Incidence, Pattern, Causes, and Outcome of Acute Chest Pain Among Patients Presenting in the Emergency Department of a Tertiary Care Hospital in North India

BACKGROUND

Acute chest pain is a common presentation in emergency departments worldwide. Differentiating between cardiac and non-cardiac chest pain is crucial for patient management and resource allocation.

METHODS

This study analyzed 714 patients presenting with acute chest pain in a tertiary care hospital in North India. We investigated demographic characteristics, chief complaints, risk factors, ECG findings, and final diagnoses to identify patterns associated with cardiac (CCP) and non-cardiac chest pain (NCCP).

RESULTS

CCP was diagnosed in 53.7% (n=383) and NCCP in 46.3% (n=331). Significant predictors of CCP included age (OR=1.05, p<0.001), smoking (OR=2.22, p<0.001), diabetes (OR=1.57, p=0.003), hypertension (OR=1.82, p<0.001), and family history of ischemic heart disease (IHD) (OR=1.42, p=0.01). Central chest pain was more common in CCP (60% vs. 40%, p<0.001), as were abnormal ECG findings such as ST-segment depression (35% vs. 10%, p<0.001) and elevation (29% vs. 6%, p<0.001). Normal ECG was more prevalent in NCCP (60%, p<0.001).

CONCLUSION

Traditional cardiovascular risk factors remain strongly associated with CCP. Smoking has a particularly high odds ratio, suggesting the need for targeted interventions. ECG findings significantly aid in differentiating CCP from NCCP. This study underscores the importance of a comprehensive approach in evaluating acute chest pain to ensure accurate diagnosis and effective treatment.

A Young Male Presenting With Chest Pain, Elevated Troponin Levels, and a Clinical Dilemma: A Case Report

Chest pain is a common presentation that may represent a wide variety of underlying etiologies ranging from mild self-limiting conditions to immediately life-threatening emergencies. The combination of "cardiac-sounding chest pain" and elevated troponin levels would raise suspicion of an acute ischemic event. An acute coronary syndrome is a diagnosis that may be straightforward; however, oftentimes, patients with elevated troponin levels and chest pain may bring about a state of diagnostic uncertainty. Alternative diagnoses to consider would be inflammatory or infectious conditions of the myocardium and pericardium. We present the case of a young gentleman in his twenties who presents with cardiac chest pain, elevated troponin, and non-specific changes on his electrocardiogram who was treated for an alternative cause of elevated troponin and chest pain, myopericarditis. We present the case of a 24-year-old male who presented with a six-hour history of debilitating retrosternal chest pain. Initial workup showed a Troponin I level greater than 15,000 ng/L, D-Dimer greater than 1,000 mcg/L with no overt ischemic features on electrocardiogram. The patient had no high-risk features in his medical history & denied the use of recreational drugs. A formal same-day echocardiogram revealed normal biventricular systolic function and no evidence of regional wall motion abnormality (RWMA). He was eventually treated clinically for myopericarditis. A Cardiac MRI (CMR) imaging was done to confirm the diagnosis and rule out, most importantly, ischemic heart disease or any other underlying pathology. The main dilemma in this case was working out whether there was indeed peri-myocardial inflammation, or an acute coronary event (such as spontaneous coronary artery dissection) given his age and clinical history. Patients presenting with a very high troponin level, particularly in young patient cohorts, should raise suspicion of a myocardial or pericardial inflammatory process. In addition to a thorough history and in the absence of ischemic changes on the electrocardiogram, subtle findings such as PR segment depression may point to a diagnosis of pericardial inflammation. While urgent echocardiography is useful to quickly assess ventricular function and for RWMA, CMR imaging is the Gold Standard modality of investigation to provide detailed structural information of the heart.

Memory T-Waves: An Uncharted Territory in T-Wave Inversions

T-wave inversions on electrocardiograms (ECGs) can present a diagnostic challenge due to their association with various underlying causes. One less-explored cause is memory T-waves, a phenomenon characterized by T-wave inversions, often seen in chest and inferior leads, following a period of abnormal ventricular conduction. In this case report, we discuss the intriguing case of an 80-year-old woman who recently underwent percutaneous coronary intervention (PCI) for a myocardial infarction and subsequently developed memory T-waves. We are also discussing how important it can be to understand and recognize memory T-waves, as it will avoid further unnecessary tests and longer hospital stays.

Impact of Obesity on Outcomes of Emergency Department Visits for Cardiac Chest Pain: Insights From a Nationwide Emergency Department Study

Background Obesity, a widespread national epidemic that impacts one in three U.S. adults, is closely linked with the development and exacerbation of cardiovascular disease. The objective of this study was to assess and contrast the outcomes of adults, both obese and non-obese, who present with cardiac chest pain in the emergency department (ED). Methodology A retrospective analysis of the 2020 Nationwide Emergency Department Sample database was conducted. Multivariate regression models were utilized to examine the association between obesity and mortality, discharge disposition, number of procedures, complications, and hospital costs. Results No significant difference in mortality odds was observed between obese and non-obese patients presenting with cardiac chest pain in the ED (adjusted odds ratio (aOR) = 0.92; 95% confidence interval (CI) = 0.59-1.46; p = 0.736). However, obesity was found to be associated with a decreased likelihood of being discharged home from the ED (aOR = 0.57; 95% CI = 0.52-0.63; p < 0.001), as well as an increased likelihood of hospital admission from the ED (aOR = 1.66; 95% CI = 1.53-1.81; p < 0.001). Obesity also correlated with higher odds of non-home discharge (aOR = 1.74; 95% CI = 1.54-1.97; p < 0.001), elevated mean total hospital costs (mean = $13,345 vs. $9,952; mean increase = $3,360; 95% CI = $2,816-$3,904; p < 0.001), and increased risks of cardiac arrests (aOR = 1.52; 95% CI = 1.05-1.88; p < 0.001) and acute respiratory failures (aOR = 1.43; 95% CI = 1.25-1.96; p < 0.001). Obese patients with cardiac pain underwent more procedures on average than non-obese patients (19 vs. 15; aOR = 3.57; 95% CI = 3.04-4.11; p < 0.001). Conclusions Obesity is associated with higher odds of hospital admission from the ED, non-home discharges, higher total hospital costs, and a greater number of procedures.

Two Cases of Highly Symptomatic Interarterial Anomalous Right Coronary Arteries

Coronary artery anomalies are a broad group of congenital coronary artery variations. Anomalous aortic origin of a coronary artery is a variant that occurs when a coronary artery arises from an inappropriate sinus of Valsalva. While most patients are asymptomatic, these congenital variants may predispose them to symptoms or even sudden cardiac death (SCD). Unfortunately, no unified consensus exists on risk stratification or management of patients with these congenital variants. We present two unique cases of symptomatic anomalous right coronary arteries and discuss their presentations, imaging findings, and management.

Novel Intracoronary Infusion of Supersaturated Oxygen Therapy in Patients Presenting With Acute ST Elevation Myocardial Infarction: Does It Help?

Supersaturated oxygen (SSO₂) is one of the emerging therapies that has shown benefit for patients suffering from acute ST elevation myocardial infarction (STEMI) in terms of reducing infarct size, which has been used as a prognostic indicator for future heart failure and hospitalizations. Trials investigating SSO₂ therapy have shown improvement in infarct size when used as an adjunct therapy to percutaneous trans-luminal coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI) in patients presenting with acute myocardial infarction (aMI).  Here we present a patient with a mid left anterior descending artery (mLAD) STEMI who underwent SSO₂ therapy. The patient presented with new onset angina and ST elevations on EKG. He underwent emergent coronary angiography, which confirmed an mLAD complete vessel occlusion. Successful PCI was done with a drug-eluting stent followed by supersaturated oxygen therapy. On follow-up evaluation, the patient had improved left ventricular (LV) ejection fraction from 35% to 60%. This case highlights the safety and efficacy of SSO₂ therapy for patients suffering from acute anterior wall myocardial infarction. We recommend further investigation of this therapy for its routine use, safety, and prognostic utility. We also recommend routine use of adjunctive SSO₂ therapy for patients suffering acute anterior STEMI.

Synthetic Cannabinoids and ST-Elevated Myocardial Infarction: A Case Report and Literature Review

The use of synthetic cannabinoids and marijuana has been known to be associated with myocardial infarction and coronary vasospasms according to a few case reports published for the pediatric population. The data on the use of synthetic cannabinoids and myocardial infarction in adults however is limited. The adverse effects of these so-called designer drugs have been far-reaching. Here, we describe a case of an adult male with ST-elevated myocardial infarction diagnosed secondary to smoking synthetic cannabinoids.

An Unexpected Cause of Chest Pain While Self-Pleasuring: A Ripping Doom Excitement

Acute aortic dissection (AD) involves the tearing of the aortic intima by shearing forces, resulting in a false lumen, which, depending on its location and extent, may lead to hemodynamic compromise, hypoperfusion of vital organs, or even rupture of the aorta. The classical presentation is a sudden chest or back pain described as sharp or ripping in quality. We present a 60-year-old male with a history of hypertension, Liddle's syndrome, obstructive sleep apnea, and chronic cannabis use for insomnia who arrived at a non-PCI hospital complaining of severe retrosternal chest pain lasting several hours in evolution that started upon masturbation. The pain was ripping in character, starting retrosternally and radiating to his neck and back. After evidence of rising troponin values, he was initially diagnosed with non-ST segment elevation myocardial infarction (NSTEMI), managed with dual antiplatelet therapy with full anticoagulation, and subsequently transferred to our institution for further care. Shortly after his arrival at our hospital, he suddenly deteriorated with recurrent chest pain and hypotension, which triggered an emergent bedside echocardiogram evaluation. This revealed a hemodynamically significant pericardial effusion, moderate to severe aortic valve regurgitation (AR), and an intimal flap visualized on the ascending and descending aorta, suggestive of an extensive AD. A computerized tomographic angiogram confirmed the diagnosis of a Stanford type A AD that required an emergent surgical pericardiotomy, ascending aorta with partial arch replacement, and aortic valve repair. Often, AD may mimic an acute coronary syndrome (ACS) or even present with an acute myocardial infarction (AMI). The appropriate diagnostic imaging evaluation prior to the initiation of anticoagulation therapy should be done in patients with higher-risk clinical criteria for AD to reduce adverse treatment outcomes. The use of a simple three-step diagnostic algorithm for acute aortic syndromes (AAS) may decrease diagnostic delays, misdiagnosis, and inappropriate therapies.

An Overlooked Cause of Myocardial Infarction With Normal Coronaries Presenting as Stress Cardiomyopathy in Females

Spontaneous coronary artery dissection (SCAD) should be considered in the differential diagnosis of patients with provisional Takotsubo cardiomyopathy (TTS). However, because of overlapping clinical features, SCAD with subtle angiographic findings and wall motion abnormality like TTS can be easily missed. Therefore, our case highlights the importance of further investigation for SCAD.

COVID-19 Vaccine-Induced Myocarditis: A Systemic Review and Literature Search

Myocarditis is one of the complications reported with COVID-19 vaccines, particularly both Pfizer-BioNTech and Moderna vaccines. Most of the published data about this association come from case reports and series. Integrating the geographical data, clinical manifestations, and outcomes is therefore important in patients with myocarditis to better understand the disease. A thorough literature search was conducted in Cochrane library, PubMed, ScienceDirect, and Google Scholar for published literature till 30 March 2022. We identified 26 patients eligible from 29 studies; the data were pooled from these qualifying case reports and case series. Around 94% of patients were male in this study, the median age for onset of myocarditis was 22 years and 85% developed symptoms after the second dose. The median time of admission for patients to hospitals post-vaccination was three days and chest pain was the most common presenting symptom in these patients. Most patients had elevated troponin on admission and about 90% of patients had cardiac magnetic resonance imaging (CMR) that showed late gadolinium enhancement. All patients admitted with myocarditis were discharged home after a median stay of four days. Results from this current analysis show that post-mRNA vaccination myocarditis is mainly seen in young males after the second dose of vaccination. The pathophysiology of vaccine-induced myocarditis is not entirely clear and late gadolinium enhancement is a common finding on CMR in these patients that may indicate myocardial fibrosis or necrosis. Prognosis remains good and all patients recovered from myocarditis, however further studies are advisable to assess long-term prognosis of myocarditis.

The Lupus Attack: A Case Report and Literature Review of Myocardial Infarction and Antiphospholipid Syndrome

Acute myocardial infarction in a young patient is a nebulous entity, but in the absence of traditional cardiovascular risk factors, particular attention must be paid to thrombotic disorders and hypercoagulable states. A 28-year-old male presented with worsening substernal chest pain for 36 hours. He was recently diagnosed with systemic lupus erythematosus (SLE) with active class II lupus nephritis. With an initial electrocardiogram revealing ischemic changes, and an elevated troponin I, a concern was raised for myocardial infarction. Transthoracic echocardiography revealed a severely reduced ejection fraction of 25%, and a subsequent emergent left heart catheterization revealed a complete, massive thrombotic occlusion of the proximal left anterior descending artery, requiring aspiration thrombectomy. After extensive workup for hypercoagulable states, he was found to have elevated anticardiolipin IgG and IgM antibodies on two occasions, twelve weeks apart. The patient was managed with triple anticoagulation with aspirin, clopidogrel, and warfarin for one month, followed by dual anticoagulation with clopidogrel and warfarin with a targetted international normalized ratio (INR) of 2.0 - 3.0. The management of acute coronary syndrome caused by antiphospholipid syndrome (APS) is highly individualized and driven by clinician gestalt owing to the lack of a standardized consensus. While systemic thrombolysis, primary percutaneous coronary intervention (PCI), and coronary artery bypass grafting all have their utility, only a very small handful of case reports exist on the benefits of each. This particular case serves to showcase an instance where a patient was successfully managed with PCI with dual antiplatelet therapy. Further prospective randomized controlled trials are necessary to determine the optimal management of this rarely encountered patient population.

Extremely Heavy Lifting Associated With Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a separation of the intimal wall by intramural hemorrhage and has been classically associated with young women. We report a case of a healthy 58-year-old man who presented with chest pain that arose shortly after lifting machinery that was known to weigh 200-250 pounds. He was admitted with a non-ST elevation myocardial infarction and was later found to have non-atherosclerotic SCAD. No underlying cause was identified, and the patient was managed medically. This case illustrates that physicians should maintain an index of suspicion for SCAD as a cause of acute coronary syndrome even in male patients without diseases associated with the condition, especially when heavy lifting is reported.

Is Noncardiac Chest Pain Truly Noncardiac?

Many causes of noncardiac chest pain (NCCP) have been studied and gastroesophageal reflux disease is considered to be the major cause. However, studies have reported that treatment with a proton pump inhibitor does not effectively provide relief for NCCP-related symptoms, and these symptoms frequently recur. These findings suggest that patients with cardiac disease may be excluded completely from the NCCP group. Several examinations can be conducted to verify the presence of cardiac disease. Such examinations include the assessment of biochemical markers, rest and exercise electrocardiogram, echocardiography, cardiac computed tomography, stress myocardial perfusion imaging, cardiac magnetic resonance imaging, and coronary angiography (CAG). However, the presence of functional coronary artery diseases (CADs), such as vasospastic angina and/or microvascular angina, cannot be detected using these modalities. These functional CADs can be diagnosed by CAG with spasm-provocation testing and/or physiological coronary measurement. Thus, when a patient who is suspected of having NCCP takes a proton pump inhibitor and does not respond well, further examination-including assessment for possible functional CADs-may be needed.