Bilateral Epicardial Coronary Microfistulas With Anomalous Deviation

61-Year-Old Man With Nausea and Vomiting

Safety assessments in the avoidance of preoperative α-receptor blockade in phaeochromocytoma surgery: the pitfalls of a zero numerator

The Silent Burden of Perioperative Myocardial Infarction After Noncardiac Surgery

Biomarkers in the triage of chest pain: are we making progress?

Prognostic implications of serial high-sensitivity cardiac troponin testing among patients with COVID-19: A Danish nationwide registry-based cohort study

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Myocardial perfusion in children with sickle cell disease

A 66-year-old man sought medical care at the hospital due to severe chest pain lasting for 24 hours. The patient was aware of being hypertensive and was a smoker. Without any prior symptom, he started to have severe chest pain and sought emergency medical care after about 24 hours, due to pain persistence. At physical examination (August 13, 2005, 10 PM) he had a heart rate of 90 bpm and blood pressure of 110/70 mmHg. Lung examination showed no alterations. Heart assessment showed a systolic murmur in the lower left sternal border and mitral area. The initial electrocardiogram (August 13, 2005, 22 h) showed HR of 100 bpm, sinus rhythm, 1st-degree atrioventricular block (PR 240 ms), low-voltage QRS complexes in the frontal plane, QRS complex electrical alternans and extensive ongoing anterior wall infarction (QS V1 to V6, ST elevation in the same leads and QS in the inferior wall, II, III and aVF) (Figure 1). Figure 1 ECG: low QRS voltage in the frontal plane, electrical alternans of QRS complexes, electrically inactive lower wall area and extensive ongoing myocardial infarction. Acetylsalicylic acid by oral route and 5 mg of intravenous metoprolol were administered. The patient had bradycardia and cardiorespiratory arrest in pulseless electrical activity, reversed after five minutes. He developed hypotension and peripheral hypoperfusion and was transferred to InCor (The Heart Institute). On admission he had received heparin and continuous intravenous norepinephrine. BP was 60/30 mmHg. The ECG (August 13, 2005, 11:36 PM) disclosed heart rate of 116 bpm, junctional escape rhythm with sinus arrest and atrial extrasystoles); low-voltage QRS complex in the frontal plane, extensive ongoing anterior acute myocardial infarction, inactive area in the inferior wall; presence of ST elevation at V1 to V5 and ST depression in leads I, II and aVF; ST elevation in aVR (Figure 2). Figure 2 ECG: low QRS voltage in the frontal plane, electrically inactive lower wall area and anterior myocardial infarction with increased ST elevation, still with positive T waves, hyperacute phase of myocardial infaction. Coronary angiography was indicated, which disclosed anterior interventricular branch occlusion and images suggestive of intracoronary thrombus, lesion of 70% in the circumflex artery, 50% in the right coronary artery and 70% in the ostium of the right posterior descending branch. Angioplasty was performed with stent implant in the anterior interventricular artery, but distal flow was not restored. This was followed by cardiac arrest in asystole, which did not respond to treatment and the patient died.

Atypical chest pain and diabetic autonomic neuropathy attract less clinical attention, leading to underdiagnosis and delayed treatment. To evaluate the long-term clinical impact of atypical chest pain and diabetes mellitus (DM), we categorized 11,159 patients with acute myocardial infarction (AMI) from the Korea AMI-National Institutes of Health between November 2011 and December 2015 into four groups (atypical DM, atypical non-DM, typical DM, and typical non-DM). The primary endpoint was defined as patient-oriented composite endpoint (POCE) at 2 years including all-cause death, any myocardial infarction (MI), and any revascularization. Patients with atypical chest pain showed higher 2-year mortality than those with typical chest pain in both DM (29.5% vs. 11.4%, p < 0.0001) and non-DM (20.4% vs. 6.3%, p < 0.0001) groups. The atypical DM group had the highest risks of POCE (hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.48–2.10), all-cause death (HR 2.23, 95% CI 1.80–2.76) and any MI (HR 2.34, 95% CI 1.51–3.64) in the adjusted model. In conclusion, atypical chest pain was significantly associated with mortality in patients with AMI. Among four groups, the atypical DM group showed the worst clinical outcomes at 2 years. Application of rapid rule in/out AMI protocols would be beneficial to improve clinical outcomes.

Risk Factors, Echocardiographic Patterns, and Outcomes in Patients With Acute Ventricular Septal Rupture During Myocardial Infarction

High-sensitivity troponin assays facilitate the rapid exclusion of acute myocardial infarction (AMI). However, elevated results are also seen in other conditions causing myocardial injury. Serial measurements increase the specificity for...

We evaluated data on blacks and whites with acute ST-segment-elevation myocardial infarction treated with either fibrinolysis or primary percutaneous coronary intervention from the National Registry of Myocardial Infarction (NRMI)-4 and -5 participating centers between July 2000 and December 2006 to determine race-related differences in bleeding and outcomes. We found that among patients with ST-segment-elevation myocardial infarction receiving fibrinolysis, the bleeding rates were higher for blacks (n2283) than whites (n42 243; 10.9% versus 10.3%; adjusted odds ratio, 1.21; 95% confidence interval, 1.02-1.43). Similarly, in patients receiving primary percutaneous coronary intervention, the bleeding rates were higher in blacks (n2826) than whites (n46 332; 10.3% versus 7.8%; adjusted odds ratio, 1.33; 95% confidence interval, 1.13-1.56). Bleeding was associated with a higher risk of death in both ethnic groups. However, there was no overall racial difference in in-hospital mortality among those with bleeding or without bleeding treated with either fibrinolysis or primary percutaneous coronary intervention. We concluded that race-related differences existed in bleeding risk among patients with ST-segmentelevation myocardial infarction receiving reperfusion therapy that portend poor prognosis. Thus, the efficacy and safety of many new drugs or treatment strategies for any disease observed in clinical trials that enroll predominantly white patients may not be similar in other ethnic groups that are underrepresented in these trials.

Introduction According to ESC guidelines, an acute myocardial infarction (MI) can be excluded without serial troponin measurements in patients presenting with a single high-sensitive troponin below the 99th percentile and chest pain starting &gt;6 hours prior to admission. However, it is unclear if single-testing of high-sensitive troponin can rule-out MI in early presenters. Purpose To investigate the diagnostic performance of a single value of high-sensitive cardiac troponin I (hs-cTnI) at presentation for ruling-out MI in patients presenting with chest pain to the Emergency Department irrespective of chest pain onset. Methods We conducted a substudy of preliminary data from the RACING-MI trial. We included patients presenting with chest pain suggestive of MI to the Emergency Department of a Regional Hospital. We used the Siemens hs-cTnI (Siemens Healthcare, TNIH, Limit of detection: 2.21 ng/L) and a diagnostic cut-off value &lt;3 ng/L to rule-out MI at presentation. Two physicians independently adjudicated the final diagnosis based on all clinical information. Patients were stratified based on time from chest pain onset to hospital admission as very early (0–3 hours), early (3–6 hours) and late presenters (&gt;6 hours). Results We included 989 patients with available hs-cTnI results at admission. MI was confirmed in 82 (8.3%) patients. Using hs-cTnI &lt;3 ng/L as diagnostic cut-off value at presentation, 302 (30.5%) patients without MI were classified as rule-out. Overall, the negative predictive value (NPV) for MI was 100% (95% CI 98.7–100). Based on chest pain onset, 33.8% of patients were classified as very early, 12.8% as early, and 42.7% as late presenters, with 10.7% patients with unreported/unknown onset. NPV was 100% (95% CI 96.5–100) for very early, 100% (95% CI 88.3–100) for early and 100% (95% CI 97.3–100) for late presenters. Conclusions Using a single hs-cTnI value &lt;3ng/L as diagnostic cut-off to rule-out MI seems to be safe and to allow rapid rule-out of MI in patients presenting with chest pain to the emergency department, even in very early presenters. ClinicalTrials.gov Identifier: NCT03634384. Acknowledgement/Funding Randers Regional Hospital, A.P Møller Foundation, Boserup Foundation, Korning Foundation, Højmosegård Grant, Siemens Healthcare (TNIH assays), etc.

Cardiopulmonary exercise test with stress echocardiography in COVID-19 survivors at 6 months follow-up

Background:Chest pain is one of the most common causes of the admission to the emergency departments. It, however, can be due to numerous diseases some of which are life threatening.Objectives:In the current study, we evaluated the prognostic value of TIMI (Thrombolysis in Myocardial Infarction) and Modified TIMI risk scores to stratify the risk for patients with atypical chest pain being discharged from the emergency department.Patients and Methods:In a prospective-analytic study, we collected data from 1020 patients with atypical chest pain enrolled to the study. All eligible patients were visited by the emergency medicine residents who were trained for this study. Based on the criteria in both systems, the emergency medicine attending decided on either discharging or hospitalizing patients. Patients were allocated into 2 equal groups randomly. In order to predict the opposing accidents in 30 days (coronary revascularization, myocardial infarction, and all-cause death) TIMI risk scores and Modified TIMI risk scores were assessed based on TIMI risk score (0 or 1) and Modified TIMI risk score (0 or 1).Results:No significant difference could be observed between both groups regarding demographic characteristics, ejection fraction, left ventricle hypertrophy, TRS criteria, risk factors and the history of coronary artery stenosis. None of the atypical chest pain patients discharged based on TIMI and modified TIMI risk scores experienced any adverse events.Conclusions:The results obtained from this study support the idea that the TIMI and modified TIMI risk scores might be valuable tools that could be used to stratify the risk of patients with atypical chest pain in the emergency department.