11/40. Vasospasm-induced heart block.A syncopal episode in an elderly patient with a history of carotid disease, multiple cardiac risk factors, and new onset chest pain presents diagnostic challenges. This case study describes the experience of a woman with coronary vasospasm accompanied by conduction deficits. The patient's history, diagnostic work-up, and treatment program are presented. The relationship between the coronary artery anatomic defects and the conduction abnormalities are discussed.- - - - - - - - - - ranking = 1keywords = chest pain, chest (Clic here for more details about this article) |
12/40. syncope in a child owing to intramural course of the left coronary artery.Coronary abnormalities are a rare cause of syncope or sudden death in childhood or adolescence. We report on a 14-y-old girl who had suffered for many years from repeated syncope after or during exertion. She had to be resuscitated twice. The left coronary artery arose from the right coronary aortic sinus and took a proximal intramural course. After successful reimplantation, the patient has now been free of symptoms for 12 mo. The pitfalls of differential diagnosis of this rare anomaly are discussed. Conclusion: Investigation of the coronary anatomy is indicated in otherwise unexplained chest pain, syncope or life-threatening events.- - - - - - - - - - ranking = 1keywords = chest pain, chest (Clic here for more details about this article) |
13/40. Acute cardiac ischemia in patients with syncope: importance of the initial electrocardiogram.OBJECTIVE: To determine the prevalence of acute cardiac ischemia in emergency department (ED) syncope patients without chest pain and to determine which of these patients are at high risk for acute cardiac ischemia. DESIGN: Data were collected prospectively during a study of ED triage of patients who had had possible acute cardiac ischemia. Supplemental retrospective review of records was performed to differentiate syncope from dizziness. SETTING: Six hospital EDs in new england (two primary teaching hospitals in urban locations, two medical-school-affiliated teaching hospitals, and two nonteaching hospitals in rural settings). patients: 5,762 patients had presented to the ED with chief complaints consistent with acute cardiac ischemia, including chest pain, shortness of breath, dizziness, and syncope. The study sample consisted of 251 patients who had had syncope and no chest pain. RESULTS: The prevalence of acute cardiac ischemia among the syncope patients was 7% (18 of the 251 patients). Univariate analysis revealed the following to have significant association with acute cardiac ischemia: ischemic abnormalities on the electrocardiogram (ECG) obtained in the ED (p less than 0.001), arm or shoulder pain on presentation (p less than 0.05), rales (p less than 0.1), and prior history of exercise-induced angina (p less than 0.05) or myocardial infarction (p less than 0.1). All 18 patients with acute cardiac ischemia had ischemic abnormalities (pathologic Q waves, ST-segment elevation or depression, or T-wave abnormalities) on their presenting ECGs. CONCLUSION: For syncope patients who have no chest pain or ischemic abnormality on the presenting ECG in the ED, acute ischemia appears to be unlikely. Admission to the cardiac care unit for these patients for possible myocardial ischemia is probably unnecessary. However, patients who have syncope and ischemic abnormalities on the ECG are at risk for acute cardiac ischemia, even in the absence of chest pain. Hospital admission to rule out myocardial infarction for these patients is prudent.- - - - - - - - - - ranking = 5keywords = chest pain, chest (Clic here for more details about this article) |
14/40. myocardial infarction in a patient with thrombotic thrombocytopenic purpura.A 63-year-old male with a prior history of thrombotic thrombocytopenic purpura was admitted with sudden onset of syncope. He denied chest pain. His initial blood chemistries were consistent with acute relapse of thrombotic thrombocytopenic purpura as indicated by microangiopathic hemolytic anemia and thrombocytopenia. The patient had evidence of myocardial injury as indicated by elevation of cardiac enzymes. A 12-lead electrocardiogram demonstrated ST elevation (up to 5 mm) in leads V(2) to V(6). The patient was treated with plasma exchange with fresh frozen plasma in addition to nitroglycerin, metoprolol and prednisone in a tapering dose. After reviewing the literature, we believe that the etiology of myocardial damage remains elusive, but may be secondary to an autoimmune phenomenon resulting in microthrombosis and myocarditis. We were unable to find any documentation about any specific treatment in such patients. Further studies are awaited regarding appropriate treatment of patients with thrombotic thrombocytopenic purpura and acute electrocardiographic changes.- - - - - - - - - - ranking = 1keywords = chest pain, chest (Clic here for more details about this article) |
15/40. Cases from the Osler Medical Service at Johns Hopkins University. diagnosis: P. carinii pneumonia and primary pulmonary sporotrichosis.PRESENTING FEATURES: A 53-year-old man who had human immunodeficiency virus (hiv) presented to the Johns Hopkins Hospital with a 3-month history of increasing dysphagia, cough, dyspnea, chest pain, and an episode of syncope. His past medical history was notable for oral and presumptive esophageal candidiasis that was treated with fluconazole 6 months prior to presentation. Three months prior to presentation, he discontinued his medications, and his symptoms of dysphagia recurred. During that time he developed intermittent fevers and chills, progressively worsening dyspnea on exertion, and a cough productive of white sputum. He also reported a 40-lb weight loss over the past 3 months. On the day prior to presentation, he had chest pain and shortness of breath followed by weakness, dizziness, and a brief syncopal episode. He denied orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema, jaundice, hemoptysis, hematemesis, melena, hematochezia, or diarrhea. There was no history of alcohol use, and he stopped smoking tobacco approximately 1 month previously. He smoked cocaine but denied injection drug use. The patient had never been on antiretroviral therapy and had never had his CD4 count or viral load measured. On physical examination, the patient was a thin, cachectic man who appeared older than his stated age. His vital signs were notable for blood pressure of 102/69 mm Hg, resting tachycardia of 102 beats per minute, resting oxygen saturation of 92% on room air, normal resting respiratory rate, and a temperature of 38.1 degrees C. His oropharynx was clear, with no signs of thrush or mucosal ulcers. His pulmonary examination was notable for diminished breath sounds in the lower lung fields bilaterally. Cardiac, abdominal, and neurologic examinations were normal. His skin was intact, with no visible petechiae, rashes, nodules, or ulcers. Laboratory studies showed a total white blood cell count of 3.2 x 10(3)/microL, with a total lymphocyte count of 330/microL, hematocrit of 30.2%, a serum sodium level of 129 mEq/L, and a serum lactate dehydrogenase level of 219 IU/L. The patient had an absolute CD4 count of 8 cells/mm3 and a hiv viral load of 86,457 copies/mL. His arterial blood gas on room air had a pH of 7.51, a PCO2 of 33 mm Hg, and a PO2 of 55 mm Hg. Electrocardiogram and serial serum cardiac enzymes were normal. A chest radiograph showed bilateral upper lobe patchy infiltrates with left upper lobe consolidation. Computed tomographic (CT) scan of the chest with contrast showed bilateral ground glass infiltrates with focal consolidation (Figure 1) and no evidence of pulmonary embolism. Induced sputum was negative for pneumocystis carinii, fungi, or acid-fast bacilli. A bronchoalveolar lavage was performed. What is the diagnosis?- - - - - - - - - - ranking = 2.0830193502498keywords = chest pain, chest (Clic here for more details about this article) |
16/40. Exertional dizziness and syncope caused by anomalous left coronary artery origin from the right sinus of valsalva.Coronary anomalies are generally rare, but has fascinating congenital cardiac disease entities, recognized in less than 1.3% of all coronary angiograms. Left coronary artery arising from right sinus of valsalva RSOV represents an extremely uncommon subtype. Initial presentations include chest pain, myocardial infarction, arrhythmias, sudden death, and rarely exertional syncope. We report a case of exertional dizziness and syncope, diagnosed to have anomalous origin of left main coronary artery from RSOV. Surgical intervention was curative.- - - - - - - - - - ranking = 1keywords = chest pain, chest (Clic here for more details about this article) |
17/40. coronary-subclavian steal syndrome presenting with chest pain and syncope.The present case is a 68-year-old patient with complaints of chest pain and syncopal attacks during physical activity of the left arm, for the last six months. He had a coronary artery bypass graft operation 10 years ago. Angiographic examination demonstrated total occlusion of the subclavian artery. The subclavian artery was stealing blood from the left anterior descending artery via the left internal mammary artery and from the brain via the left vertebral artery, leading to the diagnosis of subclavian artery steal syndrome; a rare cause of coronary and cerebral ischaemia.- - - - - - - - - - ranking = 5keywords = chest pain, chest (Clic here for more details about this article) |
18/40. syncope: a symptom of coronary artery spasm after cardiac transplantation.Two cases of coronary spasm in cardiac transplant recipients in which the presenting symptom was syncope without chest pain are reported. Diagnosing coronary spasm in transplant patients appears to be important because, based upon the few cases in the literature, prognosis is very poor. Coronary spasm may be related to accelerated atherosclerosis occurring in the transplanted heart.- - - - - - - - - - ranking = 1keywords = chest pain, chest (Clic here for more details about this article) |
19/40. Pathogenesis of unexplained drowning: new insights from a molecular autopsy.OBJECTIVE: To perform a molecular autopsy involving the RyR2-encoded cardiac ryanodine receptor/calcium release channel to determine whether mutations responsible for catecholaminergic polymorphic ventricular tachycardia (CPVT) represent a novel pathogenic basis for unexplained drownings. methods: A cardiac channel molecular autopsy was performed on 2 individuals who died of unexplained drowning and whose cases were referred to the Sudden death genomics Laboratory at the Mayo Clinic in Rochester, Minn. Comprehensive mutational analysis of all 60 protein-encoded exons of the 5 long qt syndrome-causing cardiac channel genes and a targeted analysis of 18 RyR2 exons known to host RyR2-mediated CPVT-causing mutations (CPVT1) was performed using polymerase chain reaction, denaturing high-performance liquid chromatography, and dna sequencing. RESULTS: Both individuals harbored novel mutations in RyR2. Postmortem mutational analysis revealed a familial missense mutation in exon 14, R414C, in a 16-year-old girl. A 9-year-old boy possessed a sporadic missense mutation in exon 49, V2475F. Both amino acid positions involve highly conserved residues that localize to critical functional domains in the calcium release channel. Neither substitution was present in 1000 reference alleles. CONCLUSIONS: This molecular autopsy study provides proof of principle that RyR2 mutations can underlie some unexplained drownings. A population-based genetic epidemiology study that involves molecular autopsies of individuals who die of unexplained drowning is needed to determine the prevalence and spectrum of KCNQ1 and now RyR2 mutations as potential pathogenic mechanisms for drowning.- - - - - - - - - - ranking = 0.041509675124898keywords = chest (Clic here for more details about this article) |
20/40. Angina-like chest pain and syncope as the clinical presentation of left ventricular endomyocardial fibrosis: a case report.A 47-year-old woman complained of angina-like chest pain, near-syncope, and syncopal episodes of 17 years' duration. physical examination was unremarkable. A 12-lead resting ECG showed symmetrically inverted T waves in the inferior and anterolateral leads. A graded treadmill exercise stress test precipitated angina-like chest pain accompanied by a near-syncopal episode associated with a systemic arterial pressure of 60/40 mm Hg. echocardiography disclosed left ventricular apical obliteration. Left ventriculogram showed a typical "ace of heart'' shadow as well as filling defects and apical obliteration. Endomyocardial biopsy of the left ventricle diagnosed left ventricular endomyocardial fibrosis. Thus, angina-like chest pain and near-syncopal episodes should be added to the list of clinical manifestations of pure left ventricular endomyocardial fibrosis.- - - - - - - - - - ranking = 7keywords = chest pain, chest (Clic here for more details about this article) |
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