The Interdisciplinary Management of Acute Chest Pain

Mondor's Disease: A Rare Cause of Chest Pain

Introduction

Chest pain is a very frequent reason for seeking medical care. When there is no obvious cause, patients are sometimes subjected to tests and treatments that may be unnecessary and potentially harmful. Mondor's disease is a rare but usually benign and self-limited entity characterized by thrombophlebitis in a specific region.

Case report

We report the clinical case of a 51-year-old man admitted to the emergency department with a 24-hour history of left chest pain with no other symptoms. Physical examination revealed a palpable subcutaneous cord-like structure that ultrasound confirmed to be thrombophlebitis of a superficial vein in the mammary region. Secondary causes were ruled out, and the condition resolved with ibuprofen and the application of local ice.

Discussion

Mondor's disease can be associated with neoplasms, trauma or hyperviscosity states, but it is mostly idiopathic. Usually, it resolves completely in 4-8 weeks without specific treatment. Because this infrequent diagnosis mainly relies on clinical findings, it is important that clinicians can recognize the syndrome.

LEARNING POINTS

Mondor's disease is a rare but benign disease, with no proof that specific treatment, such as anticoagulation, is beneficial.It may be secondary to underlying disease as malignancy, vasculitis, trauma or hyperviscosity states, which should be excluded.Treatment in the majority of the cases is symptomatic, but if it is secondary Mondor's disease, the underlying problem should be investigated. Physicians should be aware of this condition in order to address patient concerns and avoid unnecessary treatments or investigations.

Pre-hospital delay in patients with acute chest pain

Introduction: Incidence of chest pain and discomfort varies in general population between 2 % and 5 %. Total prehospital delay involves two components: the time it takes for patients to recognise their symptoms as severe and seek medical attention, ie the decision-making time, and the time from seeking help to hospital admission, ie the transport time. Scope of the study was to analyse time loss in patients with chest pain hesitating to contact healthcare services, as well as distribution of acute myocardial infarction (AMI) and angina pectoris (AP) among them. Methods: Retrospective analysis of medical records of physicians working at the emergency medical services (EMS) Department of the City of Belgrade, Serbia, from 20 April 2006 to 22 July 2013 on a total of 5,310 completed field interventions. When placing a call to the EMS, 10.43 % of patients cited chest pain as a major symptom. After deducting all those ones who denied having the symptom on examination thereafter and those for whom there were no data, 349 patients remained, ie 6.57 % of the total number of calls available for analysis. Results: The average time between the onset of chest pain and the decision to call the EMS was 11.97 h, median 2 h and mode 1 h. Patient's minimum prehospital delay was 2 min and the maximum was 20 days. Most patients who experienced chest pain or discomfort waited less than an hour before calling the EMS. Most commonly diagnoses made for a symptom of chest pain were AMI and AP, ie AMI with 12.32 % of the total diagnoses, as well as the elevated arterial pressure. There were more female patients, with no difference found among the age groups. Conclusion: For the majority of patients with chest pain and discomfort presented in this paper the decision-making time was up to one hour, with cardiovascular causes being the at the top of the list.

Gastric perforation through a hiatus hernia into the left lung in an 84-year-old woman

An 84-year-old woman presented to the emergency department with a sudden onset of chest pain, shortness of breath and vomiting. She had a medical history of hiatus hernia, gastro-oesophgeal reflux disease and asthma only, but had several recent courses of oral steroids to treat her asthma. Initially she was hypoxic, tachycardic and normotensive. ECG was normal, chest X-ray showed a hiatus hernia and right middle zone consolidation. Inflammatory markers were normal. CT angiogram was performed to exclude aortic pathology, for which it was negative. It did however show a large hiatus hernia which had perforated and was communicating with the left lung. The patient deteriorated clinically and became hypotensive and more hypoxic. She was transferred to the intensive care unit but died 36 hours later as she was too unwell to undergo any exploratory surgery.

Diagnostic Agreement between Prehospital Emergency and In-Hospital Physicians

BACKGROUND

The aim of the study was to determine the diagnostic agreement between the discharge diagnosis and the suspected diagnosis by the prehospital emergency physician and to run a sensitivity analysis of the most common diagnoses by the prehospital emergency physician.

METHODS

The diagnostic agreement was determined by a systematic comparison of the discharge diagnosis with suspected diagnosis by the prehospital emergency physician in a period of 24 months at the emergency medical services in Bad Belzig. The diagnostic agreement of the 13 most common discharge diagnoses was compared to the remaining diagnostic agreement. The results were tested for statistical significance using the chi-squared test.

RESULTS

In 64.1% of cases included, a diagnostic agreement occurred. There was a high proportion of diagnostic agreement for hypoglycemia (97%), atrial fibrillation (87%), cramping seizure (86%), hypertensive crisis (85.5%), and syncope (81%). There was a low proportion of diagnostic agreement for chest wall pain (27%), pneumonia (32%), and cardiac decompensation (53%).

CONCLUSIONS

Our attention in practice and emergency medical courses should be directed to chest pain patients and the main symptom of dyspnea, because of the high proportion of incorrect diagnoses by the prehospital emergency physician. It should be noted that 92% of incorrectly diagnosed chest wall pain cases were overestimated with an acute coronary syndrome.

Gastroenterological Perspectives on Acute Cardiac Care — the Management of Patients with Implanted Coronary Stents Following an Acute Coronary Syndrome

Cardiovascular and digestive diseases frequently share the same risk factors such as obesity, unhealthy diet, or several social behaviors, and the increasing prevalence of patients with overlapped cardiovascular and digestive symptoms is a challenging problem in the daily practice. Patients with gastro-esophageal reflux disease can exhibit various forms of chest pain that can be very similar to angina. Furthermore, antithrombotic therapies used for preventive or curative purposes in patients with cardiovascular diseases are frequently associated with gastrointestinal side effects including bleeding. At the same time, in patients with coronary stents presenting to the emergency department with chest pain, angina triggered by stent thrombosis or restenosis should be differentiated from angina-like symptoms caused by a gastrointestinal disease. The aim of this review was to present the complex inter-relation between gastroesophageal diseases and angina in patients on dual antiplatelet therapy following an acute coronary syndrome, with a particular emphasis on the role of anemia resulting from occult or manifest gastrointestinal bleeding, as a precipitating factor for triggering or aggravating angina.

Non-Cardiac Chest Pain

Background

Non-cardiac chest pain (NCCP) is recurrent angina pectoris-like pain without evidence of coronary heart disease in conventional diagnostic evaluation. The prevalence of NCCP is up to 70% and may be detected (in this order) at all levels of the medical health care system (general practitioner, emergency department, chest pain unit, coronary care). Reduction of quality of life due to NCCP is comparable, and partially even higher, to that caused by cardiac chest pain. Reasons for psychological strain are symptom recurrence in approximately 50%, nonspecific diagnosis with resulting uncertainty, and insufficient integration of other medical disciplines in the diagnostic workup.

Methods and Results

The management of patients with chest pain has to be multidisciplinary because non-cardiac causes may be frequently encountered. Especially gastroenterological expertise is required since the cause of chest pain is gastroesophageal reflux disease (GERD) in 50-60%, hypercontractile esophageal motility disorders with nutcracker/jackhammer esophagus or diffuse esophageal spasm or achalasia in 15-18%, and other esophageal alterations (e.g., infectious esophageal inflammation, drug-induced ulcers, rings, webs, eosinophilic esophagitis) in 32-35%.

Conclusion

This review highlights the importance of regular interdisciplinary ward rounds and management of chest pain units.

The Differential Diagnosis of Dyspnea

BACKGROUND

Dyspnea is a common symptom affecting as many as 25% of patients seen in the ambulatory setting. It can arise from many different underlying conditions and is sometimes a manifestation of a life-threatening disease.

METHODS

This review is based on pertinent articles retrieved by a selective search in PubMed, and on pertinent guidelines.

RESULTS

The term dyspnea refers to a wide variety of subjective perceptions, some of which can be influenced by the patient's emotional state. A distinction is drawn between dyspnea of acute onset and chronic dyspnea: the latter, by definition, has been present for more than four weeks. The history, physical examination, and observation of the patient's breathing pattern often lead to the correct diagnosis, yet, in 30-50% of cases, more diagnostic studies are needed, including biomarker measurements and other ancillary tests. The diagnosis can be more difficult to establish when more than one underlying disease is present simultaneously. The causes of dyspnea include cardiac and pulmonary disease (congestive heart failure, acute coronary syndrome; pneumonia, chronic obstructive pulmonary disease) and many other conditions (anemia, mental disorders).

CONCLUSION

The many causes of dyspnea make it a diagnostic challenge. Its rapid evaluation and diagnosis are crucial for reducing mortality and the burden of disease.

[Diagnostic investigation in emergency medicine: Why case history is crucial]

We present the preclinical case of a patient reporting chest pain. Pain impeded physical examination. Reviewing the patient's detailed medical history after analgesia revealed a connection between the reported pain and vomiting. This led to a suspicion of organ perforation. Thus, the patient was admitted to a surgical emergency room (ER) and Boerhaave's Syndrome was diagnosed. After deterioration in the ER, cardiopulmonal reanimation (CPR), and successful surgical treatment, the patient was transferred to the intensive care unit (ICU) seven hours after first contact.

[Gastroenterological diseases as triggers of chest pain]

BACKGROUND

Non-cardiac chest pain is very common and gastroenterological diseases are one of the most important causes. The frequency distribution of the underlying causes depends on the sector of the healthcare system in which it is ascertained. In individual cases it must always be taken into consideration that detection of coronary heart disease, for example, does not exclude another origin of chest pain.

OBJECTIVE

This article provides a systematic review of gastroenterological diseases that can cause chest pain. Furthermore, a management algorithm was developed.

MATERIAL AND METHODS

This article is based on a selective search of the literature.

RESULTS AND DISCUSSION

The most frequent cause is gastroesophageal reflux disease, which is also known as reflux-chest pain syndrome. If there are no clinical alarm signals, treatment is carried out with a proton pump inhibitor either as a diagnostic test or as a probatory therapy. If this initial management does not lead to satisfactory symptom control, extended diagnostics are indicated. In individual cases this concerns the detection or exclusion of a reflux disease, of motility disorders and structural damage to the esophagus as well as diseases of the upper abdominal organs, which can evoke chest pain. After exclusion of these morphologically and/or functionally defined diseases, a so-called functional chest pain is present. The essential mechanisms are altered pain processing, esophageal hypersensitivity and mental comorbidities. The treatment of functional chest pain often proves to be difficult.