Chest pain after coronary interventional procedures

Chest pain following successful percutaneous coronary interventions is a common problem. Although the development of chest pain after coronary interventions may be of benign character, it is disturbing to patients, relatives and hospital staff. Such pain may be indicative of acute coronary artery closure, coronary artery spasm or myocardial infarction, but may also simply reflect local coronary artery trauma. The distinction between these causes of chest pain is crucial in selecting optimal care. Management of these patients may involve repeat coronary angiography and additional intervention. Commonly, repeat coronary angiography following percutaneous transluminal coronary angioplasty (PTCA) in patients with chest pain demonstrates widely patent lesion sites suggesting that the pain was due to coronary artery spasm, coronary arterial wall stretching or was of non-cardiac origin. As reported by the National Heart, Lung and Blood Institute PTCA Registry, 4.6% of patients after angioplasty have coronary occlusions, 4.8% suffer a myocardial infarction, and 4.2% have coronary spasm. The frequency of chest pain after new device coronary interventions (atherectomy and stenting) seems to be even higher. However, only the minority of patients with post-procedural chest pain have indeed an ischemic event. Therefore, the vast majority of patients have recurrent chest pain without any signs of ischemia. There is some evidence that non-ischemic chest pain after coronary interventions is more common after stent implantation as compared to PTCA (41% vs. 12%). This may be due to the continuous stretching of the arterial wall by the stent as the elastic recoil occurring after PTCA is minimized. In conclusion, chest pain after coronary interventional procedures may potentially be hazardous when due to myocardial ischemia. However, especially after coronary stent placement, cardiologists must consider "stretch pain" due to the overdilation and stretching of the artery caused by the stent in the differential diagnosis. Clinically, it is, therefore, important to recognize that in addition to ischemia-related chest pain other types of chest pain do exist with cardiac origin.     

Chest pain after coronary artery stent implantation

A sizeable proportion of patients who undergo successful coronary artery stent implantation experiences chest pain immediately after the procedure and/or in the following months in the absence of in-stent restenosis. We investigated this phenomenon in 57 consecutive patients with stable angina who underwent successful stent implantation. Chest pain characteristics were assessed before stent implantation and during 6-month follow-up. All patients underwent coronary angiography within 6 months of the procedure 48 hours after exercise thallium-201 perfusion scintigraphy. Patients who did not exhibit in-stent restenosis underwent an ergonovine test at the end of routine coronary angiography. During follow-up, 15 patients complained of chest pain. Six of these patients exhibited scintigraphic evidence of myocardial ischemia and in-stent restenosis at angiography. In the remaining 9 patients, chest pain occurred in the absence of in-stent restenosis at angiography. In 8 of these patients intracoronary ergonovine administration reproduced their habitual pain, whereas it did not cause any pain in the 42 patients who were completely asymptomatic at follow-up and without in-stent restenosis. Ergonovine caused more intense vasoconstriction and nitroglycerin caused more intense vasodilation of the reference coronary diameter in patients with than in patients without ergonovine-induced pain (-17 +/- 3 vs -9 +/- 3%, p <0.001; 9 +/- 6 vs 5 +/- 4%, p <0.02, respectively). In conclusion, chest pain with features similar to habitual angina occurs in the absence of in-stent restenosis in 1/5 of patients after stent implantation and appears to be associated with more intense coronary vasoreactivity.     

冠状动脉支架术后的胸部不适与再狭窄

目的 :了解冠状动脉支架术后胸部不适与再狭窄关系。方法 :选择接受冠状动脉支架术并在 6个月内进行了冠状动脉造影检查的 186例患者 ,对术后胸部不适和无胸部不适患者进行冠心病易患因素和术后再狭窄比较。结果 :胸部不适和无胸部不适者术后支架内再狭窄的百分率分别为 2 1.4 %和 15 .2 % ,两组的再狭窄率差异无显著性意义。结论 :冠状动脉支架术后的胸部不适除与再狭窄有关外 ,可能与血管内皮功能紊乱及血管的反应性有关。     

Chest pain variant asthma

We present the cases of three patients who initially presented with chest pain but were ultimately diagnosed as having asthma. None had audible wheezing. A diagnosis of asthma was entertained and ultimately supported by a clinical response to bronchodilator therapy. Only one patient had significant but intermittent documentable reversible airway obstruction, while another had marked sensitivity to methacholine bronchial challenge. Two patients required short courses of oral corticosteroids before symptom ablation.     

Food-poisoning and commercial air travel

With the introduction of budget airlines and greater competitiveness amongst all airlines, air travel has now become an extremely popular form of travel, presenting its own unique set of risks from food poisoning. Foodborne illness associated with air travel is quite uncommon in the modern era. However, when it occurs, it may have serious implications for passengers and when crew are affected, has the potential to threaten safety. Quality, safe, in-flight catering relies on high standards of food preparation and storage; this applies at the airport kitchens (or at subcontractors' facilities), on the aircraft and in the transportation vehicles which carry the food from the ground source to the aircraft. This is especially challenging in certain countries. Several foodborne outbreaks have been recorded by the airline industry as a result of a number of different failures of these systems. These have provided an opportunity to learn from past mistakes and current practice has, therefore, reached such a standard so as to minimise risk of failures of this kind. This review examines: (i) the origin of food safety in modern commercial aviation; (ii) outbreaks which have occurred previously relating to aviation travel; (iii) the microbiological quality of food and water on board commercial aircraft; and (iv) how Hazard Analysis Critical Control Points may be employed to maintain food safety in aviation travel.     

Respiratory infections during air travel

An increasing number of individuals undertake air travel annually. Issues regarding cabin air quality and the potential risks of transmission of respiratory infections during flight have been investigated and debated previously, but, with the advent of severe acute respiratory syndrome and influenza outbreaks, these issues have recently taken on heightened importance. Anecdotally, many people complain of respiratory symptoms following air travel. However, studies of ventilation systems and patient outcomes indicate the spread of pathogens during flight occurs rarely. In the present review, aspects of the aircraft cabin environment that affect the likelihood of transmission of respiratory pathogens on airplanes are outlined briefly and evidence for the occurrence of outbreaks of respiratory illness among airline passengers are reviewed.     

Chest pain syndromes in pregnancy

Chest pain syndromes in pregnancy include numerous catastrophic cardiovascular events. Acute myocardial infarction, aortic dissection, pulmonary embolism, and amniotic fluid embolism are the most important causes of nonobstetric mortality and morbidity in pregnancy. Each of these could result in poor maternal and fetal outcomes if not diagnosed and treated in a timely fashion. However, their diagnosis and management is limited by fetal risks of diagnostic procedures, dangers of pharmacotherapy and interventions that have neither been widely studied nor validated. This article reviews the current literature on epidemiology, risk factors, pathogenesis, diagnosis, and management of 4 potentially lethal chest pain syndromes in pregnancy.     

Chest pain of esophageal origin

Pain of esophageal origin includes heartburn, odynophagia, and spontaneous chest pain. The etiologic causes of esophageal chest pain are varied and include gastroesophageal reflux, esophagitis from radiation, infection, accidental ingestion, medication, and systemic disorders, and motility disorders. Useful tools in the evaluation of patients with suspected esophageal disease include endoscopy, manometry with provocative agents, and prolonged pH and pressure studies.     

Chest pain of esophageal origin

Chest pain is a cause of significant anxiety in a patient. Even those who have no evidence of cardiac disease may have many visits to the emergency department and even repeated hospitalizations because of chest pain. Atypical chest pain is now the commonest reason for patients to be referred for esophageal manometry studies. The development of provocative studies has led both to an increased demonstration of esophageal origin of chest pain, as well as an increased awareness of the complexity of the esophageal response to a variety of stimuli. The possibility of a generalized smooth muscle disorder has been considered on the basis of studies demonstrating that many patients with microvascular angina have esophageal motor disorders. This review examines some of the issues related to the use of provocative agents to study patients with chest pain, in addition to briefly reviewing gastroesophageal reflux disease and esophageal mucosal disorders.