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A 33-year-old Hispanic male with a history of recent orchiectomy for suspected testicular cancer presented to the emergency department with worsening exertional chest pain and dyspnea in the setting of a 2-month history of diffuse myalgias and symmetric polyarthralgias.

Background: It is unclear whether the coronary microvascular responses to multiple, mechanistically distinct hyperaemic agents exert similar dilatory responses or share common clinical predictors. This study therefore sought to characterize the index of microvascular resistance (IMR) response to multiple hyperaemic agents in the human coronary circulation. Methods: Thermodilution-derived IMR was determined during intravenous adenosine, intracoronary acetylcholine, and intravenous dobutamine in patients with ischemic symptoms and nonobstructive coronary angiograms. A total of 128 patients were studied (44 with adenosine and acetylcholine, and 84 with all agents). Adenosine IMR >25, acetylcholine IMR >31, and dobutamine IMR >29 were used to define elevated responses. Results: IMR responses demonstrated weak-to-moderate association (adenosine vs acetylcholine IMR: ρ = 0.33; adenosine vs dobutamine IMR: ρ = 0.51; acetylcholine vs dobutamine IMR: ρ = 0.28; all P < 0.01). Logistic regression analyses revealed that: (1) elevated adenosine IMR was associated with increasing age and left ventricle hypertrophy (odds ratio [OR] = 1.27 and 1.58; both P < 0.05, respectively), (2) elevated acetylcholine IMR was associated with increasing plasma uric acid (OR = 1.09; P < 0.05), and (3) elevated dobutamine IMR was associated with hypertension and left atrial volume index (OR = 3.99 and 1.07; both P < 0.05, respectively). Subset analyses to evaluate clinical utility of the acetylcholine and dobutamine IMR, independent of abnormal adenosine IMR, revealed that elevated acetylcholine and/or dobutamine IMR were associated with higher risk exercise stress tests, left atrial volumes, and burden of exertional chest pain. Conclusions: Microvascular-specific IMR responses to different hyperaemic agents are only moderately associated, whereas the predictors for agent-specific IMR responses varied, suggesting that multiple pharmacologic agents interrogate different microvascular control mechanisms. Résumé: Contexte: On ne sait pas vraiment si les réponses microvasculaires coronariennes à de multiples agents hyperémiques aux modes d’action distincts ont des effets vasodilatateurs similaires ou partagent des facteurs prédictifs cliniques communs. Cette étude visait donc à caractériser la réponse selon l’indice de résistance microvasculaire (IMR) aux multiples agents hyperémiques dans la circulation coronarienne chez l’humain. Méhodologie: L’IMR obtenu par thermodilution a été déterminé pendant l’administration intraveineuse d’adénosine, intracoronarienne d’acétylcholine et intraveineuse de dobutamine chez des patients présentant des symptômes ischémiques et par angiogrammes coronariens non obstructifs. Un total de 128 patients (44 avec l’adénosine et l’acétylcholine, et 84 avec tous les agents) ont fait partie de l’étude. Des réponses élevées étaient définies par un IMR à l’adénosine > 25, un IMR à l’acétylcholine > 31 et un IMR à la dobutamine > 29. Résultats: Les réponses selon l’IMR ont révélé une association faible à modérée (IMR à l’adénosine vs IMR à l’acétylcholine : ρ = 0,33; IMR à l’adénosine vs IMR à la dobutamine : ρ = 0,51; IMR à l’acétylcholine vs IMR à la dobutamine : ρ = 0,28; tous : p < 0,01). Des analyses de régression logistique ont révélé que : 1) un IMR à l’adénosine élevé était associé à l’avancement en âge et à une hypertrophie ventriculaire gauche (rapport des cotes [RC] = 1,27 et 1,58; p < 0,05 respectivement pour les deux), 2) un IMR à l’acétylcholine élevé était associé à l’augmentation de la concentration plasmatique d’acide urique (RC = 1,09; p < 0,05) et 3) un IMR à la dobutamine élevé était associé à l’hypertension et à l’indice de volume auriculaire gauche (RC = 3,99 et 1,07; p < 0,05 respectivement pour les deux). Des analyses par sous-groupes visant à évaluer l’utilité clinique de l’IMR à l’acétylcholine et à la dobutamine, indépendamment d’un IMR à l’adénosine anormal, ont révélé que des IMR à l’acétylcholine et/ou à la dobutamine élevés étaient associés à une augmentation du risque lors des épreuves à l’effort, à un volume auriculaire gauche plus élevé et à une augmentation du fardeau associé à la douleur thoracique à l’effort. Conclusions: Les réponses microvasculaires selon l’IMR à différents agents hyperémiques sont seulement modérément associées, alors que les facteurs prédictifs des réponses selon l’IMR spécifique de l’agent varient, ce qui laisse croire que les multiples agents pharmacologiques font appel à différents mécanismes de contrôle microvasculaire.

Undiagnosed coronary sinus obstruction can be a source of paediatric exertional chest pain and death. We present a case series of three interesting children who developed only exertional angina from various degrees of coronary sinus stenosis or atresia. We discuss the diagnosis and management of each case and the potential pathophysiology involved with their symptoms.

Objective Anomalous left main coronary artery (LMCA) with an intraconal course is a relatively rare form of anomalous aortic origin of a coronary artery (AAOCA) from the wrong sinus of Valsalva. There is currently a paucity of information regarding this entity. The purpose of this article is to review our surgical experience with repair of anomalous LMCA with an intraconal course. Methods This was a retrospective review of 12 patients with an anomalous LMCA and an intraconal course who underwent surgical repair. The median age at surgery was 15 years (range 2-47). The seven oldest patients all had preoperative symptoms of exertional chest pain and one also had exertional syncope. The five youngest patients had no preoperative symptoms. One of these patients had a hemodynamically significant ventricular septal defect and one patient was the sibling of a patient who had undergone repair of AAOCA. Results The 12 patients underwent surgical repair including unroofing of the myocardial bridge overlying the intraconal LMCA and a LeCompte procedure. There was no early or late mortality and there were no significant complications. All 12 patients have resumed normal, unrestricted activities. Conclusions Twelve patients with an anomalous LMCA and intraconal course presented to our institution for treatment. Surgical repair was performed successfully in all 12, with resolution of symptoms in the 7 patients who were symptomatic preoperatively. These results suggest that the surgical treatment is safe and efficacious in patients with an anomalous LMCA and intraconal course.

A 49-year-old woman presented with exercise-induced chest discomfort during long-distance running that was occasionally present during rest. Significant coronary artery disease was excluded and a diagnosis of “painful left bundle branch block (LBBB) syndrome” was made after correlation of LBBB aberrancy with symptoms during Holter monitoring. The patient underwent confirmatory testing consisting of rapid atrial pacing below and above 130 beats per minute, the rate cut-off for LBBB manifestation. His bundle pacing implantation was performed resulting in both non-selective and selective morphologies depending on output, both of which manifested with a painless narrow QRS regardless of rate. She was rendered completely pain free during long-distance running and remains so 6-months later. Her pain at rest, now thought to be due to severe anxiety secondary to her painful LBBB, has also subsided. Exercise-induced, painful LBBB is a rare phenomenon that manifests as chest discomfort when LBBB is present. This disease is frequently misdiagnosed as coronary angina, has limited medical treatment options, and can be disabling. HBP is an attractive treatment for this syndrome in an effort to avoid electromechanical dyssynchrony, the presumed mechanism of discomfort. This case report adds to the growing literature of painful LBBB syndrome and its effective treatment with HBP, with the added caveat that it can present with persistent symptoms at rest, in the setting of enhanced anxiety. HBP should be considered early on in the treatment of such patients.

A 66-year-old man presented in our hospital with complain of exertional chest pain NYHA function class III from 8 months ago. The single-photon emission computed tomography (SPECT) scan revealed severe stress-induced ischemia in anterior and moderate ischemia in inferior and lateral territories. The angiogram of left coronary system showed that the left anterior descending artery (LAD) is totally cut off at mid part (after first large diagonal branch). The mid to distal part of LAD was not visualized at left coronary injection. In injection of right coronary artery (RCA), which was non-dominant, the LAD was not visualized. After withdrawal of catheter and selective conus artery injection, the mid to distal part of well-developed LAD was visualized by some collateral’s branches.

Introduction: Exertional chest pain (CP) regularly prompts performing an exercise stress test (EST) out of concern for exercise-induced ischemia. We aimed to study the diagnostic utility of EST in the evaluation of ischemia among pediatric patients without previously diagnosed congenital heart disease (CHD) who present with exertional CP and to correlate EST results with available cardiac imaging findings. Methods: Retrospective chart review of all pediatric patients who underwent EST for exertional CP from Jan 2015 to Dec 2019 at our institution. Exercise stress test was performed on treadmill utilizing Bruce protocol. Analysis included demographic medical records and all available cardiac testing. Results: A total of 106 patients (56 males; 53%) were included. Cohort mean age, height, and weight were 15.1 ± 2.6 years (range: 7.3 - 19.6yr), 165 ± 12.7 cm, and 67.5 ± 26.2 kg. ST-T wave changes were noted in 8 patients (7.5%), 7 of which were non-specific and read as normal ESTs. One (0.94%) EST was suggestive of ischemic changes. His echocardiogram (echo) showed mild thickening of papillary muscles and ventricular septum. A follow-up exercise myocardial perfusion study showed no abnormality. Echo was performed on 86/106 (81%) patients. Of these, 23/86 (27%) had incidental abnormalities on echo; none contributed to the patients’ CP. Five patients (5/86; 5.8%) had notable coronary artery abnormalities on echo; all had normal ESTs. Two of these were confirmed by Cardiac CTA: 1) Left Main Coronary Artery (LMCA) arising from non-coronary cusp, and 2) dilated LMCA (Z-score 4.67) with slight dilation of Left Anterior Descending (Z-score 2.54). In the other 3 of 5 ( prominent LMCA, possible CA fistula, RCA with more leftward origin ) further coronary evaluations were not performed. Conclusions: Incidental non-specific echo abnormalities are common among pediatric patients who undergo EST for exertional CP. EST was negative in patients with coronary artery abnormalities. ESTs have a low yield in identifying cardiac abnormalities among pediatric patients without previously diagnosed CHD undergoing evaluation for exertional CP. Larger studies are needed to better evaluate the utility of EST in patients with coronary artery anomalies.

Anomalous origin of the left coronary artery from the opposite sinus of Valsalva with an intramural aortic course is a rare congenital anomaly with a poor prognosis. We report the case of a 14-year-old soccer player who briefly lost consciousness while sprinting. He had exertional chest pain, syncope, ischemic changes on his electrocardiogram, and elevated cardiac troponin levels. Computed tomographic angiograms showed an anomalous origin of the left coronary artery from the right sinus of Valsalva and a course through the aortic wall toward the left coronary sinus. A surgically created neo-ostium in the left coronary sinus relieved the patient's ischemia, and he resumed playing soccer after cardiac rehabilitation.

A 78-year-old woman was referred to our service by her primary care physician with exertional chest pain, progressive dyspnoea, and a heart murmur. Her medical record was relevant for hypertension,...

Apical hypertrophic cardiomyopathy is an uncommon morphologic variant of hypertrophic cardiomyopathy, which is rarely diagnosed in childhood. To date, very few cases of asymptomatic children younger than 18 years have been reported in the literature. To the best of our knowledge, this is the first case of paediatric apical hypertrophic cardiomyopathy presenting with exertional chest pain, with characteristic electrocardiographic, echocardiographic, MRI, and cardiac angiography findings.

A 56-year-old man was seen in cardiology clinic with exertional chest pain, most marked when walking uphill. He was a heavy smoker but had no other cardiovascular risk factors. His 12-lead ECG was normal, and a CT coronary angiogram (CTCA) was organised with a suspected diagnosis of angina.

A myocardial bridge is a segment of a coronary artery that travels into the myocardium instead of the normal epicardial course. Although it is general perception that myocardial bridges are normal variants, patients with myocardial bridges can present with symptoms, such as exertional chest pain, that cannot be explained by a secondary etiology. Such patients may benefit from individualized medical/surgical therapy. This article describes the prevalence, clinical presentation, classification, evaluation, and management of children and adults with symptomatic myocardial bridges.

Forty per cent of patients undergoing angiography to investigate exertional chest pain have normal coronary arteries. While described for nearly half a century, this condition has remained a mechanistic enigma.[1–2][1] Diminished coronary blood flow augmentation to a pharmacological vasodilator

Coronary artery aneurysms, rare lesions of Kawasaki disease (KD) and coronary atherosclerosis, are associated with severe cardiac complications. We herein describe an interesting case of coronary artery aneurysms due to exertional angina with possible underlying KD. A 26-year-old man without traditional risk factors for atherosclerosis presented with exertional chest pain and a positive exercise electrocardiogram stress test. Coronary angiography revealed total obstruction of the right coronary artery at the proximal portion, and the proximal left anterior descending artery contained a large spherical cavity filled with contrast agent; thus, the diagnosis of coronary artery aneurysms was confirmed. This was a typical coronary lesion suggestive of KD, and coronary artery bypass grafting was recommended. The diagnosis of KD may be ignored or missed in childhood, and significant cardiovascular damage may remain silent until adulthood, when severe coronary artery stenosis or thrombosis results in angina or acute myocardial infarction. Thus, to promote timely treatment and reduce morbidity and mortality, antecedent KD should be considered in the presence of angina pectoris or acute myocardial infarction in young patients without traditional risk factors for atherosclerosis.

Anomalous coronary artery from opposite sinus (ACAOS) with malignant inter-arterial course can cause sudden cardiac death in young athletes. However, older patients ACAOS are less predisposed to adverse cardiac events. 76-year-old female presents for evaluation of exertional chest pain. Physical

Exertional chest pain with abnormal ECGs are not uncommon in patients with apical hypertrophic cardiomyopathy (aHCM). It is difficult to exclude the presence of flow limiting coronary artery disease A 73-year-old Female with history of aHCM, CAD who presented with severe exertional substernal chest

Apical variant hypertrophic cardiomyopathy (AHCM) is a rare genetic disease with variable phenotypic expression, typically associated with a benign prognosis. A 71-year-old female with AHCM presented with 3 days of exertional chest pain and was found to have NSTEMI. EKG showed deep T-wave

A 54-year-old woman presents with a long history exertional chest pain and was found to have left ventricular systolic dysfunction on trans-thoracic echocardiogram. Coronary angiography revealed no evidence of atherosclerotic coronary artery disease and showed multiple micro-fistulae draining from all three major coronary arteries to the left ventricle. This rare abnormality is the result of failure of obliteration of intra-trabecular embryonic sinusoids and may cause myocardial ischemia through the coronary steal mechanism.

In October 2015, a 74-year-old Caucasian male patient (past medical history of hyperlipidemia, paroxysmal atrial fibrillation, hypertension, and hypothyroidism) presented to the cardiologist for follow-up outpatient evaluation of exertional chest pain. The patient had recently been seen at the Emergency Department for the same complaint. At that time, the patient’s cardiac markers, EKG, and pharmacological nuclear stress testing were all reported as normal. At presentation to the cardiologist, the patient’s physical examination findings were unremarkable. Over the course of the following year, repeat electrocardiograms and myocardial perfusion imaging studies demonstrated no evidence of ischemia. Despite the persistence of symptoms, the patient was reluctant to undergo invasive testing. The cardiologist ordered a simple blood test: the Age, Sex, and Gene Expression Score, which provides the current likelihood of obstructive coronary artery disease in nondiabetic patients. Based on the high Age, Sex, and Gene Expression Score result, the patient underwent invasive coronary angiography and a 98% stenotic lesion in the proximal left anterior descending artery was discovered. A drug-eluting coronary stent was placed and resulted in the complete resolution of the patient’s symptoms.

A 60-year-old man with history of hypertension, hyperlipidemia, and diabetes mellitus presented for a coronary angiogram after an abnormal electrocardiographic treadmill stress test for exertional chest pain. He underwent successful drug-eluting stent placement to a 75% mid–left anterior

Patient Initials or Identifier Number JML ### Relevant Clinical History and Physical Exam A 37-year-old lady, underlying ASD with moderate pulmonary artery hypertension in whom ASD closure was not done due to contraindication. She presented with on and off exertional chest pain despite normal

Patient Initials or Identifier Number I.O ### Relevant Clinical History and Physical Exam A 70’s-year-old man was admitted with exertional chest pain for 1 month. His coronary risk factors were hypertension and smoking. His past history was IgA nephropathy and prostatic hypertrophy. ###

A 59-year-old Hispanic man with no prior history of coronary artery disease was admitted with a non-ST-segment elevation myocardial infarction following several months of exertional chest pain. His electrocardiogram ([Figure 1A][1]) showed inferolateral ST-segment depression. He underwent coronary

Patient Initials or Identifier Number 4546578 ### Relevant Clinical History and Physical Exam A 67 years old Saudi Gentleman known to have Diabetes mellitus and hypertension presented with exertional chest pain and shortness of breath NYHA II-III. ECG -sinus rhythm, with T-wave inversion at

Patient Initials or Identifier Number A.N ### Relevant Clinical History and Physical Exam An 82-year-old male with hypertension and diabetes mellitus was admitted with exertional chest pain (CCS Ⅲ) and claudication (Rutherford Ⅲ). Both symptoms were gradually worsening and he visited our

This article has no abstract. The first 100 words appear below:A 48 year old male attended the cardiac outpatient department with the complaints of chest pain on exertion. Two years back, he developed chest pain on exertion. The pain was retrosternal, dull in nature, non-radiating, aggravated on exertion and relieved by rest. There was no relation with food intake and not relieved by taking H2 blocker. The patient was a known case of hypertension for the last 10 years. He was on antihypertensive medication and his blood pressure was controlled with therapy. There was no history of respiratory distress and cough. With these complaints, he at first attended to a nearby Government medical college hospital in Barisal (South central division of Bangladesh).

Objective Using a Standardized Clinical Assessment and Management Plan (SCAMP) for pediatric patients presenting to clinic with chest pain, we evaluated the cost impact associated with implementation of the care algorithm. Prior to introduction of the SCAMP, we analyzed charges for 406 patients with chest pain, seen in 2009, and predicted 21% reduction of overall charges had the SCAMP methodology been used. The SCAMP recommended an echocardiogram for history, examination, or ECG findings suggestive of a cardiac etiology for chest pain. Design Resource utilization was reviewed for 1517 patients (7-21 years) enrolled in the SCAMP from July 2010 to April 2014. Results Compared to the 2009 historic cohort, patients evaluated by the SCAMP had higher rates of exertional chest pain (45% vs 37%) and positive family history (5% vs 1%). The SCAMP cohort had fewer abnormal physical examination findings (1% vs 6%) and abnormal electrocardiograms (3% vs 5%). Echocardiogram use increased in the SCAMP cohort compared to the 2009 historic cohort (45% vs 41%), whereas all other ancillary testing was reduced: exercise stress testing (4% SCAMP vs 28% historic), Holter (4% vs 7%), event monitors (3% vs 10%), and MRI (1% vs 2%). Total charges were reduced by 22% ($822 625) by use of the Chest Pain SCAMP, despite a higher percentage of patients for whom echocardiogram was recommended compared to the historic cohort. Conclusions The Chest Pain SCAMP effectively streamlines cardiac testing and reduces resource utilization. Further reductions can be made by algorithm refinement regarding echocardiograms for exertional symptoms.

A 15-year-old male with transposition of the great arteries presented with exertional chest pain. He was found to have a circumflex coronary artery from the neo-pulmonary artery that had not been transferred during his arterial switch operation. The circumflex coronary artery, fed through collaterals from a re-implanted single coronary artery, resulted in coronary steal. This report describes a management pathway to treat this rare anomaly.

Homozygous Familial Hypercholesterolaemia is a genetic disorder which usually presents with early cardiovascular disease ranging from premature ischaemic disease, including myocardial infarction to aortic root stenosis. A 21 year old Bangladeshi male presented with exertional chest pain and breathlessness. He was diagnosed as a case of Homozygous Familial Hypercholesterolaemia. His angina symptoms were due to underlying valvular aortic stenosis which is a rare presentation of Homozygous Familial Hypercholesterolaemia. DOI: http://dx.doi.org/10.3329/cardio.v6i2.18365 Cardiovasc. j. 2014; 6(2): 180-183

A 65-year-old man with known bone metastases from prostate cancer and no cardiac history attended for a restaging bone scan (BS). Diffuse increased Tc-HDP activity in the heart was noted, new since a BS 3 months earlier. A restaging contrast-enhanced CT scan on the same day showed reduced myocardial perfusion in the anterior, apical, and septal walls. On direct questioning, he described an episode of severe exertional chest pain the day before. Myocardial infarction was confirmed and treated with primary percutaneous coronary intervention. New cardiac uptake on BS, raising the possibility of myocardial infarction, is a red alert for clinicians.

Patient Initials or Identifier Number 1282201 ### Relevant Clinical History and Physical Exam CCTA – 1VD (pLAD) HBP P.I.: 56/M, he was admitted due to exertional chest pain started 1 month ago. (90/50-70-20-37) Lab WBC 6500 Hb 14.8 Platelet 167K BUN/Cr 8.5/0.81 CK-MB/Tro-T 6.18/0.008

Double right coronary artery (RCA) is a very rare coronary artery anomaly (few cases reported in the literature) that might be overlooked during left heart catheterization for chest pain evaluation or other diagnostic purposes. A 46-year-old male presented with exertional chest pain.

Double-chambered right ventricle (DCRV) seldom presents in adulthood. Diagnosis of this condition can be challenging, and requires a multimodality approach. A 38 year old woman with a history of ventricular septal defect (VSD) presented with exertional chest pain and dyspnea. A harsh systolic

Although primary cardiac osteosarcoma is uncommon, cardiac neoplasms should be in the differential diagnosis of cardiac complaints. We present a case of a 35 year old man with recurrent episodes of exertional chest pain and who was diagnosed with primary cardiac osteosarcoma. Cardiac osteosarcomas are rare but must be suspected.

Patient initials or identifier number 312342 ### Relevant clinical history and physical exam This is a 68 year old chronic smoker with underlying hyperlipidemia, gouty arthritis and hypertension. He had exertional chest pain, CCS class 2 for the last 2months. He also had dyspnea on exertion

Patient initials or identifier number Y.T ### Relevant clinical history and physical exam A 47-year-old man presented with an exertional chest pain for 1 month. However, he did not visit a hospital. As a result, he was admitted with prolonged resting chest pain. His coronary risk factor was

A 52 year old female reported to surgery department of Bangabandhu Sheikh Mujib Medical University (BSMMU) with dysphasia and exertional chest pain. With detailed history and examination she was diagnosed as a case of epigastric mass and undergone X-ray chest. The report revealed enlarged mediastinal shadow with suspicion of thoracic aortic aneurysm. X-ray chest was followed by contrast enhanced CT scan which revealed a large partially thrombosed aneurysmal dilatation of the aortic arch with sharp kinking (bend) at distal end of aneurysm and beginning of descending aorta. Then the patient was referred to cardiac surgery for immediate management. But the patient refused to have a surgery. Then two months later the patient again presented with chest pain and admitted in DMCH. But the patient died.DOI: http://dx.doi.org/10.3329/jom.v16i1.22405 J MEDICINE 2015; 16 : 53-55

A 38-year-old man with polyarteritis nodosa presented with exertional chest pain. Coronary angiography revealed 3-vessel coronary artery disease. We performed 2-vessel coronary artery bypass grafting with the saphenous vein because the left internal thoracic artery was in poor condition. Histological examination of the left internal thoracic artery showed a strong effect of polyarteritis nodosa.

The management of coronary disease has moved forward with the application of more sensitive blood biomarkers for early detection alongside more structured symptom assessment, examination and serial ECG measures. However every episode of exertional chest pain isn’t symptomatic coronary disease and given massive public awareness campaigns we now face a different management issue with undiagnosed chest pain sent as a ‘rule-out’ activity. These urgent referrals are often justified based on the management of the minority with unstable coronary disease without preliminary medical review or examination. Avoiding delay which is valuable in coronary patients may be irrelevant to the majority. The overall effectiveness of this pathway is unclear where the patient does not have coronary disease but also where superficial interpretation can be misleading through non-specificity. Do biomarker assays become the answer to every chest pain patient and has the basic assessment of the individual patient and a prior probability of disease no role to play? Does this activity represent a burden or an irrelevant dead end for non-coronary patients? We have asked for comment from two leading authorities on the evolving role and application of cardiac biomarker technologies in managing this considerable and common clinical dilemma.

Patient initials or identifier number 01511314 ### Relevant clinical history and physical exam Case summary: A 84 year-old male patient presented with exertional chest pain for several months. His coronary risk factors were hypertesion, hyperlipidemia and smoking. The echocardiography