Autoantibodies against oxidized LDL are associated with severe chest pain attacks in patients with coronary heart disease

Autoantibodies against oxidized low-density lipoprotein (oxLDL) predict the progression of atherosclerosis. Several studies have shown that oxLDL is present in atherosclerotic lesions and that several factors present in active atherosclerotic plaques can oxidatively modify LDL. Oxidation of LDL induces production of autoantibodies against oxLDL (oxLDLab) that can be measured using an EIA test. Our aim was to see whether oxLDLab are associated with severe chest pain attacks in coronary heart disease (CHD) patients. Patients having two- or three-vessel CHD, as assessed by coronary angiography, and their siblings were recruited into the study (n = 568, mean age 55.8 years, range 29.3–83.2 years). Nondiabetic patients having a history of severe chest pain attacks had significantly higher oxLDLab levels (0.611 ± 0.56) than those who did not have a history of severe chest pain attacks (0.487 ± 0.40) (p = 0.027), even though age, cholesterol level, body mass index, and blood pressure were similar in both groups. However, no difference was found in oxLDLab levels in diabetic patients with or without a history of severe chest pain attacks. Increased levels of oxLDL autoantibodies are associated with severe chest pain attacks in nondiabetic patients with CHD.     

Combination of imaging modalities in a coronary artery fistula

A 35-year-old woman was referred for diagnostic evaluation of stitching pain under her left breast. The pain was not related to exercise. There were no cardiovascular risk factors. Physical examination, routine blood testing and chest X-ray were normal. Her ECG showed abnormal ST segments in III and aVF, and down-sloping ST segments with negative T waves in V₃ to V₄.     

Extensive coronary artery disease in a young woman

A case history is presented of a 26-year-old woman who complained of substernal and left arm pain during such activities as making a bed, dancing, vacuuming and intercourse. She was diagnosed as having hyperlipidemia and mild hypertension. During the time that she took oral contraceptives (OCs) she was free of chest pain and could pursue normal activity. Coronary bypass surgery with saphenous vein graft resulted in the patient's death in the operating room. Autopsy revealed extensive atherosclerotic occlusive disease of the coronary arteries. It is generally thought that the high levels of circulating estrogens in OCs exert a protective action upon the coronary arteries.     

Severe transient left ventricular dysfunction induced by thyrotoxicosis

We report on a 44-year-old woman presenting with chest pain and dyspnoea without previous stress-related events. By means of echocardiography severe left ventricular dysfunction and wall motion abnormalities resembling stress-induced cardiomyopathy (Tako Tsubo) were seen. Laboratory investigation revealed thyrotoxicosis and elevated cardiac markers. Six days after starting medical treatment, complete restoration of the left ventricular function was observed. The transient left ventricular dysfunction was induced by thyrotoxicosis resembling stress-induced cardiomyopathy that resolved completely after medical treatment.     

Chest Pain in Adolescents—Functional Consequences

In prospectively evaluating 100 cases of adolescents with chest pain (along with two control groups), 91 were found to have recurrent chest pain; fewer than 5 had a serious organic cause. Significantly higher school absenteeism occurred in patients with either chest or abdominal pain than in patients without pain. Adolescents with chest and abdominal pain were more likely to be high users of medical services than those with no pain. Most adolescents believed that persons their age could have attacks; 44 of those with chest pain thought their symptom was due to a heart attack. The occurrence of chest pain was not influenced by an adolescent''s age, sex, race, smoking status or family structure, nor was it consistently associated with depression. Chest pain is thus a common problem of adolescence that produces considerable functional impairment not attributable to serious underlying disease.     

Plasma nociceptin/orphanin FQ levels rise after spontaneous episodes of angina, but not during induced myocardial ischemia

The aim of our study was to evaluate the effects of repeated episodes of angina and induced myocardial ischemia on plasma nociceptin/orphanin FQ (N/OFQ) levels. Patients with unstable angina (23 with new onset severe angina or accelerated angina and 18 with subacute angina at rest) who had had repeated spontaneous episodes of chest pain in the last week before the study underwent myocardial perfusion single-photon emission computed tomography using adenosine infusion. Twenty subjects without clinical symptoms of angina matched for age, sex and cardiac risk factors served as a control group. N/OFQ levels were significantly (P < 0.01) higher in the patients (15.2 ± 2.1 pg/ml) than in the control group (8.5 ± 2.6 pg/ml). Blood pressure and heart rate did not significantly differ. All patients showed transient adenosine infusion myocardial ischemia that did not induce chest pain or significantly modify plasma N/OFQ levels or hemodynamic parameters. Our findings show that unstable angina is associated with a significant increase in circulating N/OFQ levels unrelated to intervening transient myocardial ischemia or hemodynamic changes. This increase is probably related to the chest pain repeatedly occurring in the course of coronary artery disease, but absent during transient adenosine-induced myocardial ischemia.     

Primary cardiac lymphoma initially diagnosed by routine cytology. Case report and literature review

A case of primary cardiac lymphoma initially diagnosed by routine cytologic examination of pericardial fluid is presented. In a 64-year-old woman woman who originally presented with chest pain and heart block, the initial clinical impression was ischemic heart disease. However, coronary angiography failed to reveal significant disease. An echocardiogram demonstrated pericardial fluid, which was drained. A small amount was sent for cytologic examination, and the diagnosis of malignant lymphoma, large cell type, was made. Subsequent radiologic examinations revealed an intracardiac mass involving the atrioventricular canal; surgical biopsy confirmed the diagnosis of a large cell lymphoma. While primary malignant lymphoma of the heart is rare, this case highlights the efficacy of routine cytologic examination of an effusion fluid (often drained therapeutically) in establishing the correct diagnosis.     

Association of cytokines with endothelium dependent flow mediated vasodilation (FMD) of systemic arteries in patients with non-ischemic cardiomyopathy

Background

Takotsubo cardiomyopathy is an acute cardiac syndrome characterized by transient LV regional wall motion abnormalities (with peculiar apical ballooning appearance), chest pain or dyspnea, ST-segment elevation and minor elevations of cardiac enzyme levels

Case presentation

A 68-year-old woman was admitted to the Emergency Department because of sudden onset chest pain occurred while transferring her daughter, who had earlier suffered a major seizure, to the hospital. The EKG showed sinus tachycardia with ST-segment elevation in leads V2–V3 and ST-segment depression in leads V5–V6, she was, thus, referred for emergency coronary angiography. A pre-procedural transthoracic echocardiogram revealed regional systolic dysfunction of the LV walls with hypokinesis of the mid-apical segments and hyperkinesis of the basal segments. Coronary angiography showed patent epicardial coronary arteries; LV angiography demonstrated the characteristic morphology of apical ballooning with hyperkinesis of the basal segments and hypokinesis of the mid-apical segments. The post-procedural course was uneventful; on day 5 after admission the echocardiogram revealed full recovery of apical and mid-ventricular regional wall-motion abnormalities.

Conclusion

Takotsubo cardiomyopathy is a relatively rare, unique entity that has only recently been widely appreciated. Acute stress has been indicated as a common trigger for the transient LV apical ballooning syndrome, especially in postmenopausal women. The present report is a typical example of stress-induced takotsubo cardiomyopathy in a Caucasian Italian postmenopausal woman.     

Clinical and diagnostic features of partially anomalous pulmonary venous connection in an adult female patient: a case report and review of the literature

A 40-year-old woman presented with dyspnoea, chest pain and fatigue. Her medical history was unremarkable. An early systolic ejection murmur was heard in the 3D left inter-costal space. Chest X-ray revealed normal cardiothoracic ratio with an anomalous vessel adjacent to the left pulmonary hilum. Echocardiography and exercise tolerance test were normal. Right heart catheterisation revealed normal pulmonary pressures with normal cardiac output. CT scan and MRI of the thorax were diagnostic for an aberrant pulmonary venous connection between the left lower lobe pulmonary vein and the left brachiocephalic vein without atrial septal defect. She was treated conservatively and remained well.     

Evaluating a new graphical ordinal logit method (GOLDminer) in the diagnosis of myocardial infarction utilizing clinical features and laboratory data

OBJECTIVE: We used a new graphical ordinal logit method (GOLDminer) to assess a single cardiac troponin T (cTnT) analysis at the time of admission (first generation monoclonal; Roche BMC Corp., Indianapolis, Indiana), the character of chest pain, and electrocardiographic (ECG)findings in predicting the likelihood of acute myocardial infarction (AMI) in patients presenting with suspected myocardial ischemia. The final diagnosis of AMI was based on serial ECG findings and evolution of CKMB isoenzyme levels in conjunction with clinical findings. SUBJECTS: The study population consisted of 293 consecutive patients who presented at a mean of six hours after onset of chest pain or associated symptoms warranting a "rule-out" for AMI assessment to a university-affiliated community hospital. RESULTS: The odds-ratio for an elevated cTnT (> 0. 1 ng/ml) in AMI was 22.2:1. There was an association between typical chest pain and cTnT (chi square = 78.23, p < .0001) and between abnormal ECG findings and cTnT (chi square = 108, p < .0001). The cTnT yielded diagnostic benefit in addition to chest pain characteristics and ECG findings in AMI. We present the odds-ratios for the combined features in GOLDminer plots. CONCLUSION: We demonstrate how the odds-ratios for AMI are obtained after scaling continuous to ordinal the values for a single cTnT determination alone and with other features in patients presenting with chest pain.     

Exertional gastro-oesophageal reflux: a mechanism for symptoms in patients with angina pectoris and normal coronary angiograms.

During 24 hour oesophageal pH monitoring 52 patients who had angina pectoris and normal coronary angiograms underwent exercise testing, as far as their symptoms allowed, on a treadmill to determine whether gastro-oesophageal reflux occurred during exertion. In 11 patients the 24 hour oesophageal pH score was abnormally high; 10 of these showed exertional gastro-oesophageal reflux, and in nine this was associated with their usual chest pain. A further 13 patients had a normal 24 hour pH score but had exertional reflux coincident with chest pain during exercise testing. The mean lower oesophageal sphincter pressure in both of these groups of patients was appreciably lower than that in 28 patients who had a normal 24 hour pH score and no exertional reflux. These findings suggest that exertional gastro-oesophageal reflux accounts for the symptoms of a large proportion of patients who have angina pectoris and normal coronary angiograms and that oesophageal pH monitoring during exercise testing on a treadmill enables this group of patients to be identified.     

Asymptomatic papillary fibroelastoma of the aortic valve

A previously healthy 63-year-old woman with multiple risk factors for coronary artery disease was referred to the outpatient clinic with a three-month history of atypical chest pain. At physical examination no abnormalities could be detected and the ECG was completely normal. At transthoracic echocardiography and transoesophageal echocardiography a mass, 1 cm in diameter and attached to the right coronary cusp of the aortic valve, was detected. The mass had the echocardiographic appearance of a nonhomogeneous, round, dense, mobile structure, typical features of a fibroelastoma (figure 1). On dipyridamole-thallium scintigraphy, no coronary insufficiency could be demonstrated. Since cardiac papillary fibroelastomas are associated with a risk of thromboembolic events, the patient underwent complete tumour excision by a simple shave excision (figure 2).     

Intermittent spastic coronary occlusion at site of non-significant atherosclerotic lesion requiring stent implantation

A 65-year-old woman was admitted with severe but mainly atypical chest pain at rest for some weeks. Two years ago, primary percutaneous coronary intervention with stenting of the mid left anterior descending artery (LAD) had been performed in the setting of an anterior myocardial infarction. Physical examination, electrocardiogram, serum levels of troponin I, and echocardiography were normal. During maximal treadmill test, a significant depression of the ST segment was found in leads V⁴ to V⁶ while the patient remained asymptomatic. Coronary angiography demonstrated normal right (figure 1A) and circumflex (figure 1B) coronary arteries while the LAD was totally occluded just proximal to the previously implanted stent (figure 1B). However, a few minutes later, ventriculography showed – besides normal left ventricular function – anterograde filling of the LAD (figure 1C, arrows).     

低风险胸痛急性冠状动脉综合征患者心电图特征及其对诊断的价值研究

摘要 目的：分析低风险胸痛急性冠状动脉综合征(acute coronary syndrome,ACS)患者心电图特征及其对诊断的价值。方法：选择我院自2017年1月至2019年8月接诊的194例疑似低风险胸痛ACS患者,均采取心电图检查和冠状动脉造影检查;分析低风险胸痛ACS患者的心电图特征,观察心电图结果与冠状动脉病变支数、狭窄程度的关系,计算心电图诊断低风险胸痛ACS的特异性、敏感性等效能指标,使用受试者工作特征(receiver operating characteristic,ROC)曲线下面积(curve,AUC)定量分析ST段偏移值预测主要不良心血管事件的效能。结果：在194例疑似低风险胸痛ACS患者中,低风险胸痛ACS患者134例,低风险不稳定型心绞痛(UA)患者心电图表现以ST-T缺血性改变为主,发作时改变明显或呈现伪性改善;低风险非ST段抬高的心肌梗死(non-ST-segment elevation myocardial infarction,NSTEMI)患者心电图表现为肢体和胸导联ST段压低,T波低平、倒置,ST-T改变持续存在和呈动态衍变;低风险胸痛ACS患者心电图结果与冠状动脉病变支数无关(P＞0.05),与狭窄程度有关(P＜0.05);心电图诊断低风险胸痛ACS的特异性为71.67 %,敏感性为69.40 %,阳性预测值为84.55 %,阴性预测值为51.19 %,符合率为70.62 %;所有患者均获得随访,经ROC曲线分析,ST段偏移值预测低风险胸痛ACS患者发生主要不良心血管事件的最佳截值为1.85 mm,AUC为0.695,对比全球急性冠状动脉事件注册(GRACE)风险评分的0.675,差异无统计学意义(P＞0.05)。结论：低风险胸痛ACS患者心电图具有多样化,与冠状动脉狭窄程度有关,有助于初步诊断和风险评估,且ST段偏移值预测主要不良心血管事件的效能较好,值得进一步研究应用。     

Pregnancy associated plasma protein-A as a prognostic biomarker of all-cause mortality and cardiovascular events in patients presenting with chest pain: a systematic review

Aim: Novel biomarkers have been proposed for identification of patients at greater risk of future adverse events among those presenting with chest pain. In this review, we aim to elucidate the ability of pregnancy associated plasma protein-A (PAPP-A) to predict mortality and other cardiovascular events in this patient population.

Methods: A literature search of the electronic databases Medline, Scopus, Cochrane Library and ClinicalTrials.gov was performed in order to identify studies investigating the utility of PAPP-A to predict mortality and adverse cardiovascular events in patients with chest pain.

Results: Eight studies met our inclusion criteria. Five of these studies pertained to patients with confirmed ischemic chest pain, while the rest included patients presenting with chest pain possibly due to acute coronary syndrome, irrespectively of the underlying cause. Although the results for long-term events were inconclusive in both groups of patients, higher PAPP-A concentrations were found to be a significant predictor of short-term adverse events in patients with confirmed ischemic chest pain.

Conclusions: PAPP-A appears to be a potentially useful biomarker for short-term risk stratification of patients presenting with chest pain of ischemic origin. However, there is an eminent need for more standardized clinical studies investigating the prognostic value of this biomarker.     

Value of measuring end tidal partial pressure of carbon dioxide as an adjunct to treadmill exercise testing

The end tidal partial pressure of carbon dioxide (Pco₂) was measured during treadmill exercise in 30 normal controls and 113 patients referred for assessment of chest pain. Among the 92 patients without significant ST depression hypocapnia occurred more often in those reporting “typical” than “atypical” chest pain (17 of 22 patients compared with 29 of 70; p<0·01). Hypocapnia was uncommon in patients with significant ST depression whether reporting typical or atypical chest pain (one of 10 patients and two of 11, respectively).Hypocapnia at rest (Pco₂ <4 kPa) occurred in 16 (14%) patients but in only one control. Hypocapnia occurred during or after exercise in only one control and three of the 21 patients with significant ST depression on exercise (group 1). The remaining 92 patients were divided into those with a history suggestive of hyperventilation (group 2; n=30) and those without (group 3; n=62). Hypocapnia developed significantly more often in both these groups (21 and 25 patients respectively) than in controls or patients with significant ST depression.An abnormal response of the Pco₂ to exercise provided objective data to support a clinical suspicion of chest pain induced by hyperventilation in 24 cases, suggested a cause for equivocal ST depression other than coronary stenosis in five patients, and led to the diagnosis of previously unsuspected respiratory disease in 14 patients.Measurement of end tidal Pco₂ gives additional valuable diagnostic information during the conventional treadmill exercise test in patients with both typical and atypical chest pain.     

Prinzmetal's angina,normal coronary arteries and pericarditis.

A woman with Prinzmetal''s variant angina had spontaneous attacks of myocardial ischemia characterized by severe chest pain, hypotension, inferior ST-segment elevation, transient complete heart block and selective right ventricular dysfunction. Despite initial improvement following intravenous administration of atropine and sublingual administration of nitroglycerin she died of cardiogenic shock. Autopsy showed normal coronary arteries and acute pericarditis, more pronounced over the right side of the heart. It is postulated that the pericardial inflammation elicited severe spasm of the subjacent right coronary artery.     

改良HEART评分法对急诊胸痛患者分层治疗的指导价值研究

目的:研究改良HEART评分法对急诊胸痛患者分层治疗的指导价值。方法:选择我院急诊科收治的急性胸痛患者197例,根据疾病分为心源性胸痛组(n=132)和非心源性胸痛组(n=65),所有患者均行改良HEART评分和传统HEART评分,并根据评分进行危险分层,比较患者去向,建立受试者工作特征(ROC)曲线,评价HEART评分对危险分层和预后预测的价值。结果:心源性胸痛组改良HEART评分和常规HEART评分均高于非心源性胸痛组,两组改良HEART评分和常规HEART评分比较差异有统计学意义(P0.05)。改良HEART评分低危者100%未住院,中危62.71%住院,高危住院、入ICU的构成比例为73.17%、36.59%;HEART评分低危11.11%住院,中危住院、入ICU的构成比例为57.38%、6.56%,高危住院、入ICU的构成比例为68.57%、31.43%,差异有统计学意义(P0.05)。改良HEART评分用于对心源性胸痛患者分层的AUC值为0.916,敏感度为0.883,明显高于HEART评分的0.831和0.765。结论:改良HEART评分法可提高急诊胸痛患者分层的准确性,对指导患者去向和治疗价值较高。     

Early warning signs of an acute myocardial infarction and their influence on symptoms during the acute phase,with comparisons by gender

Background: Identifying early warning signs of an acute myocardial infarction (AMI) may aid in the early diagnosis of coronary artery disease.Objectives: This study was conducted to assess early warning signs (prodromal symptoms) of AMI, with comparisons made by gender. Another aim was to determine whether these early warning signs had any influence on the patients' acute symptoms of AMI.Methods: This was a multicenter, cross-sectional study of Norwegian patients (aged ≤75 years) hospitalized with their first AMI. A self-administered questionnaire was used to gather information on prodromal symptoms, defined as pain in the chest, pain in the shoulder or back, radiating pain or numbness in the arms, dyspnea, and fatigue. Symptoms were reported for the year before AMI and during the acute stage. Logistic regression analyses were used to examine the association between prodromal symptoms and acute symptoms and the effect of medical history (hypertension, diabetes, and hypercholesterolemia).Results: The self-administered questionnaire had a 72% response rate; the study included 149 women and 384 men diagnosed with first-time AMI. Symptoms occurring during the year before AMI included pain in the chest in 45% (240/533), shoulder or back pain in 51% (270/533), arm pain in 38% (205/533), dyspnea in 33% (176/533), and fatigue in 62% (330/533). There were no statistically significant gender differences. The risk of experiencing chest symptoms in the acute phase was >5 times higher in women who had experienced prodromal symptoms in the chest (adjusted odds ratio [OR] = 5.11; 95% CI, 1.38-18.88) and nearly 3 times higher in men (OR = 2.80; 95% CI, 1.17–6.70). The risk of experiencing shoulder or back pain was almost 5 times higher in men with prodromal shoulder or back pain (OR = 4.96; 95% CI, 3.01–8.19), but no statistically significant association was found in women. The risk of experiencing radiating arm pain or numbness in the acute phase was more than doubled in women with prodromal arm pain (OR = 2.68; 95% CI, 1.19–6.20) and more than tripled in men with prodromal arm pain (OR = 3.11; 95% CI, 1.90–5.07). The risk of experiencing dyspnea in the acute phase was more than doubled in women with prodromal dyspnea (OR = 2.67; 95% CI, 1.25–5.71) and >5 times higher in men with prodromal dyspnea (OR = 5.73; 95% CI, 3.42–9.62). Finally, the risk of fatigue was almost tripled in women (OR = 2.97; 95% CI, 1.28–6.85) and more than doubled in men (OR = 2.51; 95% CI, 1.54–4.11). Hypertensive women, but not men, were less likely to experience chest symptoms in the acute phase (OR = 0.29; 95% CI, 0.10–0.82).Conclusions: Almost half of the study patients (45%) experienced prodromal chest symptoms the year before their first AMI. These prodromal symptoms predicted the symptoms that occurred during the acute stage of AMI, with some differences between the sexes.     

Duration of chest pain associated with acute myocardial infarction: a predictor of long-term prognosis.

This paper describes 109 patients who had their first myocardial infarction and were then followed up for 3 to 8 years. The following data were collected at the time of the infarction: duration and severity of chest pain, type of infarction and peak SGOT (serum glutamic oxaloacetic transaminase) level. The duration of chest pain has previously been shown to correlate with infarct size. Duration of chest pain, age and peak SGOT level were found to be the most important predictors of survival. None of the other independent variables contributed further to survival when the effects of duration of pain, age and SGOT level were taken into account. However, there was a significant association between pain duration and functional status. These data suggest that the duration of chest pain during first myocardial infarctions is a predictor of long-term prognosis and probably of functional status.