A pedunculated left ventricular hemangioma initially misdiagnosed as thrombus in a woman with atypical chest pain

The incidence of cardiac masses increased as echocardiography is becoming increasingly popular. Benign tumors of the heart constitute about 72% of all primary cardiac neoplasms and hemangioma accounts for 5–10% of benign cardiac tumors. Cardiac hemangiomas are generally asymptomatic and diagnosed incidentally during echocardiography or magnetic resonance imaging (MRI). We reported a 52-year-old woman presented with atypical chest pain and exertional dyspnea. The echocardiographic examination revealed a hyperechoic round mass in the left ventricle. With an initial diagnosis of left ventricular thrombus, the patient underwent cardiac MRI. The mass was found compatible with cardiac hemangioma. It was removed surgically and histopathologic evaluation identified a cardiac hemangioma. As reports of cardiac hemangioma are extremely rare and cardiac masses are mostly thought to be thrombi or myxomas (being the most common primary cardiac tumor), such hemangioma cases warrant attention as possibility of hemangioma should also be kept in mind.     

ST segment elevation and chest pain during cryoablation of atrial flutter.

A 61-year-old male was treated with cryoablation for typical atrial flutter. Cryoablation was performed percutaneously with an 8-mm tip catheter to achieve a bidirectional conduction block of the cavo-tricuspid isthmus. When freezing at the point where bidirectional isthmus block occurred, the patient experienced chest pain and ECG showed ST segment elevations corresponding to the right coronary artery. Cryoablation may be painless per se, but patients should be told to report chest discomfort and surface ECG must be followed carefully during ablation.     

联合心脏负荷试验对非典型胸痛患者鉴别诊断的意义

目的探讨利用心电图运动试验（S-ECG）和核素灌注心肌显像负荷试验（S-MPS）在非典型胸痛患者临床诊断中的价值。方法对非典型胸痛为主诉、临床诊断明确且S-ECG、S-MPS、冠状动脉（冠脉）造影和冠脉痉挛激发试验资料完整的患者为研究对象,回顾性分析两种负荷试验结果并与最后诊断进行对照分析。结果资料完整的186例非典型性胸痛患者,最后诊断冠心病患者占20％,冠脉痉挛占27％,冠脉肌桥占14％,X综合征5％,非冠脉疾病占34％。在除外冠脉痉挛后,S-ECG诊断冠脉缺血性病变的敏感性和特异性分别为92％和65％;S-MPS的敏感性和特异性分别为62％和79％。非典型胸痛患者中S-ECG阴性,但S-MPS呈反向再分布诊断冠脉痉挛的敏感性和特异性分别为94％和96％。结论非典型胸痛患者中多数具有缺血意义的冠脉病变基础,联合负荷试验对鉴别诊断具有重要临床价值。     

Clinical symptoms in young adults with atypical chest pain attending the emergency department

Clinical symptoms were studied in 69 consecutive patients below the age of 40 years who were attending the emergency unit because of unexplained chest pain. In a structured interview a few weeks after the emergency visit, only one-third of the patients reported that they believed in the doctor's diagnosis; they believed in a psychological or cardiac origin of the pain more often than the doctors. The chest pain was most often described as oppressive and/or stabbing. In 95% of cases it was central or left-sided. Associated symptoms were commonly reported, breathlessness being most commonly reported by two-thirds of the patients, followed by dizziness, palpitation and numbness/tingling. Mental symptoms such as tiredness, anxiety and tension were frequently reported. On the basis of the background literature the aetiology is discussed. We conclude that immediate symptom analysis, including psychosomatic symptoms, particularly breathing problems, is of central importance.     

Congenital complete absence of pericardium in a young woman with non-specific symptoms

Congenital absence of the pericardium is a very rare entity that is usually asymptomatic and hence difficult to diagnose. However, cases of sudden death have been reported in patients with partial pericardial defects (even asymptomatic ones), and such patients require surgical treatment.We report the case of a 17-year-old patient with complete pericardial agenesis (diagnosed by chance during a cardiological consultation) and briefly review the radiological findings of this entity.     

非特异性胸痛患者运动试验前后血清心肌肌钙蛋白I水平的变化

目的探讨以非特异性胸痛(ACP)患者运动负荷前、后血清心肌肌钙蛋白I(cTnI)值的变化,间接推断其是否存在心脏微血管病变的可能性.方法冠状动脉造影结果正常的ACP患者33例,健康正常人17例和冠心病心绞痛患者16例,均进行运动平板试验,并分别于运动前,运动后1小时、24小时进行血清cTnI浓度、CK值和LDH值的测定.结果ACP组中运动试验阳性者及冠心病心绞痛组患者运动后1小时及24小时血清cTnI浓度明显升高(P<0.01及 P<0.05),提示ACP组运动试验阳性者可能存在心脏微血管病变;ACP组中运动试验阴性者运动前、后血清cTnI浓度的变化无显著性差异.在冠心病心绞痛组患者中,运动试验后1小时血清cTnI浓度随患者病变程度的加重而逐渐增加,且变化有显著性差异(P<0.05).结论ACP患者运动负荷前后血清cTnI值的检测有助于间接推断患者是否存在心脏微血管病变,且其升高程度可以间接反映冠状动脉的病变程度.     

运动平板试验对不典型胸痛的诊断价值

目的探讨基层医院运动平板试验对不典型胸痛的诊断价值。方法分析2011年3-12月来我院就诊的不典型胸痛患者进行运动平板试验的临床资料。结果98例不典型胸痛患者的冠心病阳性率为60．20％。结论在基层医院中,运动平板试验可作为不典型胸痛患者诊断冠心病或判断预后的重要无创     

A huge cardiac hydatid cyst: An unusual cause of chest pain revealing multivisceral hydatidosis in a young woman

Hydatid disease remains endemic in some parts of the world. Cardiac hydatidosis with multivisceral involvement is uncommon but potentially fatal. We report the case of a 36-year-old Tunisian woman admitted with chest pain and T-wave inversion in the inferior leads on her electrocardiogram. Transthoracic echocardiography revealed a large hydatid cyst in the epicardium throughout the left ventricle. Thoraco-abdominal computerized tomography (CT) scan showed several hydatid cysts in the left lung, the liver, and in both breasts.After one week of albendazole treatment, surgical excision of the cardiac cyst on cardiopulmonary bypass was carried out as well as excision of the pulmonary and breast cysts. The postoperative course was uneventful and albendazole treatment was continued for six months. Though hydatid cardiac involvement is very rare, it should be considered in the differential diagnosis of atypical chest pain in young patients, especially those living in regions where hydatid disease is endemic.     

Myocardial bridging as one of the causes of atypical chest pain in young women

Introduction

Myocardial bridging is congenital anomaly which usually has benign prognosis but there are also reports suggesting that it can be associated with ischemic clinical syndromes presenting with chest pain. Coronary computed tomography angiography is a well-established method for detecting myocardial bridging. However, clinical significance of this anomaly still remains unclear.

胸痛患者正常心电图对排除急性心肌梗死的价值

目的 :评价因急性心肌梗死 (AMI)症状就诊的患者症状发作持续时间对心电图阴性预测值的影响。方法 :前瞻性观察 52 6例根据症状发作时间长短 ,以每 3h间隔时间分组的心电图阴性预测值变化。结果 :10 4例 (2 0 % )诊断为 AMI。各时间组心电图的阴性预测值 :0～ 3h组为93.2 % ,3～ 6 h组为 93.0 % ,6～ 9h组为 92 .6 % ,9～ 12 h组为 94 .1% (P=1.0 )。结论 :心电图阴性预测值并不随症状发作持续时间的延长而提高 ,即使在症状发作后 12 h描记的正常心电图也不能排除 AMI     

Is every chest pain a cardiac event?

Chest pain is one of the most common presenting complaints of a cardiac ischemic event. As the presenting complaint often dictates further interventions, it is necessary to identify and stratify the risk of a cardiac ischemic event in cases of chest pain as the primary complaint. The study also aimed to evaluate the actual number of cardiac ischemic events from all cases of complaints of chest pain. The study aimed to evaluate the occurrence of chest pain as an emergency attended by our emergency management service—108 services. During the period of January 1st–December 31st 2007, a total of 9,130 calls with chest pain were attended to, out of which 6,235 (68.3%) were included who were patients above 30 years of age and for whom complete data were available. Risk factor analysis to predict myocardial events and stratification was done to calculate an odds ratio. A cardiac risk scoring was devised and analyzed for probability of survival against final outcome. Probable cardiac cases were 5,887, out of which the critical/mortal cases were chosen for risk factor analysis and stratification. This resulted in age (odds ratio: 1.6; 95% CI: 1.3–2.0) and respiratory rate (odds ratio: 1.4; 95% CI: 1.1–1.8) being significant risk factors. The cardiac risk scoring accurately predicted 71% of final outcome. Age and respiratory rate may be constituted as primary qualifying criteria to define a cardiac ischemic event and given higher weights in risk scoring. Systolic blood pressure, which showed a non-significant change, may also be included to accurately identify cardiac ischemic events. From the total sample of patients presenting with chest pain, only 5.5–8% were definitive cardiac ischemic events.     

Precordial chest pain in patients with chronic Chagas disease

Precordial chest pain affects about 15% to 33% of patients with chronic Chagas disease. In the absence of megaesophagus, it should be ascribed to chronic Chagas heart disease. Precordial chest pain is atypical because it can usually neither be associated to physical exercise nor be alleviated by nitroglycerin. However, in certain circumstances, precordial chest pain can masquerade as acute coronary syndrome. Although obstructive coronary artery disease can occasionally be found, microvascular angina seems to be the mechanism behind such phenomenon. Precordial chest pain not always has a benign clinical course; sometimes, it can herald a dismal prognosis. On the basis of cases previously reported, it seems that nitrates, betablockers and/or calcium channel blockers can be of value in the treatment of this condition.     

Risk scores for patients with chest pain: evaluation in the emergency department

Chest pain is a common reason for presentation to the emergency department (ED). Absolute criteria for Acute Coronary Syndrome without ST elevation (NSTE-ACS) are lacking. An acute coronary syndrome (ACS) needs to be distinguished from a variety of other cardiac and non-cardiac diseases that may cause chest pain.For patients with confirmed ACS, several scoring methods can be applied in order to distinguish patients in the coronary care unit who may benefit most from therapies. The PURSUIT, TIMI, GRACE and FRISC risk scores are well validated with this respect. However, none of these risk scores has been used in the identification of an ACS in the emergency setting. The vast majority of patients with chest pain due to causes other than ACS were not evaluated in these trials. An evidence-based systematic stratification and policy for these patients does not currently exist.The more recently developed HEART score is specifically designed to stratify all chest pain patients in the ED. The HEART score was validated in a retrospective multicenter study and proved to be a strong predictor of event free survival on one hand and potentially life threatening cardiac events on the other hand. The HEART score facilitates risk stratification of chest pain patients in the ED.     

Double-blind randomized trial of alteplase versus placebo in patients with chest pain at rest

Patients who have chest pain occurring at rest are at a significantrisk of myocardial infarction and or sudden death. Most trialsenter patients with anginal rest pain after an initial screeningperiod. Thus, the clinical efficacy of early thrombolytic treatmentfor patients with rest pain remains unproven. Eighty patients with chest pain at rest and with ECG changesof ST depression of at least 1 mm in any ECG lead, were randomizedto alteplase 100 mg infused over 3 h, or placebo. Concomitantly,all patients received intravenous heparin and 300 mg of aspirindaily (unless contra-indicated). Seventy-four patients had coronaryangiography (the majority within 72 h of admission) of which73 were assessable. The patency of the ischaemia-related vesselwas not significantly greater in the alteplase treated group(81% vs 78%, P =0.82). The culprit lesion morphology tendedto be more concentric in the alteplase treated group (84% vs56%, P = 0.06) although alteplase treatment was not associatedwith a significant reduction in the severity of the culpritlesion stenosis. Intra-coronary thrombi were detected in 7%of patients (3% placebo, 11% alteplase, P =0.35). The mean leftventricular ejection fraction for the alteplase-treated groupwas 49 ± 3% and for the placebo-treated patients 56 ±3% (P=0.05). There was no difference in the total in-hospitalcardiac event rate i.e. cardiac death, myocardial infarctionand coronary revascularization between patients receiving alteplase(10%, 63%, and 38%) and those receiving placebo (8%, 65%, and30%) respectively. At 6-month follow-up, 17 patients were readmitted to hospitalwith cardiac causes (eight in the alteplase-treated group andnine in the placebo-treated group). A further two patients diedbefore 6-month review, one in the alteplase group and one inthe placebo group. Alteplase treatment for patients with chest pain at rest doesnot significantly improve culprit vessel patency or reduce in-hospitalor long-term cardiac event rates. Thus, alteplase cannot berecommended as an adjuvant to conventional therapy in patientspresenting with rest pain and EGG changes of ST segment depression.     

Diagnosis of chest pain with foregut symptoms in Chinese patients

AIM： To evaluate the diagnosis of chest pain with foregut symptoms in Chinese patients.
METHODS： Esophageal manometric studies, 24-h introesophageal pH monitoring and 24-h electrocardiograms （Holter electrocardiography） were performed in 61 patients with chest pain.
RESULTS： Thirty-nine patients were diagnosed with non-specific esophageal motility disorders （29 patients with abnormal gastroesophageal reflux and eight patients with myocardial ischemia）. Five patients had diffuse spasm of the esophagus plus abnormal gastroesophageal reflux （two patients had concomitant myocardial ischemia）, and one patient was diagnosed with nutcracker esophagus.
CONCLUSION： The esophageal manometric studies, 24-h intra-esophageal pH monitoring and Holter electrocardiography are significant for the differential diagnosis of chest pain, particularly in patients with foregut symptoms. In cases of esophageal motility disorders, pathological gastroesophageal reflux may be a major cause of chest pain with non-specific esophageal motility disorders. Spasm of the esophageal smooth muscle might affect the heart-coronary smooth muscle, leading to myocardial ischemia.