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We present the case of a young male with an orthopedic injury after a mechanical fall, who developed atypical chest pain associated with ST elevation and elevated biomarkers suggestive of myocardial injury. He was found to have myocarditis on cardiac magnetic resonance imaging that we postulate was secondary to inhalation of marijuana. Cannabis-induced myocarditis and its potential complications are a health hazard that is bound to grow with the legalization of marijuana use in many countries. Résumé: Nous présentons ici le cas d'un jeune homme souffrant d'une lésion orthopédique subie après une chute mécanique, qui a développé une douleur thoracique atypique associée à une élévation du segment ST et à des biomarqueurs élevés évocateurs d'une lésion myocardique. L'imagerie par résonance magnétique cardiaque a révélé qu'il souffrait d'une myocardite que nous supposons être consécutive à l'inhalation de marijuana. La myocardite induite par le cannabis et ses complications potentielles constituent un risque pour la santé qui ne peut que croître avec la légalisation de l'usage de la marijuana dans de nombreux pays.

This is a case of 52-year-old male after episode of syncope and with atypical chest pain referred to hospital with acute anterior ST elevation myocardial infarction. Urgent coronary angiography showed normal coronary arteries and only ECG made the next day made us to suspect Brugada syndrome. The patient had ICD implanted and because of high defibrillation threshold, subcutaneous electrode implantation was decided. Our case highlights, that ECG changes in Brugada syndrome can mimic ST elevation in the course of acute coronary syndrome and that subcutaneous electrode implantation may be useful method of lowering defibrillation treshold.

Qiuzhen Lin,1– 4 Ousseina Bonkano,1– 5 Keke Wu,1– 4 Qiming Liu,1– 4 Toure Ali Ibrahim,5 Ling Liu1– 4 1Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China; 2Research Institute of Blood Lipid and Atherosclerosis, Central South University, Changsha, People’s Republic of China; 3Modern Cardiovascular Disease Clinical Technology Research Center of Hunan Province, Changsha, People’s Republic of China; 4Cardiovascular Disease Research Center of Hunan Province, Changsha, Hunan, 410011, People’s Republic of China; 5Department of Cardiovascular and Internal Medicine Niger, Niamey Amirou Boubacar Diallo National Hospital, Abdou Moumouni University, Niamey, NigerCorrespondence: Ling LiuDepartment of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, #139 Middle Renmin Road, Changsha, Hunan, 410011, People’s Republic of ChinaFax +86-73185295407Email feliuling@csu.edu.cnBackground: Atypical chest pain in some outpatients could derive from mental disorders. It is necessary for them to have a preliminary emotional assessment in the outpatient department of Cardiology before psychiatric outpatient visits.Methods: This study included 122 Chinese outpatients with atypical chest pain in the department of Cardiology. They accepted routine examinations, including treadmill test, and were judged by the three-question method as highly likely to have emotional disorders. Then, a standard questionnaire package containing the Chinese version of the seven-item scale for General Anxiety Disorder (GAD-7), Self-rating Anxiety Scale (SAS), the nine-item Patient Health Questionnaire (PHQ-9) and Self-rating Depression Scale (SDS) was administered to evaluate anxiety and depression.Results: The percentages of anxiety evaluated by GAD-7 and SAS were 62.3% and 26.2%, respectively. Analogously, the assessment by PHQ-9 showed a significantly higher percentage of depression than that by SDS (61.5% vs 29.5%) (P < 0.05). Kappa analysis showed that the consistency between GAD-7 and SAS, or that between PHQ-9 and SDS was not very good. About 73% outpatients suffered from emotional disorders, presenting as anxiety/depression evaluated by GAD-7 and PHQ-9. Furthermore, sleep disorders accounted for more than 80% of patients with mental disorders. Finally, the suicidal tendency of depression patients was about 17% that should not be ignored.Conclusion: Compared with SAS and SDS, GAD-7 and PHQ-9 detected more participants with emotional disorders in the Chinese outpatients with atypical chest pain, indicating that GAD-7 and PHQ-9 could be briefly well-validated tools to screen emotional disorders in the outpatient department of Cardiology before psychiatric visits.Keywords: depression, anxiety, screen, atypical chest pain

A 30-year-old man was admitted to the cardiology department with complaints of recurrent episodes of atypical chest pain for the last 6 months. He had a history of chest trauma from a car accident during his childhood. The ECG showed sinus rhythm and ‘q’ waves in the inferior wall. Blood analyses were unremarkable, with negative myocardial necrosis markers. Transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) were performed (figure 1). Figure 1 (A) Transthoracic echocardiogram with ultrasonic contrast (two-chamber view). (B) Late gadolinium enhancement, cardiac magnetic resonance (two-chamber view). What is …

A 47-year-old woman presented with atypical chest pain and a troponin level of 30.15 ng/dl. A detailed diagnostic work-up did not detect an acute myocardial infarction but revealed the presence of heterophile antibodies. Laboratory values need to be interpreted in the context of the clinical picture when test results do not correspond to clinical findings. (Level of Difficulty: Beginner.), Graphical abstract, A 47-year-old woman presented with atypical chest pain and a troponin level of 30.15 ng/dl. A detailed diagnostic work-up did not detect an acute…

The following is a case report of an atypical presentation of spontaneous coronary artery disease. In this case, a male with risk factors, precipitated by an emotional stress, presented to the emergency room with atypical chest pain. Cardiac catheterization revealed tapering of the mid-left anterior descending artery, consistent with non-atherosclerotic spontaneous coronary artery disease. However due to repeat chest pain, a repeat cardiac catheterization was performed, revealing 100% occlusion of the mid-LAD. This case represents an atypical presentation of a pathology that is frequently missed, and underreported. This is important to discuss in order to increase awareness, as the management and follow up are actually conservative.

With the introduction of the coronavirus disease 2019 (COVID-19) mRNA vaccines, the incidence of severe infection has significantly decreased. While the vaccines have been shown to be effective and safe, there have been few case reports of acute myocarditis within 3-5 days following the second dose of the vaccine. We report a case of an elderly man who presented with acute-onset chest pain after three months of receiving the second dose of the mRNA vaccine. He was found to have acute myocarditis on cardiac magnetic resonance imaging (CMRI), which was attributed to exposure to the COVID-19 vaccine in the absence of any other risk factors. Our patient demonstrated quick resolution of symptoms and was discharged within 72 hours. We review the literature and summarize published case reports on COVID-19 vaccine-associated myocarditis. The present case report provides new evidence regarding the possible subacute presentation of myocarditis post-COVID-19 vaccine, and further highlights the favorable outcome in this newly described clinical entity.

Aortic dissection is relatively uncommon, but often presents with acute severe chest or back pain and acute hemodynamic compromise and is associated with high mortality. We present a case of aortic dissection with an atypical presentation in a heart failure patient and the challenges encountered to make the diagnosis. The patient was a 54-year-old African American female who presented with progressively worsening exertional dyspnea and orthopnea for three days and sensation of indigestion and bloating. The patient denied any recent history of chest pain and she was initially admitted for heart failure exacerbation. Her admission chest x-ray showed severe cardiomegaly with a prominence of pulmonary vascular but there was a borderline widening of mediastinum measuring 8.2 cm. Physical exam showed unequal dorsalis pedis pulses (fainter on the right side) and systolic blood pressure difference of more than 20 mmHg between bilateral upper extremities. Computed tomography angiography (CTA) of chest, abdomen, and pelvis confirmed the diagnosis of dissection of thoracic and abdominal aorta extending from the left subclavian artery to the femoral artery. The patient was managed with labetalol drip and later transferred to a tertiary center for an elevated level of care where the endovascular intervention was performed. The patient then followed up with a vascular clinic for serial CTA and heart failure clinic for optimization of core measures. In conclusion, this case highlights the importance of clinical suspicion of aortic dissection and discusses the various clinical presentations of aortic dissection and its management. Being a highly fatal condition, prompt diagnosis is extremely important and is often life-saving. Therefore, it is important for physicians to be aware of atypical presentations of aortic dissection to initiate timely interventions to avoid catastrophic complications.

Background Approximately 1% to 2% of patients with stable atypical chest pain (SACP) experienced a major coronary event, even after a negative functional or anatomical test. Methods Over the past 15 years, 1706 patients with SACP evaluated in our clinics underwent functional stress testing or coronary computed tomographic angiography (CTA). In these patients, we also assessed the presence of three major modifiable lifestyle‐related risk factors (cigarette smoking, low intake of fruit and vegetables, and physical inactivity). Patients were stratified according to the presence of at least one risky lifestyle factor or no risky lifestyle factors. Functional or anatomical tests were positive in 170 patients (10%). We followed the remaining 1536 patients with negative tests for 1 year to evaluate the incidence of major coronary events. Results The percentage of patients reporting major coronary events was 1.2% in the group with risky lifestyles and 0.2% in the non‐risky lifestyle group (P

Dual left anterior descending artery (LAD) is a rare phenomenon that occurs in less than one percent of the population. To date, 12 variants have been identified. Proper identification of coronary vessels is crucial in emergent situations that require prompt action, such as percutaneous coronary intervention (PCI). We propose that our case highlights a novel 13th (type XIII) variant. We present the case of a 57-year-old African American woman with a past medical history of hypertension, glaucoma, cerebral vascular accident, dyslipidemia who presented to the ED complaining of atypical chest pain for one day duration. Electrocardiography showed normal sinus rhythm at 60 beats per minute (bpm), normal axis, normal intervals, no acute ischemic changes, and an isolated T wave inversion in DIII. Cardiac markers were within normal limits. The patient was started on aspirin 81mg, atorvastatin 40mg, and restarted on amlodipine 5mg. Echocardiography showed a left ventricular ejection fraction (LVEF): 65%, normal right ventricular size and systolic function, mild mitral valve regurgitation, and mild aortic regurgitation. Computed tomographic (CT) angiography showed a novel subtype of dual LAD, the left circumflex and right coronary arteries were patent. The patient was discharged once stabilized and advised to follow up with cardiology. Dual LAD describes a rare anatomic variant in which two coronary branches, known as short and long LAD arteries, supply the territory normally supplied by the solitary LAD artery. To date, 12 variants of dual LAD, classified by origin and course of the short and long LAD arteries, have been described in the literature. To the best of our knowledge, the current case describes a novel subtype of dual LAD, variant XIII. The LAD originates as usual from the left main coronary artery (LMCA) and initially runs in the anterior interventricular groove for a short course before bifurcating into two long LADs which both leave the interventricular groove and course out to the apex. One of the vessels courses laterally and the other courses medially of the interventricular groove. It is pertinent to identify the coronary vessels accurately before certain interventions are taken. Acknowledgement of this phenomenon can help guide accurate management in the future for patients with this condition.

The patient is a 31-year-old lady whom complained of atypical chest pain, she had no family history of coronary artery disease. Her physical examination was nonremarkable. In electrocardiogram only nonspecific ST-T change was seen in inferior leads. In echocardiography abnormal turbulent coronary flow was seen, so coronary CT angiography and then coronary angiography performed. After these imaging we reached to ARCAPA diagnosis. We scheduled patient for surgical procedure, but she refused.

Objective: This study sought to investigate the association between volume and attenuation of epicardial fat and presence of obstructive coronary artery disease (CAD) and high-risk plaque features (HRPF) on CT angiography (CTA) in patients with atypical chest pain and whether the association, if any, is independent of conventional cardiovascular risk factors and coronary artery calcium score (CACS). Methods: Patients referred for coronary CTA with atypical chest pain and clinical suspicion of CAD were included in the study. Quantification of CACS, epicardial fat volume (EFV) and epicardial fat attenuation (EFat) was performed on non-contrast images. CTA was evaluated for presence of obstructive CAD and presence of HRPF. Results: 255 patients (median age [interquartile range; IQR]: 51[41-60] years, 51.8% males) were included. On CTA, CAD, obstructive CAD (≥50% stenosis) and CTA-derived HRPFs was present in 133 (52.2%), 37 (14.5%) and 82 (32.2%) patients respectively. A significantly lower EFat was seen in patients with obstructive CAD than in those without (−86HU [IQR:−88 to −82 HU] vs −84 [IQR:−87 HU to −82 HU]; p = 0.0486) and in patients with HRPF compared to those without (−86 HU [IQR:−88 to −83 HU] vs −83 HU [−86 HU to −81.750 HU]; p < 0.0001). EFat showed significant association with obstructive CAD (unadjusted Odd’s ratio (OR) [95% CI]: 0.90 [0.81–0.99];p = 0.0248) and HRPF (unadjusted OR [95% CI]: 0.83 [0.76–0.90];p < 0.0001) in univariate analysis, which remained significant in multivariate analysis. However, EFV did not show any significant association with neither obstructive CAD nor HRPF in multivariate analysis. Adding EFat to conventional coronary risk factors and CACS in the pre-test probability models increased the area-under curve (AUC) for prediction of both obstructive CAD (AUC[95% CI]: 0.76 [0.70–0.81] vs 0.71 [0.65–0.77)) and HRPF (AUC [95% CI]: 0.92 [0.88–0.95] vs 0.89 [0.85–0.93]), although not reaching statistical significance. Conclusion: EFat, but not EFV, is an independent predictor of obstructive CAD and HRPF. Addition of EFat to traditional cardiovascular risk factors and CACS improves estimation for pretest probability of obstructive CAD and HRPF. Advances in knowledge: EFat is an important attribute of epicardial fat as it reflects the “quality” of fat, taking into account the effects of brown-white fat transformation and fibrosis, as opposed to mere evaluation of “quantity” of fat by EFV. Our study shows that EFat is a better predictor of obstructive CAD and HRPF than EFV and can thus explain the inconsistent association of increased EFV alone with CAD.

Background: Women present more commonly with atypical angina, false-positive exercise test, and normal/nonobstructive coronary angiogram. It thus becomes essential to identify the predictors of obstructive coronary artery disease (CAD) in women to avoid unnecessary invasive angiograms. Methods: We prospectively recorded the data of consecutive 578 women who underwent coronary angiography in our institute for typical/atypical chest pain suspected to be secondary to CAD. Results: Normal coronaries/nonobstructive CAD were seen in 273 (47.2%) patients, whereas 305 (52.8%) patients were found to have obstructive CAD (P < 0.0001). On multivariate logistic regression analysis, the presence of typical angina, age >55 years, smoking, diabetes mellitus, hypertension, low-density lipoprotein cholesterol >150 mg/dl, and high-density lipoprotein cholesterol

OBJECTIVE: To report the prevalence of interstitial lung disease in Systemic Sclerosis patients at the Royal Hospital and compare our data with the literature. METHODS:All adult Omani patients with Systemic Sclerosis (SSc) who are under regular follow-up at the Royal Hospital were retrospectively enrolled from January 2006 to January 2014. RESULTS: A total of 49 cases of Systemic Sclerosis (SSc) patients were included. The mean age was 44.06 ± 11.9 years. There was a predominance of females (48 cases; 98%). Interstitial lung disease present in 30 cases (61%). The most frequent symptoms were dyspnea 47%, cough 33%, and others (e.g. atypical chest pain) 20%. There was no association with smoking, non-smoker (47 cases, 95.5%) versus ex. smoker (2 cases, 4%). The most high resolution computed tomography (HRCT) finding was traction bronchiectasis (21 cases, 42.9%) followed by honey comb appearance (19 cases, 38.8%). Pulmonary Function Test (PFT) was done in 33 cases. The mean total lung capacity (TLC) was 81. 06 ± 26.2. The mean diffusion lung capacity (DLCO) was 61.8± 28.3. Pulmonary hypertension was found in 10 cases only (20.4%) based on echocardiography. CONCLUSIONS: ILD was present in 30 cases out of 49 cases of SSc (61.2%) with female predominance. The most frequently observed HRCT change was traction bronchiectasis. Similarities and differences were found with respect to the previous reports from other countries

A 36-year-old woman with atypical chest pain was referred for CT coronary angiography to exclude coronary artery disease. CT angiogram showed normal coronary arteries without any atherosclerotic co...

We performed real-time myocardial contrast echocardiography on a patient with cardiac amyloidosis and previous normal coronary angiography presenting with atypical chest pain to assess myocardial blood flow reserve (MBFR). Myocardial contrast echocardiography was performed and flash microbubble destruction and replenishment analysis was used to calculate myocardial blood flow. Dipyridamole was used to achieve hyperemia. MBFR was derived from the ratio of peak myocardial blood flow at hyperemia and rest. The results show a marked reduction in MBFR in our patient. Previous reports of luminal obstruction of intramyocardial rather than epicardial vessels by amyloid deposition may be causing microvascular dysfunction.

SUMMARY: Positive troponin test results in peripheral blood can be detected either during myocardial injury or from falsely positive test results. In this report, we present the positive results of a troponin test in a 24-year-old pregnant woman referred to the emergency department with atypical chest pain, and the clinical algorithm that we used to make the correct diagnosis. This patient presented with the same complaint of chest pain at different times while positive troponin levels were detected. In the absence of signs of myocardial injury, we suspected that heterophil antibodies were playing a major role. Further examinations revealed heterophil antibodies that could cross react with the troponin tests in peripheral blood. Key words: False positive troponin, heterophil antibodies

Background: Smoking increases the risk of coronary artery disease. Very few studies have evaluated the temporal relationship of electrocardiographic changes with smoking. We sought to study and compare the electrocardiogram (ECG) changes during smoking and tobacco chewing in current smokers and tobacco chewers presenting with atypical chest pain with either negative or mild positive exercise ECG test (treadmill test [TMT]). Materials and Methods: We screened male smokers and tobacco chewers with atypical chest pain with TMT. A total of 60 patients, 30 in each group in whom TMT was either negative or mildly positive, underwent a 24-h Holter monitoring. We asked patients to note down their time of smoking and tobacco chewing along with the timing of symptoms if any. Results: All patients were male with an average age of 45 years in smokers and 42 years in the tobacco chewer group. The mean number of cigarettes consumed was 6 ± 2.8 and tobacco chewed was 5 ± 4.7 g/day. Heart rate (HR) in smokers increased from 82.5 ± 14.56/min 10 min before smoking to 90.63 ± 15.34/min, during smoking with peak HR achieved at the time of smoking (P < 0.0001). HR in the tobacco chewers peaked at 10 min after chewing from 80.62 ± 13.52/min 10 min before to 87.89 ± 13.86/min 10 min after chewing (P < 0.0001). Smoking was associated with a significant increase in supraventricular ectopics (VEs) from 3.98/h before smoking to 7.43/h during and 6.92/h after smoking (P < 0.0001). Two patients in the smoker subgroup had spontaneous smokeless tobacco -T changes lasting for 10–25 min. Smoking was associated with a significant decrease in HR variability (HRV) index than the controls (P = 0.023). Tobacco chewing was not associated with any significant changes in the HRV parameter. Conclusions: Smoking and tobacco chewing both significantly increase the HR acutely. Smoking leads to an increase in both supraventricular and VEs. We observed reduced HRV in patients who smoked cigarettes.

Background: Rehospitalizations with acute coronary syndromes (ACSs) have declined over the last years, but there is a remaining need for potential further reduction of rehospitalization after ACS to determine the most predominant predictors that can guide strategies to reduce re-hospitalizations burden. Aim: This multi-center study aimed to evaluate the demographic, clinical characteristics, and medications of rehospitalized patients who suffered a new cardiac event in 12 months after admission due to ACS. Material and Methods: Patients age >18 years who have been hospitalized between November 1 2017, and April 1 2018, for ACS within12 months before the readmission for a new acute coronary event were enrolled. Results: The present study included a total of 628 (65.9% from Turkey) consecutive patients rehospitalized with ACS (ST-elevation myocardial infarction [STEMI], 23.0%; ACS without ST-elevation [NSTE-ACS], 76.9%) from 15 different countries. The majority of the rehospitalized patients were men (67.9%), and the mean age was 63.1 ± 12.53 years. 406 (64.6%) had typical, 209 (33.2%) of patients had atypical chest pain and 13 (2.07%) had not any chest pain complaint during readmission. 304 (48.41%) of patients were discharged from hospital earlier than 3 days and 107 (17.04%) of patients stayed more than 7 days. The subcategories of first index diagnosis were 227 (36.1%) STEMI; 401 (63.8%) NSTE-ACS. The mean time from index discharge to rehospitalization was 189.25 ± 118 days. 248 (39.4%) patients were re-hospitalized more than once after index discharge. The most common risk factors were diabetes mellitus (471, 75.0%). 175 (27.87%) of patients stopped taking medication before re-hospitalization. Most of the patients (69.4%) had multivessel disease. Conclusion: Several factors identify patients at higher risk of rehospitalization with ACS. Understanding and preventing these causes can prevent rehospitalization and improve their outcome.

A 48-year-old man with dextrocardia presented with atypical chest pain for 2 hours. Right-side ECG showed convex upward ST elevations in leads V4 and V5. Coronary angiogram showed complete occlusion of mid portion of the left anterior descending artery (LAD). Several attempts at engaging the left main origin was successful and the LAD was opened with placement of a drug-eluting stent. The post-procedure course was uneventful, and he was discharged home two days later.

CT angiography in a 45-year-old woman with atypical chest pain revealed two left anterior descending (LAD) arteries in the anterior interventricular sulcus (AIS). The longer LAD (white arrowhead in [figure 1A–D][1]) was arising from the left main coronary artery (LMCA) and was coursing up to the

It is uncertain whether patients with elevated troponin and non-classical presentation of acute coronary syndrome (ACS) should receive coronary CT angiography (CCTA). A proportion of these patients will have no coronary artery disease (CAD) and would benefit from non-invasive investigations and expedited discharge. Objectives were to determine most common diagnoses and rate of ACS among patients with positive troponin and low clinical suspicion of ACS who received CCTA.IRB approved retrospective analysis of 491 consecutive patients in a level I trauma center ED referred for CCTA between April 4, 2015 to April 2, 2017. Patients were included if there was an elevated troponin (TnI 0.045 μg/L) and atypical chest pain within 24 h prior to imaging. One hundred one patients met inclusion criteria; 17 excluded due to technical factors or history. Scans performed on dual-source CT.Eighty-four patients (47 men, 37 women) with median TnI of 0.11 ± 0.21 μg/L underwent CCTA 8.20 ± 6.41 h after first elevated Tn. Mean age was 53.2 ± 14.6 years. CCTA demonstrated absence of CAD in 39 patients (46.4%; 20 M, 19 F). CAD 25% stenosis was observed in 24 (28.6%; 9 M, 15 F). CAD with 25-50% stenosis was observed in seven (8.3%; six M, one F). CAD 50% stenosis was observed in 11 (13.1%; 9 M, 2 F), and non-diagnostic in three (3.6%, 3 M, 0 F). Forty-six (56.8%) were discharged directly from ED with median stay 15.82 ± 6.41 h.Use of CCTA in ED patients with elevated troponin and low clinical suspicion for ACS allowed obstructive CAD to be excluded in 83%.

OBJECTIVE The purpose of the study is to evaluate the clinical usefulness of bone scintigraphy for etiological diagnosis of patients with atypical chest pain. PATIENTS AND METHODS We retrospectively enrolled 225 patients with atypical chest pain who underwent bone scintigraphy for etiological diagnosis. No patients showed any symptoms or signs other than chest pain and had low-to-intermediate Framingham risk with insignificant findings on initial cardiac evaluation. They had no recent traumatic events or history of cerebrovascular and coronary heart diseases. The usefulness of bone scintigraphy for clinical diagnosis in enrolled patients was assessed and compared according to age (

Objective To assess the usefulness of cardiac stress magnetic resonance imaging (MRI) with adenosine in the detection of ischemic heart disease in patients with a low pretest probability of disease. Material and methods We used the probability ratio to analyze the usefulness of cardiac stress MRI in a selection of patients with a low pretest probability of ischemic heart disease (low or moderate cardiovascular risk, atypical chest pain, or absence of prior ischemic heart disease). Results We included 295 patients followed up for a median of 28 (19–36) months. A total of 60 patients had an event. Cardiac stress MRI was more useful in patients with a low pretest probability: atypical chest pain (probability ratio [PR] positive 8.56), absence of prior ischemic heart disease (PR positive 4.85), and low or moderate cardiovascular risk (PR positive 3.87). Conclusions Cardiac stress MRI can be useful in the diagnosis of ischemic heart disease in patients with a low pretest probability.

Background: To assess the presence of coronary artery disease (CAD) in women with atypical chest pain with low or intermediate risk for significant CAD by means of calcium scoring (CaSc) combined with coronary computed tomography angiography (CCTA) and to estimate the equivalent radiation dose in women. Patients and Methods: From December 2011 until July 2013, all consecutively performed cardiac CTs in women with atypical chest pain were included prospectively in the present study. Both CaSc and CCTA were obtained by a dual source flying focal spot 2×64 slice Somatom Definition Flash. Absence of CAD was defined as CaSc 0 and absence of noncalcified plaques. Presence of CAD was determined as CaSc>0 and/or presence of noncalcified plaques. The impact on patient management was also scored within our patient cohort. Results: A total of 1033 procedures in 1014 women (mean age 59±10 years; mean BMI 26±8) were analyzed. In 520 (51%) women, CAD was absent. In 494 (49%) women, CAD was diagnosed, and in th...

Aims Silent myocardial ischaemia occurs commonly in diabetes. Whether altered perception of ischaemia also predisposes to atypical presentations with under-diagnosis of coronary disease is not known. To determine whether (i) patients with diabetes diagnosed with angina are more likely to report atypical symptoms compared with patients without diabetes, and (ii) atypical symptoms in patients with diabetes cause angina to go unrecognized, increasing the risk of coronary events. Methods and results Prospective, multicentre cohort study of 8662 ambulatory patients with suspected angina, of whom 906 had diabetes. We recorded detailed chest pain descriptors and fatal and non-fatal coronary events over a median of 3.08 years of follow-up. Proportionately more patients with than without diabetes received a diagnosis of angina (42.7 vs. 25.1%). Among patients with diabetes diagnosed with angina, a greater proportion had atypical chest pain compared with patients without diabetes (21.0 vs. 11.3%), but the hazard of fatal and non-fatal coronary events was similar. However, among patients diagnosed with non-cardiac chest pain, those with diabetes—most of whom had atypical symptoms—remained at greater risk of coronary events [2.29 (95% CI 1.54, 3.41)] and all-cause mortality [1.67 (95% confidence interval, CI 1.04, 2.69)] compared with non-diabetic patients. Conclusion Patients with diabetes and atypical symptoms are nearly twice as likely to be diagnosed with angina compared with non-diabetic patients. Those diagnosed with non-cardiac pain are at increased risk of coronary events. Our study emphasizes the need for more intensive investigation of diabetic patients with chest pain, particularly those presenting with atypical symptoms.

A 41-year-old man, without a history of smoking and cardiac disease, presented with a sudden onset of left-sided atypical chest pain. Findings on the physical examination and ECG were unremarkable. Echocardiography and stress single-photon emission computed tomography showed no signs of myocardial i

A 42-year-old man who had been treated for severe coronary stenosis 4 years earlier presented with atypical chest pain. The imaging findings showed the potential value of medical therapy in treating stenosis.

A 21year-old male presented to the emergency department with 6 h of atypical chest pain after suffering blunt chest trauma. His electrocardiogram revealed 1-1.5mm ST segment elevation in leads V1-V3 with reciprocal depressions in II, III, and aVF. Mid-anterior wall akinesis was observed on echocardiography associated with an estimated left ventricular ejection fraction of 40%. A left main coronary artery dissection was diagnosed and treated surgically with a bypass graft. Although rare, coronary dissections can be a catastrophic complication of chest trauma.

Background: The cholesterol esterifying enzyme, lecithin: cholesterol acyltransferase (LCAT), plays a key role in HDL maturation and remodeling. Myeloperoxidase (MPO) may compromise LCAT enzymatic activity. We tested the extent to which plasma LCAT activity is altered in acute myocardial infarction (MI) in conjunction with abnormal MPO levels. We also assessed the impact of LCAT and MPO on newly developed major adverse cardiovascular events (MACE).Methods: Two-hundred one consecutive patients referred for acute chest pain of whom 134 had MI (95 with ST-elevation) participated. Forty-five new MACE were ascertained during 1203 (range 13-1745) days of follow-up among 185 patients. Plasma LCAT activity was measured using an exogenous substrate assay. MPO mass was assayed by chemiluminescent microparticle immunoassay.Results: Plasma LCAT activity was decreased by 15%, coinciding with 7-fold increased MPO levels in acute MI patients vs. patients with non-cardiac chest pain (p Conclusion: In acute MI patients, plasma LCAT activity is decreased coinciding with increased MPO levels. Higher MPO but not lower LCAT activity prospectively predicts adverse cardiac outcome. (C) 2014 Elsevier Ireland Ltd. All rights reserved.

Coronary artery aneurysm (CAA) is a life-threatening cardiovascular abnormality. We report a case of coronary ostial aneurysm (COA) after a valve sparing surgery. 46 y-o female with Marfan's syndrome presents with atypical chest pain. She has h/o aortic root reconstruction by modified David re

A myocardial bridge (MB) is a phenomenon in which a segment of coronary artery that is usually overlying the myocardium dives under and into the myocardial wall. A 67-year-old woman presented with atypical chest pain. Her past medical history included breast cancer for which she had a left breast

Ehlers-Danlos syndrome is a rare clinical condition caused by a genetic change that results in the formation of structurally or functionally altered collagen. The clinical manifestations are varied, being the most obvious skin hypermotility and increased joint flexibility, although other systems - such as cardiovascular, respiratory and neurological - may also be affected. This paper presents the report of a patient who sought medical attention with complaints of atypical chest pain. Clinical evaluation enabled hypothetical diagnosis of hypertrophic obstructive cardiomyopathy and Ehlers-Danlos syndrome. Initial electrocardiogram, echocardiogram and 24 hours holter allowed the confirmation of the first hypothesis. A skin biopsy performed later associated clinical data and confirmed the second hypothesis.

The effect of computed tomography (CT)-guided statin therapy on patients with atypical chest pain and mild-to-moderate coronary artery disease has not been elucidated yet.A total of 1,952 patients who had 1-69 % stenosis on CT were reviewed retrospectively. After propensity score matching, 643 patients who were prescribed statins after CT (statin users) and 643 patients without statin therapy (statin non-users) were compared. Major cardiovascular events included all-cause death, acute coronary syndrome and stroke.During a median of 42 months' follow-up, all-cause death was reported in 17 patients (1.3 %), of whom 6 (0.9 %) were statin users and 11 (1.7 %) statin nonusers. Major cardiovascular events developed in 6.1 % in the statin user group and 5.6 % in the statin non-users (P = 0.812). When evaluated according to plaque subtypes, statins showed significant benefit in patients who had non-calcified or mixed plaque (HR 0.47, 95 % CI 0.22-1.01, P = 0.047). However, in patients with calcified plaques, statins had no benefit in reducing adverse events (P = 0.620).In most patients with mild-to-moderate coronary artery stenosis on CT, statin therapy has no beneficial effect on reducing adverse events. However, in patients with non-calcified or mixed plaques, statin therapy showed a significant benefit.• Multidetector CT now identifies numerous subjects with mild-to-moderate coronary stenosis. • Statin therapy has little beneficial effect on patients with calcified plaques. • However, statins reduce adverse events in those with non-calcified or mixed plaques.

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. ----- METHODS: We studied 977 patients who presented with recurrent typical or atypical chest pain in outpatient clinic. All patients have undergone detailed clinical examination, ECG stress testing and coronary computed tomography angiography. ----- RESULTS: Highest positive prediction for having myocardial bridging was for patients presenting with atypical chest pain with negative ECG stress test and who were younger women. ----- CONCLUSION: Coronary computed tomography angiography may be preferable method for evaluation of chest pain in younger women presenting with atypical chest pain.

A woman aged 25 years was referred to cardiology for atypical chest pain. This was described as sharp non-exertional left-sided chest pain lasting a few seconds. Vitals showed BP 122/85 and pulse 87 bpm. Cardiovascular examination revealed normal S1 and S2, an S4 and no murmurs. ECG showed normal sinus rhythm. Transthoracic echocardiography showed marked trabeculation of the apical lateral segments (figure 1). Cardiac MRI confirmed these trabeculations with no diagnostic criteria for non-compaction. Figure 1 (A) Cardiac MRI showing the …

Not all acute coronary syndromes (ACS) exhibit the classic symptoms of chest pain. The diagnosis of ACS in patients without typical chest pain is often challenging. These patients are at increased risk for delayed or incorrect diagnosis, less aggressive treatment and high in-hospital mortality. The association between diabetes mellitus and absence of chest pain in ischemic heart disease is established. As well, it is known that women, more frequently than men, have atypical presentation. However, there is a lack of standardization in characterizing the population of patients with ACS and atypical presentation. The identification of other factors influencing and/or related with the absence of chest pain in ACS could be helpful for patients' outcomes. The object of our study was to examine the current literature on the clinical features, other than female gender and diabetes, associated with the atypical presentation of ACS. We found that patients with non-ST-elevation ACS more frequently than patients with ST-elevation myocardial infarction have atypical presentation. Atypical symptoms in aged population are common both among female and male. Subjects with history of comorbidities, specifically heart failure, chronic kidney disease, chronic obstructive pulmonary disease and stroke are less likely to report chest pain as chief complain of ACS.

Parachute mitral valve (PMV) is rarely seen in the adult population, in isolation or in association with other congenital heart defects, since most patients may have had milder lesions previously that were asymptomatic early in life, or were not detected due to lack of a comprehensive examination. We report a case of an 18-year-old woman with a history of exertional dyspnea, atypical chest pain, and cough for about 1 year. The echocardiographic examination identified a PMV with severe mitral regurgitation associated with bicuspid aortic valve and coarctation of the aorta. Most patients present with mitral stenosis of varying degree of severity, and rarely present with severe mitral regurgitation as seen in our patient.

Q waves can regularly be observed in the 12-lead electrocardiogram either due to heart axis underlying pathology such as subacute myocardial infarction, myocardial scar, or accessory pathways. Rarely, other entities such as circumscribed hypertrophy can induce significant Q wave and represent an important differential diagnosis especially in younger patients. In the setting of atypical chest pain determination of the correct diagnosis can be challenging. Therefore, circumscribed hypertrophy should be taken into account to avoid unnecessary invasive procedures.

Summary Background Patients with acute coronary syndrome (ACS) frequently present with typical chest pain; however a considerable proportion may present with atypical symptoms. Objective The purpose of this study was to evaluate the prognostic value of different presenting symptoms in ACS patients. Methods Over a 5-month period in 2007, 6704 consecutive patients presenting with ACS were enrolled and categorized into three groups according to their presenting symptom (typical chest pain, atypical chest pain, and dyspnea). Data were collected from a prospective, multicenter, multinational, observational study from 6 countries. The baseline characteristics, therapy, and in-hospital outcomes were analyzed and compared in the three groups. Results In comparison to typical chest pain, patients with atypical pain or dyspnea were older and had more cardiovascular risk factors. These two groups were significantly less likely to receive evidence-based therapy and coronary angiography and suffered worse in-hospital outcomes. The mortality rates were 3%, 2.5%, and 6% in patients presenting with typical, atypical chest pain, and dyspnea, respectively. After adjustment for confounders, the absence of typical chest pain was associated with higher mortality rate (odds ratio 2.0, 95% confidence intervals 1.29–2.75). Conclusions Across ACS, patients presenting without chest pain were frequently underestimated, less well treated with evidence-based therapy, and had worse in-hospital outcomes. Clinical presentation of ACS may provide additional prognostic impact particularly in high-risk populations.

A 45-year-old man presented in the outpatient clinic with occasional atypical chest pain. ECG was normal, and echocardiography did not reveal any wall motion abnormality. The patient was referred to us for CT angiography (CTA) to rule out coronary artery disease. The CTA, done on 192(×2)-slice