Search

A 61-year-old woman with a 3-month history of exertional chest pain was referred for further investigation. She was a smoker with a history of hypertension and hypercholesterolemia. Sublingual nitrates exacerbated her symptoms. A resting ECG demonstrated sinus rhythm with anterolateral and inferior T-wave inversion (Figure 1A). Echocardiography demonstrated normal left ventricular (LV) function with no regional wall motion abnormalities or hypertrophy. ECG stress testing was terminated early because of chest discomfort in stage 2 of the Bruce protocol. At peak exercise, there were non-diagnostic ST changes, with pseudonormalization of the resting T-wave inversion seen both at peak exercise and …

A 61-year-old man was referred with 9 years of exertional chest pain. He described daily episodes of sharp, substernal chest pain, associated with shortness of breath and extreme fatigue. His symptoms were progressive, despite both β and calcium channel blockade, and he was no longer able to perform

Stable angina pectoris is characterised by typical exertional chest pain that is relieved by rest or nitrates. Risk stratification of patients is important to define prognosis, to guide medical management and to select patients suitable for revascularisation. Medical treatment aims to relieve angina and prevent cardiovascular events. Beta blockers and calcium channel antagonists are first-line options for treatment. Short-acting nitrates can be used for symptom relief. Low-dose aspirin and statins are prescribed to prevent cardiovascular events.

Angina pectoris is a common condition and while presentation can vary, patients typically present with exertional chest pain that is relieved by rest. Rapid-access chest-pains clinics are an established ser vice that provide the specialized assessment of patients who present with new-onset chest pain. This care study focuses on the assessment, investigation and diagnosis of a 55-year-old man. He was seen and assessed by a nurse practitioner and this care study discusses further management and follow-up of this gentleman.

Patient initials or identifier number PS ### Relevant clinical history and physical exam Mr. PS 37 years non-diabetic, non-hypertensive male presented with exertional chest pain (CCS-Class-II) for 3 months. He is smoker, dyslipidaemic and hyperuricaemic. His mother died suddenly at the age of

We performed treadmill exercise magnetic resonance imaging in 27 patients with exertional chest pain who were referred for contrast coronary angiography to determine the feasibility of this method to identify severe coronary artery stenoses. The sensitivity and specificity for detecting >70% coronary artery luminal diameter narrowings on contrast coronary angiography were 79% and 85%, respectively.

Hypertrophic cardiomyopathy is characterized by the idiopathic hypertrophy of the left ventricle (and occasionally right ventricle). HCM is an autosomal dominant disease, with variable penetration. In Asian population, apical hypertrophic cardiomyopathy is relatively common (25%). However, this is relatively rare in Caucasian population (0.2%). Patients with HCM, often presents with typical exertional chest pain and shortness of breath. Apical HCM patients tend to have milder symptoms. However, the clinical presentation and electrocardiographic features of Apical HCM often mimic acute coronary syndrome and high index of suspicion is warranted in differentiating this condition. Patients with apical HCM have relatively better prognosis when compare to the other varieties. Here, we are presenting a patient who presented with typical exertional chest pain whose electrocardiographic changes are concerning for acute ischemic changes.

An 81 year-old female with severe aortic stenosis was admitted electively to determine her anatomic suitability for trans-catheter aortic valve implantation (TAVI). Transthoracic echocardiogram prior to referral confirmed critical aortic stenosis with a mean transaortic valve gradient of 106mmHg, aortic valve area (AVA) 0.6cm 2 and dimensionless index (DI) 0.18. She reported a significant symptom burden with New York Heart Association Class III dyspnoea, four episodes of syncope in the month prior to admission and exertional chest pain.

Aman in his 30swith amedical history of remote pulmonary embolus (PE) and antiphosholipid antibody (APLA) syndrome presented to theemergencydepartmentwithprogressivedyspneaon exertion of 3 months’ duration. He also reported subacute, occasional, dull, substernal and right-sided exertional chest pain and a 10-pound unintentional weight loss. His temperature was 36.4°C; heart rate,60bpm;bloodpressure, 117/82mmHg; respirations, 18/ min; and resting oxygen saturation, 98%on ambient air. However, hisoxygensaturationdecreased to82%withambulation.Theother findingsofhisphysicalexaminationwere largelyunremarkable,other thanwidened splitting of S2. The laboratory evaluations, including cardiac troponin levels, were unremarkable. The initial electrocardiogram (ECG) is shown in the Figure. Question: Should this patient be taken for emergency coronary angiography?

Woven coronary artery is a rare congenital anomaly with an unknown etiology. A 53-year-old male presented with exertional chest pain and dyspnea for six months. Electrocardiogram and transthoracic echocardiography were in normal range. Dobutamine stress echocardiography revealed reversible ischemia in the inferior wall. Right coronary angiography showed an 80% stenosis before the sinoatrial branch and a twisting course of the right coronary artery lumen after it divided into multiple thin channels. Left coronary angiogram revealed noncritical lesions. A diagnosis of woven right coronary artery was considered, and he was discharged with medical therapy.

A 50-year-old male smoker with hypertension was brought to the emergency room by EMS. He reported several months of exertional chest pain. Over the previous week, the pain had increased in frequency; on the day of admission, it occurred while the patient was at rest. The last episode was accompanied by diaphoresis and shortness of breath. The patient was given nitrates in the ambulance and was pain free by the time of arrival at the emergency room. Physical examination was unremarkable. Electrocardiogram (ECG) showed nonspecific changes (Figure 1).

We report the case of a 55-year-old woman who was admitted for exertional chest pain with dyspnea. The patient was diagnosed with an isolated double-chambered right ventricle (DCRV) without associated congenital anomalies. Most cases of DCRV are diagnosed at a young age and commonly associated with VSD; isolated DCRV in adults is extremely rare.

Cardiac fibromas are benign tumours, often diagnosed in childhood, but rarely they may be diagnosed in adults or the elderly. We present an interesting case of a middle-aged lady presenting with exertional chest pain and breathlessness, who was found to have a heavily calcified mass within the myocardium. With a previous history of chest trauma, a calcified myocardial haematoma was initially suspected. Complete surgical excision led to a total resolution of symptoms. Histological examination confirmed the diagnosis of a cardiac fibroma. Complete excision of cardiac fibromas, where possible, is advised and is associated with excellent survival.

Nuclear medicine uses radioactive isotopes for the diagnosis and treatment of patients. Whereas radiology provides data mostly on structure, nuclear medicine provides complementary information about function. Limited undergraduate teaching, together with regional differences in the provision of nuclear medicine services, means that many clinicians know little about how radionuclide techniques can help in the management of patients. Consequently, patients who would benefit from such a procedure are not referred. This review highlights how nuclear medicine techniques can be used in the investigation of patients presenting with such common conditions as ischaemic chest pain, malignancy, and suspected pulmonary embolism. Many promising new tracers are being developed, particularly for the investigation of patients with malignancy and suspected infection, and readers will be directed elsewhere for information. Fig 1 201Tl myocardial perfusion images in a patient with exertional chest pain. Reversible ischaemia of the anterior, inferior, and lateral walls suggests a high probability of future cardiac events #### Summary points The published articles reviewed here were chosen primarily for the clarity and simplicity with which they describe the role of nuclear medicine techniques in specific fields. Six short texts commissioned by the British Nuclear Medicine Society provide detailed reviews of the …

David Arthur Conn was the son of a general practitioner and a teacher. At the age of 8 he developed exertional chest pain, and his father, Ian (see obituary: http://www.bmj.com/content/336/7646/727.1), diagnosed aortic stenosis. Cardiac catheterisation in Glasgow revealed a complex aortic root hypoplasia. At the National Heart Hospital, under the care of Jane Sommerville and Donald Ross, David underwent aortoplasty and later, an aortic homograft. A second homograft was required in his late teens when the first graft calcified. With remarkable strength of character, David turned a childhood of …

The patient was a 13-year-old male with chief complaints of exertional chest pain and dyspnea. Cardiac murmur was suspected in a medical checkup at 1 month old, at which time he was diagnosed with subvalvular aortic stenosis. He had subsequently been under follow-up observation at a nearby hospital for subvalvular aortic stenosis. He was admitted to our department for surgery due to aggravation of symptoms that had occurred over the previous year. Transthoracic echocardiography after admission showed an abnormal structure in the subvalvular aortic area, and the maximum pressure gradient between the left ventricle and aortic valve was 84 mmHg. The preoperative valve area was 0.71 cm(2), as measured by the Doppler method. Measurement of valve area by the trace method was difficult. Transesophageal echocardiography (TEE) showed a septum-like structure extending from the ventricular septum in the subvalvular area. On 3D TEE, the valve areas in the systolic and diastolic phases were 0.86 and 0.49 cm(2), respectively. Postoperative echocardiography showed resection of the structure in the subvalvular area, and the postoperative course was favorable.

Women with valvular heart disease have an increased risk of adverse outcomes in pregnancy; however, with appropriate evaluation and treatment, most women can successfully bear healthy children. During pregnancy, pulmonary stenosis is generally well tolerated in the absence of other haemodynamically significant lesions. We present a case of a multiparous woman,who is pregnant with her sixth child, with a severe pulmonary stenosis. She presented with exertional chest pain and dyspnea. She was managed successfully with balloon valvuloplasty.

To determine the accuracy of using nitroglycerine as a 'test of treatment' in the diagnosis of cardiac chest pain we undertook a systematic review of studies of diagnostic accuracy. Databases searched included PubMed, Cochrane Database, Google Scholar, Science Citation Index, EMBASE and manual searching of bibliographies of known primary and review articles. Studies were included if sublingual nitroglycerine was the index test, its effect on the patient's pain score was recorded and the reference test was performed on at least 80% of patients. The data from the five papers were used to form 2×2 contingency tables. Five eligible studies were found, all in the acute setting (although one paper collected its data in the follow-up setting, all patients had acute presentations). The sensitivity ranged from 35% to 92% and the specificity from 12% to 63%. However, in all but one paper the Youden indices were close to zero suggesting that the response to nitroglycerine is not useful as a diagnostic test. The combined sensitivity was 0.52 (95% CI 0.48 to 0.56) and combined specificity was 0.49 (95% CI 0.46 to 0.52). The diagnostic OR from the combined studies was 1.2 (95% CI 0.97 to 1.5), which is not significantly different from 1. In the acute setting, nitroglycerine is not a reliable test of treatment for use in the diagnosis of coronary artery disease. However, further studies are needed to determine the diagnostic accuracy of nitroglycerine for recurrent exertional chest pain.

An 80-year-old man presented with a one-week history of constant epigastric pain and left-sided exertional chest pain. On the day of presentation, he had experienced four episodes of nonbilious vomiting, but had no other gastrointestinal symptoms. He did not report fever, chills or sweats. There was

A 60-year-old female presented with a two-year history of exertional chest pain and progressive dyspnea. Resection of a cardiac hemangioma arising from the area of the bifurcation of the left anterior descending and circumflex coronary arteries resulted in complete resolution of her symptoms. The symptoms were likely caused by coronary steal.

A 49-year-old man was evaluated because of exertional chest pain of 1 month's duration that began during vigorous tennis. Initially, the pain was substernal and lasted 1 to 2 minutes. Recurrent episodes were always exercise related, though the activity might be mild, and episodes were relieved by several minutes of rest. At times, the pain radiated to the left side of the neck.

A 10-year-old boy presented with a history of exertional chest pain. An electrocardiogram demonstrated an inferior apical myocardial infarction. Cardiac catheterization revealed myocardial bridging of the left anterior descending coronary artery with evidence of intramyocardial obstruction during systole. The patient underwent successful treatment with supraarterial decompression myotomy and remains symptom free at 1 year.

Congenital coronary artery anomalies are a rare cause of major cardiovascular events in adolescents who practise sports activities. Therefore, symptoms suggestive of cardiac ischaemia should always be carefully considered and subjects should undergo a complete cardiovascular assessment. We describe the case of a young non-competitive athlete, referring episodes of exertional chest pain and syncope, in whom multiple imaging techniques allowed the diagnosis of intramural course of the left anterior descending coronary artery.

The diagnosis of angina is challenging because it relies on symptom descriptions. Natural language processing (NLP) of the electronic medical record (EMR) can provide access to such information contained in free text that may not be fully captured by conventional diagnostic coding.To test the hypothesis that NLP of the EMR improves angina pectoris ascertainment over diagnostic codes.Billing records of inpatients and outpatients were searched for International Classification of Diseases, Ninth Revision (ICD-9) codes for angina pectoris, chronic ischemic heart disease, and chest pain. EMR clinical reports were searched electronically for 50 specific nonnegated natural language synonyms to these ICD-9 codes. The 2 methods were compared to a standardized assessment of angina by Rose questionnaire for 3 diagnostic levels: unspecified chest pain, exertional chest pain, and Rose angina.Compared with the Rose questionnaire, the true-positive rate of EMR-NLP for unspecified chest pain was 62% (95% CI 55-67) versus 51% (95% CI 44-58) for diagnostic codes (P.001). For exertional chest pain, the EMR-NLP true-positive rate was 71% (95% CI 61-80) versus 62% (95% CI 52-73) for diagnostic codes (P = .10). Both approaches had 88% (95% CI 65-100) true-positive rate for Rose angina. The EMR-NLP method consistently identified more patients with exertional chest pain over a 28-month follow-up.EMR-NLP method improves the detection of unspecified and exertional chest pain cases compared to diagnostic codes. These findings have implications for epidemiological and clinical studies of angina pectoris.

A 78 year old woman suffered a near syncopal event and was diagnosed with a possible transient ischaemic attack (TIA). Clinical history revealed a vague 3 year history of stable exertional chest pain. Initial diagnostic …

We report an unusual case of cardiac hamartoma involving the ventricular septum. The patient presented with palpitations and exertional chest pain. Echocardiography indicated a large homogeneous mass occupying the superior two-thirds of the ventricular septum. This report confirms the use of transthoracic echocardiography as a screening tool in the diagnosis and management of an uncommon case of a benign cardiac tumor.

Although numerous investigators have examined the physical manifestation of coronary heart disease (CHD) and its prognostic implications, most of these studies were conducted in samples of middle-aged men and used the Rose Questionnaire on Angina.1–6 Few, however, have examined the manifestation of CHD in the Mexican American population, and none has provided stable estimates of Rose angina in elderly Mexican Americans.7,8 In this brief, we examine the prevalence of and risk factors for exertional chest pain in Mexican Americans aged 65 and older with data from the Hispanic Established Population for the Epidemiological Study of the Elderly.

A 32-year-old man was referred with exertional chest pain. He had been diagnosed with glycogen storage disease type IIIa (GSDIIIa) by liver biopsy in childhood. Cine cardiovascular magnetic resonance (CMR) demonstrated profound symmetrical hypertrophy (483 g) with impaired systolic function. Gadolinium-diethylene triamine penta-acetic acid (DTPA) rest perfusion demonstrated multifocal first pass mid-myocardial defects and late imaging demonstrated …

A 16-year-old male was referred to our hospital because of exertional chest pain. There was no personal or family history of any cardiovascular disease. Findings on physical examination and vital signs were normal. An ECG showed a right bundle superoanterior zonal block pattern with low potentials in frontal plane and intraventricular conduction delay (QRS Complex 120 msg) with pseudo-epsilon wave in V1 …

A 59-year-old man with long-standing hypertension presented with exertional chest pain. The patient was noted to have bilateral Frank's sign, a diagonal crease that runs across the earlobe at a 45-degree angle and may be a predictor of coronary artery disease.

A 62 year old woman presented with a six month history of exertional chest pain and dyspnoea on moderate exertion. She had no significant risk factors for ischaemic heart disease. A diagnosis of Takayasu's arteritis had …

Primary tracheal tumors are rare. Typically slow growing, they present late in the course of disease, with obstructive respiratory symptoms. A 25-year-old man developed external substernal chest pain and pressure with dyspnea that were relieved with rest. Noninvasive evaluation identified a tracheal tumor, adenoid cystic carcinoma by biopsy, which was previously undescribed as a cause of pseudo-angina pectoris. The patient's evaluation, management, and 20-month follow-up are presented. A mechanism for the patient's noncardiac exertional chest pain is proposed. Previous experience with adenoid cystic carcinomas of the trachea is reviewed.

In a 17-year-old man complaining of exertional chest pain, computed tomography and magnetic resonance imaging showed a mass originating from the right atrium invading the pulmonary artery compatible with malignant lymphoma. However, its invasion to the left ventricular myocardium was not evident. Conventional echocardiography only identified the thickened left ventricular posterior wall. However, transmural myocardial strain distribution obtained by myocardial strain imaging clearly demonstrated abnormal myocardium at the posterior wall suggesting myocardial invasion. The abnormal finding disappeared after chemotherapy. Assessment of transmural myocardial strain profile using myocardial strain imaging was useful to differentiate normal and abnormal myocardium, leading to a correct diagnosis of myocardial invasion.

A 61-year-old male patient with diabetes mellitus and hypertension was referred because of exertional chest pain. Coronary angiography was performed, and severe stenosis at the mid-segment of left anterior descending (LAD) artery, marginal obtuse branch of the circumflex artery, and descending posterior branch of the right coronary artery were assessed. Distal vessels were not …

We report the case of a 51-year-old man who presented with worsening exertional chest pain in whom subsequent percutaneous coronary intervention resulted in a coronary arteriovenous fistula. Fortunately, the patient was stable and coronary angiography revealed resolution of the fistula 20 minutes later. This case study emphasizes the management of iatrogenic coronary perforations, depending on the type and severity of perforation, which generally involves initial conservative management. (Korean J Med 2012;82:337-340)

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 76-year-old man was admitted to our hospital because of exertional chest pain and mild intermittent claudication. Computed tomography revealed total occlusion at both common iliac arteries, the distal portions of which were

A 39-year-old cardiologist with no cardiovascular risk factors presented with a 6-month history of exertional chest pain. A stress echocardiogram was negative at a high workload, and she subsequently underwent 320-slice coronary CT for persistent symptoms. This revealed an anomalous right coronary artery (RCA) originating from the left aortic sinus. The course of the proximal RCA was anterior to the aorta and posterior to the right ventricular …

A total of 2705 people aged 60 years and over were sent a postal questionnaire requesting information about the symptoms of four common conditions--exertional chest pain, chronic productive cough, breathlessness, and exertional pain in the calves. These were elicited using a standardized questionnaire. The effect of these symptoms on the dependence of those suffering them was assessed in relation to a series of activities associated with normal daily living. There was a consistent rank order in the activities that people were unable to perform for the different symptoms studied, but this order altered with increasing severity and multiple symptoms. There was a consistency about the activities which changed order. It is suggested that symptoms and their associated dependence need to be assessed in relation to each other, using simple scaling systems by professional service personnel, managers/, and planners, in order to bring together the therapeutic rehabilitative, and social aspects of health needs. These are felt to be vital before decisions about service development can be made.

A previously healthy 55-year-old patient presented with progressive exertional chest pain. Physical examination showed no abnormalities except for a diastolic cardiac murmur. The ECG showed left ventricular hypertrophy. The laboratory findings and the chest x ray were normal. An exercise treadmill test was positive. The echocardiogram showed multiple diastolic jets draining …

To the Editor. —A 49-year-old recently widowed woman with a 2-year history of substernal chest pressure and pain with exertion, was admitted to a coronary care unit for increasing frequency of exertional chest pain. As part of admission evaluation, she was asked the reason for her use of alprazolam. Immediately following this question, the patient burst into tears, hurriedly reached for a picture of her husband from the nightstand, and clutching the photograph to her chest, began to complain of pain in her chest. Electrocardiograms of a patient during (A) and following (B) an acute grief response. The patient's electrocardiogram (ECG) at that time revealed new 0.5- to 1.0-mm down-sloping ST-T wave changes in leads V4 to V6 (Figure). She was treated with two sublingual nitroglycerin tablets and the pain resolved in 4 to 6 minutes. Vital signs remained within normal limits and the ECG returned to normal. Cardiac catheterization

Presentation of Case A 60-year-old man was admitted to the hospital because of an intracardiac mass. There was a questionable history of a coronary attack 15 years earlier, characterized by "crushing" chest pain, for which he was treated in another hospital for one month. The patient recovered but experienced bouts of exertional chest pain that usually radiated to the left arm and episodes of exertional dyspnea and palpitations. Thirteen months before entry the exertional dyspnea worsened, and chest pain on exertion and palpitations became more frequent. He was admitted repeatedly to a second hospital because of recurrent chest pain, with . . .