1/35. Interesting cases from the University of texas Medical Branch.This article discusses the cases for four patients with unstable angina. The first case is an example of the "high-risk" patient with widespread ECG changes, heart failure, and enzymatic elevations during an episode of chest pain. The second patient illustrates an unusual cause of unstable angina in a young women. The third patient had a large thrombus visible on angiography and management strategies for dealing with intracoronary thrombus are discussed. The final patient had an extensive past cardiac history with two prior coronary artery bypass operations and we discuss the recent advances made in the treatment of degenerative vein graft disease.- - - - - - - - - - ranking = 1keywords = chest pain, chest (Clic here for more details about this article) |
2/35. The nondiagnostic ECG in the chest pain patient: normal and nonspecific initial ECG presentations of acute MI.The 12-lead electrocardiogram (ECG) is a powerful clinical tool used in the evaluation of chest pain patients, assisting in the selection of the proper therapy. Unfortunately, the ECG is diagnostic of acute myocardial infarction (AMI) in only one-half of such patients at initial hospital evaluation. In the remaining group of patients with the nondiagnostic 12-lead electrocardiogram, the ECG may be entirely normal, show nonspecific sinus tachycardia (ST) segment-T wave abnormalities, or obvious ischemic changes. In adult chest pain patients treated in the emergency department (ED), 1% to 4% of such patients with an absolutely normal ECG had a final hospital diagnosis of AMI; furthermore, patients with nonspecific electrocardiographic abnormalities experienced AMI in 4% of cases. These findings reinforce the teaching point that the history is the most important tool used in the evaluation of chest pain patients. Furthermore, overreliance on a normal or nonspecifically abnormal ECG in a patient with a classic description of anginal chest pain is dangerous.- - - - - - - - - - ranking = 8keywords = chest pain, chest (Clic here for more details about this article) |
3/35. thyrotoxicosis, unstable angina and normal coronary angiogram.It is well known that thyrotoxicosis may elicit acute myocardial ischemia even in patients with angiographically normal coronary vessels. The involved mechanisms are not clearly defined although some hypothesis have been suggested. We report a case of a 54-year-old woman affected by Graves' disease with thyrotoxicosis which was referred to our Institute because of unstable angina. During hospitalization a two dimensional echocardiogram, performed during chest discomfort, showed left ventricular apical akinesis and impaired global systolic function. A subsequent coronary angiography revealed normal epicardial vessels. She was successfully treated with high-dose methimazole and propranolol and a repeat echocardiogram evaluation showed normalization of left ventricular systolic function. Six months later, because of the appearance of paroxysmal atrial fibrillation, the patient underwent total thyroidectomy and a substitutive therapy with L-T4 (100 micrograms/die) was started. The authors review the possible mechanisms involved in the pathogenesis of myocardial ischemia during thyrotoxicosis.- - - - - - - - - - ranking = 0.025572897793249keywords = chest (Clic here for more details about this article) |
4/35. Transient microvascular vasoconstriction: a possible cause of unstable angina.We report the case of a 65-year-old woman who developed unstable angina 2 months after successful coronary angioplasty of the left anterior descending coronary artery. coronary angiography failed to show angiographic restenosis, but intracoronary ergonovine caused ST segment elevation and her habitual chest pain in the absence of epicardial coronary spasm and important pressure changes in the distal left anterior descending coronary artery assessed by a pressure wire, thus suggesting that distal vessel constriction was responsible for unstable angina.- - - - - - - - - - ranking = 1keywords = chest pain, chest (Clic here for more details about this article) |
5/35. Successfully treated unstable angina pectoris in a young Japanese female.A 25-year-old Japanese female complaining chest oppression and palpitation was admitted to hospital under the presumptive diagnosis of ischemic heart disease (IHD), although no obvious underlying disease associated with IHD was detected. coronary angiography showed stenosis at the proximal site of left anterior descending artery (LAD), with dilatation and tortuosity at the bifurcation of the first and the second septal branches. Intravascular ultrasound imaging of the LAD showed intimal thickness without calcification at the site of stenosis. The stenosis was successfully and smoothly dilated by percutaneous transluminal angioplasty. Even with precise evaluation, the cause of the coronary artery disease in this young female patient was not clarified. Further careful follow-up is needed.- - - - - - - - - - ranking = 0.025572897793249keywords = chest (Clic here for more details about this article) |
6/35. Unusual atrial response to electrical pacing during ischemia.A 76-year-old woman with a dual chamber pacemaker underwent coronary intervention of the right coronary artery for unstable angina. After the procedure, she had recurrent chest pain, and after the repeat angiography showed reduced coronary flow in the distal vessel, she underwent emergent coronary artery bypass grafting. During this course of events, the stimulation-excitation interval of the atrium was prolonged and paralleled with the severity of the ischemia. Additionally, a transient but unusual electrophysiological phenomenon was observed that the atrium could be captured at a rate of 90 ppm, but not 80 ppm. This phenomenon might be caused by phase 4 depolarization or rate-dependent facilitation of conduction in the ischemic atrium.- - - - - - - - - - ranking = 1keywords = chest pain, chest (Clic here for more details about this article) |
7/35. Unusual case of a large midoesophageal diverticulum mimicking unstable angina pectoris.We describe a 77-year-old lady who presented with progressive retrosternal pain radiating to the left arm and the back. After exclusion of cardiac causes a large midoesophageal diverticulum was found on oesophago-gastro-duodenoscopy. Importantly, the retrosternal pain completely disappeared after endoscopic removal of impacted food from the diverticulum. After the surgical resection the patient became fully asymptomatic. This is the first example of angina-like chest pain which definitively resulted from a midoesophageal diverticulum. Therefore, midoesophageal diverticula should be considered as a rare differential diagnosis of exercise-induced retrosternal pain.- - - - - - - - - - ranking = 1keywords = chest pain, chest (Clic here for more details about this article) |
8/35. chest pain evaluation.chest pain is one of the frequent complaints in patients presenting to emergency rooms and ambulatory care clinics. For the primary care physician evaluating these patients, there are three essential steps in the evaluation of chest pain. The first step is to determine whether the chest pain is cardiac in origin or not. If the pain is suspected to be cardiac, then the next step would be to determine if the chest pain is secondary to an acute coronary syndrome (acute myocardial infarction or unstable angina) that requires immediate referral to an emergency room to initiate therapy and admit to the hospital. If the pain is not considered to be due to an acute coronary syndrome, then we proceed with a systematic approach to try to determine the likelihood that a particular patient has significant coronary artery disease (CAD). This is determined based on the patient's history, risk factors and electrocardiogram. Once the likelihood is assessed, this will determine what further invasive or non-invasive tests would be required to complete the patient's evaluation.- - - - - - - - - - ranking = 3keywords = chest pain, chest (Clic here for more details about this article) |
9/35. Off-pump coronary artery bypass grafting in a patient with liver cirrhosis.We report a case of unstable angina pectoris and alcohol-related child-Pugh class B cirrhosis. The patient was a 60-year-old man who was admitted to hospital with chest pain. He had previously been diagnosed to have child B cirrhosis due to alcoholic liver dysfunction at 58 years of age. He also had experienced ruptured esophageal varices, moderate ascites, and hyperammonemia. We performed percutaneous catheter intervention; however, he developed re-stenosis in the right coronary artery, and progression in the disease in other coronary arteries. We then performed coronary artery bypass grafting on the beating heart without cardiopulmonary bypass. He was discharged on the 13th postoperative day without any complications. This case demonstrated that off-pump coronary artery bypass grafting was safe for such a patient.- - - - - - - - - - ranking = 1keywords = chest pain, chest (Clic here for more details about this article) |
10/35. Management of a patient admitted with acute non-ST-elevation MI.This case study reviews the history, symptoms, management and rehabilitation of a patient admitted to accident and emergency with severe chest pain. After other conditions had been ruled out he was diagnosed with acute non-ST-elevation myocardial infarction. He later underwent a coronary angioplasty.- - - - - - - - - - ranking = 1keywords = chest pain, chest (Clic here for more details about this article) |
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