On the use of chest leads in clinical electrocardiography

The literature on chest leads in clinical electrocardiography is reviewed. This review is accompanied by comments on articles and case reports dealing with the subject.The early literature appears to be colored by an unwarranted enthusiasm on the subject, leading on the one hand to an overemphasis of the value of chest leads, and on the other to a tendency to underrate the significance of abnormalities in the standard leads.The coventional chest leads, Leads IV, V, and VI have been examined, and their significant features are discussed.It is suggested that a chest lead for routine electrocardiography embody the following features: (a) that its tracing record maximal deflections and that it include well-defined auricular as well as ventricular complexes; (b) that its tracing be symmetrical with the standard leads; and (c) that the chest lead require but a single chest electrode.The right arm chest lead has been found to fulfill these requirements.Objections are offered to the numerical designation of chest leads. It is suggested that instead chest leads be designated by well-known anatomical landmarks, indicating the location of the principal or chest electrode.Right pectoral (Rp), left pectoral (Lp), and apical (Ap) leads are suggested as routine chest leads in clinical electrocardiography. In these the right arm attachment used in the standard leads serves as the fixed secondary electrode, and the principal or chest electrode is attached to the left arm cable.It is concluded that while chest leads have found a permanent place in clinical electrocardiography, standard leads are still to be regarded as the more dependable, and a parallel study of standard lead tracings, particularly with reference to minor deviations, should be persued with at least as much attention as the study of chest leads.     

A case of smoking-induced chest pain improved with beta2-stimulant

A 24-year-old Japanese man presented with a complaint of chest pressure. He began to have severe chest pressure several times a day. The attack was frequently induced by smoking. During an attack, we gave him an inhalation with procaterol hydrochloride, and his chest tightness disappeared. He was suspected to have chest pain variant asthma. We asked him to stop smoking, and gave him corticosteroid, and his chest pressure did not reappear. This disease is relatively unknown. There is a need for a better dissemination of knowledge about this disease.     

The prevalence of the cardiac origin of chest pain: the experience of a rural area of southeast Italy

This study was designed to assess the application of diagnostic guidelines to the management of chest pain by an observational study carried out in a small town (Ragusa) of southeast Sicily. This study was an attempt to compare a Sicilian experience with the literature. In this observational study, we examined all the patients referred for chest pain to the Emergency Department (ED) of “Civile-M. P. Arezzo” Hospital during a period of 6 months (from January 1st 2008 to June 30th 2008). As much as 857 patients were studied. The results of our study show that musculoskeletal chest pain is the most common final diagnosis (49%), followed by cardiac chest pain (26.3%), gastrointestinal chest pain (13%), pulmonary chest pain (7%) and psychiatric chest pain (4%). The majority of patients (95%) never made contact with their primary care providers, and came straight to ED. These results emphasize the need for reworking a strategy to avoid the situation in which all cases of non-emergency chest pain, such as musculoskeletal ones, come to the hospital for evaluation, thereby overwhelming the ED, particularly in rural areas where the management of any emergency is centralized in a single hospital.     

Acute chest syndrome as the inaugural sign of sickle cell anemia. A case report and review of the literature

Acute chest syndrome is a frequent complication of sickle cell disease. This syndrome is characterized by recent infiltrate on chest X-ray with chest pain or fever or dyspnea. We report the case of a 26-year-old man in whom an acute chest syndrome with fat embolism was the inaugural sign of sickle cell disease. This report illustrates the frequency of potentially serious fat embolism in the acute chest syndrome and the importance of bronchoscopy and bronchoalveolar lavage (fatty macrophages) for determining the etiology of acute chest syndrome.     

Evaluation of chest wall distortion related to cardiac activity by structured lights. A study of the apical impulse by the Moiré technique

The use of structured lights and especially of the Moiré technique to evaluate chest wall distortion in front of the apical impulse allows a topographic study of the precordial movement in relation with cardiac activity. Shade Moiré technology offers the possibility to study a reduced area of the chest with a good enlargement effect and well contrasted fringes. Projected Moiré allows the study of an increased area of the chest (40 cm2) and provides less contrasted pictures with a reduced enlargement effect. Both techniques offer the possibility of automatic imaging. The study of a normal subject is realized with a topographic evaluation of the chest wall distortion on a endsystolic frame. 3D representation of the chest wall deformation is performed after image treatment on a endsystolic print.     

Chest CT of incidental breast lesions

Chest computed tomography (CT) is routinely used for the evaluation of diseases of the chest involving the lung, mediastinum, pleura, chest wall, and diaphragm. Benign and malignant breast lesions are not uncommonly encountered incidentally on chest CT. The chest CT radiologist should be aware of the different breast pathologies and their CT appearances as some can be diagnosed by chest CT, whereas others, such as breast cancer, should not be overlooked. The purpose of this pictorial essay is to show various common and uncommon breast conditions encountered while interpreting chest CT scans in our daily practice.     

Chest Pain Relieved with a Bronchodilator or Other Asthma Drugs

BackgroundAlthough many patients who experience chest pain or pressure consult their physicians, unfortunately a large number of them do not, and consequently they remain undiagnosed and untreated. Chest pain, in a subset of these patients, may be relieved with a bronchodilator or other asthma drugs.MethodsThis retrospective study included twenty cases of chest pain that were relieved with asthma drugs. Chest pain was categorized into three types: chest pain variant asthma, bronchial asthma with chest pain, and non-asthmatic allergic chest pain. Chest pain variant asthma was defined as chest pressure that improved in response to a bronchodilator, without the characteristic attacks of bronchial asthma. Bronchial asthma with chest pain was defined as chest pressure, with the characteristic attacks of bronchial asthma that improved following the administration of a leukotriene receptor antagonist, systemic corticosteroid, or bronchodilator. Non-asthmatic allergic chest pain was defined as chest pressure without the typical asthma attack, but with chest pressure that improved in response to a leukotriene receptor antagonist or systemic corticosteroid, but not a bronchodilator.ResultsFourteen cases of chest pain were diagnosed as variant asthma, three cases were diagnosed as bronchial asthma with chest pain, and three cases were diagnosed as non-asthmatic allergic chest pain.ConclusionsThe results suggest that the mechanism underlying chest pain that is relieved with asthma drugs can involve either an airway constriction pathway or a non-constrictive pathway presumably airway inflammation. Analysis of the patient's response to treatment with asthma medication is useful for the correct diagnosis of the source of chest pain.     

A case of Boerhaave's syndrome presenting as diffuse left pulmonary infiltrate

A case of spontaneous esophageal rupture (Boerhaave's syndrome) is presented. The patient was referred from an outside hospital emergency department to Los Angeles County/University of Southern California Medical Center with a history of acute left-sided chest pain immediately after an episode of forceful vomiting. An upright chest radiograph revealed a left hydropneumothorax. The diagnosis of Boerhaave's syndrome was confirmed with the placement of a chest tube and extraction of serosanguinous fluid and partially digested food particles from the left hemithorax. The patient underwent surgical repair and was discharged from the hospital in good condition. Boerhaave's syndrome is extremely rare. The predominant symptoms of chest pain and dyspnea also are found in many common disease entities, making early diagnosis difficult. Delay in diagnosis and treatment results in substantial morbidity and mortality. This case exemplifies the importance of obtaining an upright chest radiograph to make a prompt diagnosis.     

Acute chest syndrome of adults suffering from sickle cell disease

Sickle cell disease is a common but often poorly understood by chest physicians. The acute chest syndrome represents its main respiratory complication. STATE OF ART: Sickle cell disease is an autosomal recessive disorder inducing, in certain circumstances, sickling of red cells. Natives from western or central Africa and from the Caribbean islands are mainly affected. Acute chest syndrome is defined by the association of chest pain or fever and recent radiographic infiltrates, in patients suffering from sickle cell disease. Determination of etiology, infection, fat embolism or hypoventilation, is difficult, as a self-perpetuating vicious circle is ongoing. Support, largely undervalued, is based on etiological treatment and measures to avoid worsening linked to complications, especially microcirculatory disease. CONCLUSIONS: Acute chest syndrome is a severe respiratory complication of sickle cell disease. Therapeutic measures are simple but undervalued.     

Reversible cardiogenic shock due to chest tube compression of the right ventricle

A 62-year-old woman developed shock immediately after the insertion of a right-sided chest tube. A chest roentgenogram showed the chest tube to be overlying the heart and possibly compressing the right ventricle. An animal model was developed to replicate this clinical situation. Using a domestic goat model pulmonary artery, peripheral arterial catheters were inserted along with a right sided chest tube placed to suction. A second chest tube guided by a flexible fiberoptic bronchoscope placed within its lumen was positioned between the right ventricle and the sternum of the animals. Thirteen paired measurements in three goats (average of 4.3 measurements per animal) of cardiac output, heart rate, and mean arterial blood pressure were made at baseline and after chest tube placement over the right ventricle. The data were analyzed using a paired t test statistic. Compared with baseline measurements, there was a significant decrease in cardiac output (p less than 0.001) and mean arterial pressure (p less than 0.001) as well as an increase in heart rate (p = 0.0056) after placement of the chest tube across the right ventricle. We conclude that a misplaced chest tube compressing the right ventricle can impede cardiac output and lead to a low cardiac output state. Physicians inserting chest tubes in patients should be aware of this potential complication as it is easily treated by withdrawal of the chest tube.     

Cardiac output increases prior to development of pulmonary edema after re-expansion of spontaneous pneumothorax

Pulmonary edema following reexpansion of spontaneous pneumothorax is an uncommon complication. The underlying mechanism of this condition is unclear. We report the hemodynamic characteristics in a series of 7 male patients with spontaneous large (>50%) pneumothoraces of > or = 24 h and correlate the changes with reexpansion pulmonary edema (REPE). A pulmonary artery floatation catheter was inserted and hemodynamic data were obtained before therapeutic chest tube insertion, 1 h after chest tube insertion and the following day. Four (57%) patients developed REPE. There was a tendency for larger pneumothorax to develop REPE. Capillary wedge pressure did not change significantly 1 h after the insertion of chest tube in all our patients. Cardiac output increased significantly in patients who developed REPE compared to those who did not (+ 1.06 l/min vs -0.27 l/min; P = 0.03) 1 h after insertion of chest tube. One patient did not develop pulmonary edema despite having a large (> 80%) pneumothorax. His cardiac output did not rise 1 h after chest tube insertion. REPE is not an uncommon complication following chest tube drainage in patients with large and long-standing pneumothorax. The increase in cardiac output after chest tube insertion may be associated with subsequent development of REPE.     

急性胸痛早期危险分层的研究进展

急性胸痛是急诊常见病症,早期危险分层识别高危和低危急性胸痛,既可缩短治疗时间,改善临床预后,又可避免过度诊疗,节约医疗资源。目前急性胸痛风险评估策略不断改善,急性胸痛早期危险分层的准确度逐步提高,但是危险分层工具的敏感性和特异性不一。现对目前急性胸痛早期危险分层的现状进行综述。     

Scintigraphic detection of carcinoid tumors with a cost effectiveness analysis

AIM: To evaluate the diagnostic sensitivity and accuracy and the cost-effectiveness of this technique in the detection of gastroenteropancreatic carcinoid tumors and their metastases in comparison with conventional imaging methods. METHODS: Somatostatin receptor scintigraphy (SRS) was performed in 24 patients with confirmed carcinoids and 7 under investigation. The results were compared with those of conventional imaging methods (chest X-ray, upper abdominal ultrasound, chest CT, upper and lower abdominal CT). Also a cost-effectiveness analysis was performed comparing the cost in Euro of several combinations of SRS with conventional imaging modalities. RESULTS: SRS visualized primary or metastatic sites in 71.0% of cases and 61.3% of conventional imagings. The diagnostic sensitivity of the method was higher in patients with suspected lesions (85.7% vs 57.1%). SRS was less sensitive in the detection of metastatic sites (78.9% vs 84.2%). The undetectable lesions by SRS metastatic sites were all in the liver. Between several imaging combinations, the combinations of chest X-ray/upper abdominal CT/SRS and chest CT/upper abdominal CT/SRS showed the highest sensitivity (88.75%) in terms of the number of detected lesions. The combinations of chest X-ray/upper abdominal US/SRS and chest CT/upper abdominal ultrasound /SRS yielded also a quite similar sensitivity (82%). Compared to the cost of the four sensitive combinations the combination of chest X-ray/upper abdominal ultrasound/SRS presented the lower cost, 1183.99 Euro vs 1251.75 Euro for chest CT/upper abdominal ultrasound/SRS, 1294.93 Euro for chest X/ray/upper abdominal CT/SRS and 1362.75 Euro for chest CT/upper abdominal CT/SRS. CONCLUSION: SRS imaging is a very sensitive method for the detection of gastroenteropancreatic carcinoids but is less sensitive than ultrasound and CT in the detection of liver metastases. Between several imaging combinations, the combination of chest X-ray/upper abdominal CT/SRS shows the highest sensitivity with a cost of 1294.93 Euro.     

Trauma: an unusual aetiology of pulmonary pseudocyst

Traumatic pulmonary pseudocyst due to blunt chest trauma is rare. It is a clinical entity that manifests itself with minor clinical and major radiological signs. We report a case of a 16-year-old girl, who during an attack by a violent cow sustained a chest impact that resulted in a traumatic pulmonary pseudocyst, confirmed with a computed tomographic (CT) scan of the chest. The patient recovered with conservative management.     

Chest computed tomography in the staging of pancreatic and periampullary carcinoma

BACKGROUND: Staging of the tumours in the pancreas and periampullary region usually consists of abdominal computed tomography (CT). Laparoscopy is also advocated. Little attention has been paid to extra-abdominal staging. In addition to peritoneal, lymphatic and hepatic metastases, lung metastases are frequently found. The chest CT scan has been demonstrated as better than the plain chest roentgenogram or conventional tomography in demonstrating lung tumours. This study was done to evaluate whether the chest CT scan gives information additional to the plain chest roentgenogram in the staging of pancreatic and periampullary tumours. METHODS: Fifty-three patients with a pancreatic or periampullary tumour underwent helical CT scan of the chest in addition to the abdominal CT scan. The CT scans and the chest roentgenograms were read separately without the result of the other being known; the results were compared with each other and with the clinical and operative findings. RESULTS: In the chest CT scan, 7 out of 53 (13%) patients had nodules in the lungs. The chest pathologies were not seen in the chest roentgenogram except for pneumonia in one patient and lung tumours in another (sensitivity of the chest roentgenogram 2/7 = 29%). Liver metastasis, local invasion of the tumour or poor general condition of the patient made lung biopsy or bronchoscopy unnecessary or impossible. CONCLUSION: Lung metastases seldom appear in patients with pancreatic or periampullary carcinoma without other contraindications for resection, which is why the chest CT scan cannot be recommended in the staging of these tumours for operation.     

A case of blunt chest trauma induced acute myocardial infarction involving two vessels

Blunt chest trauma rarely induces acute myocardial infarction. We report a 36-year-old man who suffered from blunt trauma to the anterior chest wall while operating a punching machine. This case is the first report of simultaneous blunt chest trauma to the left anterior descending artery and left circumflex artery. The patient was treated surgically and discharged without any serious sequela. Early detection of the lesion site is important with regard to selecting the appropriate treatment strategy in patients with coronary injury caused by blunt chest trauma. Routine 12-lead electrocardiography and serial cardiac enzyme evaluation are necessary in every patient with chest trauma because they supply crucial information about the extent of cardiac damage. Treatment with primary angioplasty or bypass surgery should be based on the characteristics of the lesion and the associated problem.     

Diaphragmatic paralysis caused by malposition of chest tube placement after pediatric cardiac surgery

Diaphragmatic paralysis is a recognized complication after pediatric cardiac surgery. It is universally acknowledged that direct phrenic nerve injury during surgery is the etiology. However, we experienced two unusual cases of diaphragmatic paralysis following malposition of chest tube placement after pediatric cardiac surgery. The malposition of too deeply placed chest tube with resultant phrenic nerve injury was presumably the underlying cause. One patient underwent successful diaphragmatic plication due to intractable respiratory distress. The other was asymptomatic. Our report highlights the previously unreported complication of chest tube-induced phrenic nerve injury following its malposition after pediatric cardiac surgery. Prompt recognition and correction of tube malposition or selection of a softer chest tube probably can ameliorate the problem.     

Chest computed tomography in the staging of pancreatic and periampullary carcinoma

Background: Staging of the tumours in the pancreas and periampullary region usually consists of abdominal computed tomography (CT). Laparoscopy is also advocated. Little attention has been paid to extra‐abdominal staging. In addition to peritoneal, lymphatic and hepatic metastases, lung metastases are frequently found. The chest CT scan has been demonstrated as better than the plain chest roentgenogram or conventional tomography in demonstrating lung tumours. This study was done to evaluate whether the chest CT scan gives information additional to the plain chest roentgenogram in the staging of pancreatic and periampullary tumours. Methods: Fifty‐three patients with a pancreatic or periampullary tumour underwent helical CT scan of the chest in addition to the abdominal CT scan. The CT scans and the chest roentgenograms were read separately without the result of the other being known; the results were compared with each other and with the clinical and operative findings. Results: In the chest CT scan, 7 out of 53 (13%) patients had nodules in the lungs. The chest pathologies were not seen in the chest roentgenogram except for pneumonia in one patient and lung tumours in another (sensitivity of the chest roentgenogram 2/7?=?29%). Liver metastasis, local invasion of the tumour or poor general condition of the patient made lung biopsy or bronchoscopy unnecessary or impossible. Conclusion: Lung metastases seldom appear in patients with pancreatic or periampullary carcinoma without other contraindications for resection, which is why the chest CT scan cannot be recommended in the staging of these tumours for operation.     

Low yield of chest radiography in screening for active pulmonary tuberculosis in HIV-infected patients in Hong Kong.

This study assessed the usefulness of routine chest radiography for detecting active pulmonary tuberculosis in persons infected with human immunodeficiency virus (HIV) without suggestive symptoms in Hong Kong. Tuberculosis is common in this locality and tuberculosis/HIV co-infection has been a frequent and significant problem. Records of patients attending the largest HIV clinic were reviewed. Three hundred and eleven routine chest radiographs were performed among 191 HIV-infected patients with a total follow-up period of 792 person years. Of the 22 routine chest radiographs that had abnormalities in the lungs or hilar region, only one had led to the diagnosis of pulmonary tuberculosis. No patient with a normal chest radiograph was diagnosed to have tuberculosis within the following 2 months. The low yield (0.32%) suggests that routine chest radiography is not useful in screening for active pulmonary tuberculosis in asymptomatic HIV-infected patients even in a locality where the tuberculosis rate is high.