rule was 100% sensitive (95% CI 32.0%–10.4%) and 36.1% specific (95% CI 32.0%–40.4%).Conclusion:This rule has potential to reduce health care costs and enhance ED patient flow. It requires validation in an independent patient population before introduction into clinical practice.

scholarly journals A Suspected COVID-19-associated Myocarditis Case Mimicking Life-threatening STEMI: a Shark Fin Appearance

2021 ◽  
Vol 2 (1) ◽  
pp. 23
Author(s):  
Ratna Mariana Tamba ◽  
Andika Sitepu
Keyword(s):  
Chest Pain ◽  
Rapid Test ◽  
Myocardial Damage ◽  
Ground Glass Opacity ◽  
Normal Coronary Artery ◽  
Proinflammatory Response ◽  
Cardiac Biomarker ◽  
Life Threatening ◽  
History Of ◽  
St Elevation

Some cases of myocarditis have been reported associated to Covid-19. The presence of proinflammatory response from immune cells suggested occurs by binding to membrane protein ACE-2 leading to myocardial damage. Our hospital got a refferal from a non-PCI-capable hospital with a 51-years-old woman chest pain and progressive heavy breath with history of fever two days ago. She was diagnosed with anterior STEMI and cardiogenic shock on vassopressors. Her electrocardiogram showed shark fin appearance suggesting life-threatening STEMI. Her rapid test for covid-19 are non-reactive for both IgM and IgG. Her NCCT-thorax showed ground glass opacity in both lungs. Her laboratories finding showed elevated inflammatory markers and elevated cardiac biomarker. We took her naso-oro-pharingeal swab in the same day and process her with emergency PCI. Surprisingly, her angiography showed normal coronary artery without any significant stenosis. From There was no SARS-CoV-2 detected. In myocarditis, patient can mimick the same symptoms as STEMI such as chest pain and heavy breath with elevated cardiac biomarker, but the electrocardiogram usually shows widespread concave ST-elevation with PR-segment depression. Shark fin appearance is usually seen in life-threatening STEMI. In our patient, the NCCT-thorax showed GGO suggested Covid-19 involvement. But, the first swab was negative for SARS-CoV-2. Unfortunately, the patient was discharged without doctor’s consent, so we can not process the second swab and echocardiography to evaluate the function of myocardium. We still can not confirmed this case if it is true myocarditis-associated covid-19 and how was the involvement of the myocardium creating a shark fin mimicking life-threatening STEMI.

scholarly journals TREMORS MIMICKING ATRIAL FLUTTER IN AN ELDERLY LADY

2022 ◽  
Vol 54 (4) ◽  
pp. 370-372
Author(s):  
Intisar Ahmed ◽  
Hunaina Shahab ◽  
Aamir Hameed Khan
Keyword(s):  
Chest Pain ◽  
Sinus Rhythm ◽  
Hospital Stay ◽  
Atrial Flutter ◽  
Normal Sinus Rhythm ◽  
Correct Diagnosis ◽  
Normal Sinus ◽  
Inappropriate Treatment ◽  
History Of

A 77 -year-old lady with history of hypertension and Parkinson`s disease was admitted with cough and fever and diagnosed as pneumonia. On second day of admission, she started having chest pain, initial ECG was interpreted as atrial flutter. When her ECG was reviewed by a cardiologist, ECG features were found to be consistent with artifacts due to tremors. A repeat 12 leads ECG clearly demonstrated normal sinus rhythm and the patient remained completely asymptomatic throughout the hospital stay. Tremor induced artifacts can be mistaken for arrhythmias. Correct diagnosis is important, in order to avoid inappropriate treatment and unnecessary interventions.

Abstract 359: Lack Of Blood Pressure Augmentation During Stress Testing Is Associated With Increased Mortality.

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Geoffrey D’Cruz ◽  
Ashish Rastogi ◽  
Neil Yager ◽  
Amarinder Bindra ◽  
Steven A Fein ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Chest Pain ◽  
Stress Echocardiography ◽  
Stress Testing ◽  
Systolic Function ◽  
Stress Test ◽  
Care Center ◽  
Tertiary Care ◽  
History Of ◽  
Response To Exercise

Objective: We investigated long-term outcomes associated with hypertensive response to exercise in patients with chest pain referred for stress echocardiography. Methods: Records of 404 patients with normal baseline LV systolic function (45% females, mean age 60+/-11 years, baseline SBP 136+/-20 mmHg, 26% with CAD, 4% with CHF, 39% with hypertension, 13% with diabetes mellitus, 5% with peripheral vascular disease, 21% with history of smoking or active smoking, 43% on beta-blockers, 23% on ACE-inhibitors/ARBs) referred for chest pain evaluation with stress echocardiography at a single tertiary care center were reviewed. Demographics, clinical data, and outcomes were collected. Median length of followup was 35+/-0.3 months. Patients were divided into four groups depending on their maximum blood pressure during exercise (greater or less than 180mmHg) and whether they achieved their age-adjusted target heart rate. Results: Contrary to the expectations, hypertensive response to exercise was not associated with the increased mortality (Table). Instead, lack of blood pressure augmentation during exercise and low double product were predictive of increased mortality. History of CHF (p=0.0003) and/or PVD (p=0.001) were the strongest predictors of failure to augment blood pressure during stress testing. Conclusions: Failure to augment systolic blood pressure during exercise appears to be associated with increased mortality. Although ischemia on echocardiography and reduced exercise capacity are the stress test outcomes traditionally associated with poor prognosis, failure to augment blood pressure during exercise may be an important predictor of mortality as well. Additional studies of this subject are needed.

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