To Be or Not to Be … Acute Coronary Syndrome

AbstractIntroduction: The association between ST segment abnormalities, elevated cardiac enzymes, and chest pain is usually a marker of acute coronary injury. However, certain other pathologies can sometimes mimic acute coronary syndromes.Case report: A 40-year-old Caucasian male, former smoker, with no other cardiovascular risk factors, presented to the Emergency Department for typical ischemic, prolonged chest pain. The ECG demonstrated inverted T waves in leads I, II, aVL, and V3 to V6. The patient presented high cardiac necrosis markers (troponin I 2.65 ng/ml). Based on these findings, the case was interpreted as non-ST segment elevation myocardial infarction, but coronary angiography excluded the presence of significant coronary lesions. The ventriculography showed an efficient left ventricle, with mild hypokinesia of the two apical thirds of the anterior left ventricular wall. Cardiac magnetic resonance imaging demonstrated areas of hypersignal on the T2-weighted imaging sequence in the left ventricular myocardium, suggestive for acute myocarditis. The patient was started on antiplatelet, beta-blocker, and angiotensin converting enzyme inhibitor, with favorable evolution.Conclusion: This case underlines the polymorphic appearance of acute myocarditis, which can often mimic an acute coronary event.

Download Full-text

Decitabine Induced Transient Cardiomyopathy: A Case Report

Clinical Medicine Insights Oncology ◽

10.4137/cmo.s8598 ◽

2012 ◽

Vol 6 ◽

pp. CMO.S8598 ◽

Cited By ~ 4

Author(s):

Chitradeep De ◽

Jaya Phookan ◽

Valay Parikh ◽

Tarun Nagrani ◽

Mayur Lakhani ◽

...

Keyword(s):

Case Report ◽

Chest Pain ◽

Troponin I ◽

Acute Myocarditis ◽

Coronary Vessels ◽

Left Ventricular ◽

Ventricular Rate ◽

Heart Catheterization ◽

Exertional Dyspnea ◽

Coronary Syndrome

Case Report A 75-yr-old gentleman, with a past medical history of diabetes mellitus and Acute Myeloid Leukemia presented to our emergency department with a chief complaint of exertional dyspnea and chest pain. A week prior to this visit, he had recieved a cycle of decitabine chemotherapy at 20 mg/metered square for ten days. This was his second cycle of decitabine. His out patient medications included megesterol, omeprazole, morphine sulfate and insulin glargine. The patient was admitted to the Coronary Care Unit for Acute Coronary Syndrome. His cardiac enzymes were elevated (peak troponin 30 ng/mL, CKMB 67.4 ng/mL). His 12 lead EKG revealed sinus tachycardia with a ventricular rate of 113, but without acute ST–T wave changes. The BNP was 259 pg/mL. A 2D echo revealed moderate diffuse hypokinesis with an EF of 35%. He subsequently underwent a left heart catheterization, which showed non-obstructive CAD. In our patient, the elevated troponins (peak troponin 30 ng/mL) and BNP were seen concomitant with the onset of cardiogenic shock. Two months ago, his 2 D echocardiogram revealed an ejection fraction of about 55%–65% with slightly increased left ventricular (LV) wall thickness. Discussion The most common adverse effects of decitabine include cytopenia, nausea, pain and erythema/nodules at the injection site. To date, there has been only one reported case of a hypomethylating agent inducing acute myocarditis. We a present a case of reversible, non-ischemic cardiomyopathy secondary to decitabine chemotherapy, which resolved after the drug was discontinued. Trials involving decitabine for the treatment of MDS reported no myocarditis. In our case, the diagnosis of transient cardiomyopathy was highly probable since the patient's troponins and echocardiogram returned to baseline after discontinuation of treatment. Also, the patient never had any further chest pain at his 6 month follow up. In this case, we believe that the elevated Troponin I levels, along with a cardiac catheterization revealing patent coronary vessels, favor our hypothesis that our patient suffered from acute myocarditis as a result of direct toxicity from decitabine chemotherapy. We doubt that there was an underlying infectious etiology, since the patient had three negative blood cultures, two negative urine cultures and a negative viral serology. Our case demonstrates that chest pains in a patient treated with hypomethylating agents should be further explored in order to rule out acute myocarditis.

Download Full-text

The Use of Echocardiography in Certified Chest Pain Units: Results from the German Chest Pain Unit Registry

Cardiology ◽

10.1159/000443475 ◽

2016 ◽

Vol 134 (2) ◽

pp. 75-83 ◽

Cited By ~ 6

Author(s):

Frank Breuckmann ◽

Matthias Hochadel ◽

Thomas Voigtländer ◽

Michael Haude ◽

Claus Schmitt ◽

...

Keyword(s):

Chest Pain ◽

Systolic Function ◽

Clinical Signs ◽

Acute Chest Pain ◽

Final Diagnosis ◽

Left Ventricular ◽

St Segment Elevation ◽

Coronary Syndrome ◽

St Segment ◽

Invasive Management

Objectives: To analyze the current usage of transthoracic echocardiography (TTE) as a rapid, noninvasive tool in the early stratification of acute chest pain in certified German chest pain units (CPUs). Methods: A total of 23,997 patients were enrolled. Analyses comprised TTE evaluation rates in relation to clinical presentation, risk profile, left ventricular impairment, final diagnosis and invasive management. Critical times were assessed. Multivariable analyses for independent determinants for the use of TTE were performed. Results: TTE evaluation was available in CPUs in 70.1% of cases. It was associated with lower rates of invasive management in unstable angina pectoris (UAP) and with higher rates in patients with initially suspected non-cardiac origin of symptoms and/or reduced systolic function (p < 0.05). Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) was an independent determinant favoring TTE evaluation [NSTE-myocardial infarction: odds ratio (OR) 1.62; UAP: OR 1.34; p < 0.001 for both]. Clinical signs of heart failure (OR 1.31; p < 0.001), referral by emergency medical service (OR 1.18; p < 0.001) and kidney failure (OR 1.16; p < 0.05) were independently associated with higher TTE rates. TTE did not delay door-to-balloon times. Conclusions: About two thirds of the patients admitted to certified CPUs received TTE evaluation, with the highest rates being in ACS patients, and thereby providing diagnostic information supporting or refuting further invasive management.

Download Full-text

Case Report: Phloroglucinol-Induced Kounis Syndrome

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.668318 ◽

2021 ◽

Vol 8 ◽

Author(s):

Hao-Yu Wu ◽

Tian-Jiao Gao ◽

Yi-Wei Cao ◽

Peng-Hua You

Keyword(s):

Chest Pain ◽

Coronary Artery ◽

Right Coronary Artery ◽

Troponin I ◽

Plaque Rupture ◽

Type Ii ◽

Kounis Syndrome ◽

St Segment Elevation ◽

Coronary Syndrome ◽

St Segment

Background: Kounis syndrome is an allergy-related acute coronary syndrome that is induced by various pharmacological and environmental factors. Given that many clinicians are not aware of this condition, many cases may be underdiagnosed. We report a case of type II Kounis syndrome induced by phloroglucinol.Case Summary: A 52-year-old man with pre-existing coronary artery stenosis presented with a 30-min history of chest pain and erythematous rash after intramuscular administration of phloroglucinol. An electrocardiogram demonstrated ST-segment elevation in leads II, III and aVF. Emergency coronary angiography revealed severe stenosis in the distal right coronary artery. Intravascular ultrasound showed plaque rupture and thrombosis, and the minimum lumen area was 3.0 mm2. A 3.5 × 38 mm stent was implanted in the distal right coronary artery. Troponin I levels were elevated. A diagnosis of type II Kounis syndrome induced by phloroglucinol was made, and the condition manifested as acute ST-segment elevation myocardial infarction.Conclusions: Clinicians should be aware of Kounis syndrome as a possible diagnosis in a patient who presents with chest pain and allergic manifestations given that an increasing number of triggers are being reported.

Download Full-text

Acute Pericarditis after Percutaneous Coronary Intervention: A Case Report

Medicina ◽

10.3390/medicina57050490 ◽

2021 ◽

Vol 57 (5) ◽

pp. 490

Author(s):

Greta Rodevič ◽

Povilas Budrys ◽

Giedrius Davidavičius

Keyword(s):

Percutaneous Coronary Intervention ◽

Chest Pain ◽

Troponin I ◽

Stable Condition ◽

Coronary Intervention ◽

Prior History ◽

Acute Pericarditis ◽

St Segment Elevation ◽

St Segment ◽

Percutaneous Coronary

Background: Percutaneous coronary intervention (PCI) is known as a very rare possible trigger of pericarditis. Most frequently it develops after a latent period or early in the case of periprocedural complications. In this report, we present an atypical early onset of pericarditis after an uncomplicated PCI. Case Summary: A 58-year-old man was admitted to the hospital for PCI of the chronic total occlusion of the left anterior descending (LAD) artery. An initial electrocardiogram (ECG) was unremarkable. The PCI attempt was unsuccessful. There were no procedure-related complications observed at the end of the PCI attempt and the patient was symptom free. Six hours after the interventional procedure, the patient complained of severe chest pain. The ECG demonstrated ST-segment elevation in anterior and lateral leads. Troponin I was mildly elevated but a coronary angiogram did not reveal the impairment of collateral blood flow to the LAD territory. Due to pericarditic chest pain, typical ECG findings and pericardial effusion with elevated C-reactive protein, the diagnosis of acute pericarditis was established, and a course of nonsteroidal anti-inflammatory drugs (NSAIDs) was initiated. Chest pain was relieved and ST-segment elevation almost completely returned to baseline after three days of treatment. The patient was discharged in stable condition without chest pain on the fourth day after symptom onset. Conclusions: Acute pericarditis is a rare complication of PCI. Despite the lack of specific clinical manifestation, post-traumatic pericarditis should be considered in patients with symptoms and signs of pericarditis and a prior history of iatrogenic injury or thoracic trauma.

Download Full-text

Analysis of risk factors for different subtypes of acute coronary syndrome

Journal of International Medical Research ◽

10.1177/03000605211008326 ◽

2021 ◽

Vol 49 (5) ◽

pp. 030006052110083

Author(s):

Lei Zhang ◽

Juledezi Hailati ◽

Xiaoyun Ma ◽

Jiangping Liu ◽

Zhiqiang Liu ◽

...

Keyword(s):

Risk Factors ◽

Myocardial Infarction ◽

Acute Coronary Syndrome ◽

Brain Natriuretic Peptide ◽

Left Ventricular ◽

St Segment Elevation ◽

Amino Terminal ◽

Coronary Syndrome ◽

Segment Elevation Myocardial Infarction ◽

St Segment

Aims To investigate the different risk factors among different subtypes of patients with acute coronary syndrome (ACS). Methods A total of 296 patients who had ACS were retrospectively enrolled. Blood and echocardiographic indices were assessed within 24 hours after admission. Differences in risk factors and Gensini scores of coronary lesions among three groups were analyzed. Results Univariate analysis of risk factors for ACS subtypes showed that age, and levels of fasting plasma glucose, amino-terminal pro-brain natriuretic peptide, and creatine kinase isoenzyme were significantly higher in patients with non-ST-segment elevation myocardial infarction (NSTEMI) than in those with unstable angina pectoris (UAP). Logistic multivariate regression analysis showed that amino-terminal pro-brain natriuretic peptide and the left ventricular ejection fraction (LVEF) were related to ACS subtypes. The left ventricular end-diastolic diameter was an independent risk factor for UAP and ST-segment elevation myocardial infarction (STEMI) subtypes. The severity of coronary stenosis was significantly higher in NSTEMI and STEMI than in UAP. Gensini scores in the STEMI group were positively correlated with D-dimer levels (r = 0.429) and negatively correlated with the LVEF (r = −0.602). Conclusion Different subtypes of ACS have different risk factors. Our findings may have important guiding significance for ACS subtype risk assessment and clinical treatment.

Download Full-text

Left ventricular hydatid cyst: an uncommon cause of chest pain in young adults

Cardiology in the Young ◽

10.1017/s1047951112001230 ◽

2012 ◽

Vol 23 (3) ◽

pp. 460-462 ◽

Cited By ~ 1

Author(s):

Ravindranath K. Shankarappa ◽

Nagaraja Moorthy ◽

Prabhavathi Bhat ◽

Manjunath C. Nanjappa

Keyword(s):

Chest Pain ◽

Hydatid Cyst ◽

Hydatid Disease ◽

Cardiac Involvement ◽

Ventricular Myocardium ◽

Acute Onset ◽

Left Ventricular ◽

Left Ventricular Myocardium ◽

Resonance Imaging ◽

Conventional Risk Factors

AbstractIsolated cardiac involvement in hydatid disease is very rare. We report the case of a young adult male who presented to the emergency department with acute onset of chest pain and was surprisingly detected to have a hydatid cyst in the left ventricular myocardium. The transthoracic echocardiography and cardiac magnetic resonance imaging confirmed the diagnosis. Cardiac hydatid disease should be considered in the differential diagnosis of chest pain in young individuals in the absence of conventional risk factors of atherosclerosis.

Download Full-text

Takotsubo Syndrome: Contemporary Views on the Pathogenesis, Prevalence and Prognosis

Rational Pharmacotherapy in Cardiology ◽

10.20996/1819-6446-2018-14-4-598-604 ◽

2018 ◽

Vol 14 (4) ◽

pp. 598-604 ◽

Cited By ~ 1

Author(s):

A. S. Shilova ◽

A. O. Shmotkina ◽

A. A. Yafarova ◽

M. Yu. Gilyarov

Keyword(s):

Genetic Predisposition ◽

Randomized Clinical Trials ◽

Myocardial Dysfunction ◽

Specific Treatment ◽

Left Ventricular ◽

Takotsubo Syndrome ◽

St Segment Elevation ◽

Coronary Syndrome ◽

St Segment ◽

Reversible Left Ventricular Dysfunction

Takotsubo syndrome (TTS) is a reversible left ventricular dysfunction characterized by local apical hypokinesia usually triggered by a physical or emotional stress. According to the last available data TTS may represent 2% of all admissions for acute coronary syndromes. Despite the reliable prevalence, diagnosis of TTS remains difficult. The initial presentation, both clinically and electrocardiographically, is similar to an acute myocardial infarction (AMI). The biomarker profile is also similar, although the peaks of troponin and creatinine kinase levels are lower, and brain natriuretic peptide levels are higher in patients with TTS compared with ST-segment elevation AMI. Modified Mayo diagnostic criteria are the most common for the diagnosis. Pathogenesis of TTS currently is not well understood. Catecholamines appear to play a central role in the pathophysiology of TTS. However, it is conceivable that some people have a genetic predisposition to stress-induced TTS. A genetic predisposition has been suggested based on the few familial TTS cases described. Despite reversible myocardial dysfunction, acute heart failure is the most common complication in the acute phase of TTS. In-hospital mortality rate is comparable to that of ST-segment elevation AMI. There are no randomized clinical trials to support specific treatment recommendations in TTS. It is believed that the tactics of managing patients with TTS hospitalized with suspicion of acute coronary syndrome should comply with the protocol of management of patients with AMI while acute coronary pathology is not excluded.

Download Full-text

Loeffler’s endocarditis and possible coronary spasm secondary to eosinophilic coronary periarteritis with ECG change mimicking acute non-ST-segment elevation myocardial infarction: A case report

10.21203/rs.2.24315/v1 ◽

2020 ◽

Author(s):

Fan-xin Kong ◽

Meng Li ◽

Chun-Yan Ma ◽

Ping-ping Meng ◽

Yong-huai Wang ◽

...

Keyword(s):

Myocardial Infarction ◽

Differential Diagnosis ◽

Coronary Artery ◽

Troponin I ◽

Hypereosinophilic Syndrome ◽

Coronary Spasm ◽

St Segment Elevation ◽

Coronary Syndrome ◽

Segment Elevation Myocardial Infarction ◽

St Segment

Abstract Background Loeffler’s endocarditis is an inflammatory cardiac condition of hypereosinophilic syndrome which rarely involves coronary artery. When coronary artery is involved, known as eosinophilic coronary periarteritis, the clinical presentation, electrocardiographic changes and troponin level are extremely nonspecific and may mimic acute coronary syndrome. It is very important to make differential diagnosis for ECPA in order to avoid the unnecessary further invasive coronary angiography. Case presentation We report a case with chest pain, ST-segment depression in electrocardiogram and increased troponin-I mimicking acute non-ST-segment elevation myocardial infarction. However, quick echocardiography showed endomyocardial thickening with normal regional wall motion, which corresponded to the characteristics of Loeffler’s endocarditis. Emergent blood analysis showed marked increase in eosinophils and computed tomography angiography found no significant stenosis of coronary artery. Manifestations of magnetic resonance imaging consisted with findings of echocardiography. Finally, the patient was diagnosed as Loeffler’s endocarditis and possible coronary spasm secondary to eosinophilic coronary periarteritis. Conclusion This case exhibits the crucial use of quick transthoracic echocardiography and the emergent hematological examination for differential diagnosis in such scenarios as often if electrocardiogram change mimicking myocardial infarction.

Download Full-text

Study of Cardiac Troponin I level in Acute Coronary Syndrome and its correlation with Left Ventricular Systolic Function

Cardiovascular Journal ◽

10.3329/cardio.v12i1.43415 ◽

2019 ◽

Vol 12 (1) ◽

pp. 24-29

Author(s):

Mohammad Jakir Hossain ◽

Khondoker Asaduzzaman ◽

Solaiman Hossain ◽

Muhammad Badrul Alam ◽

Nur Hossain

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Cardiac Troponin ◽

Troponin I ◽

Systolic Function ◽

Left Ventricular ◽

Cardiac Troponin I ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Coronary Syndrome

Background: In the diagnosis of acute coronary syndrome, cardiac troponin I is highly reliable and widely available biomarker. Serum level of cardiac troponin I is related to amount of myocardial damage and also closely relates to infarct size. Our aim of the study is to find out the relationship between cardiac troponin I and left ventricular systolic function after acute coronary syndrome. Methods: Total of 132 acute coronary syndrome patients were included in this study after admission in coronary care unit of Sir Salimullah Medical College, Mitford Hospital. Troponin I level was measured at admission and left ventricular ejection fraction (LVEF) was measured by echocardiography between 12-48 hours of onset of chest pain. Results: There was negative correlation between Troponin I at 12 to 48 hours of chest pain with LVEF in these study patients. With a cutoff value of troponin I e”6.8 ng/ml in STEMI patients there is a significant negative relation between 12 to 48 hrs troponin I and LVEF (p<0.001). Sensitivity of troponin I e” 6.8 ng/ml between 12 to 48 hours of chest pain in predicting LVEF <50% in STEMI was 93.75% and specificity was 77.78%. In NSTEMI sensitivity of troponin I e” 4.5 ng/ml between 12 to 48 hours of chest pain in predicting LVEF <50% was 65% and specificity was 54.05%. Conclusion: Serum troponin I level had a strong negative correlation with left ventricular ejection fraction after acute coronary syndrome and hence can be used to predict the LVEF in this setting. Cardiovasc. j. 2019; 12(1): 24-29

Download Full-text

Takotsubo Cardiomyopathy and Non-ST-Segment Elevation Myocardial Infarction: Predictors of Left Ventricular Dysfunction

Clinical Medicine Insights Cardiology ◽

10.1177/1179546817716103 ◽

2017 ◽

Vol 11 ◽

pp. 117954681771610

Author(s):

Andrew Hinojos ◽

Thomas E Vanhecke ◽

Susan Enright ◽

Nathan Elg ◽

Kristina Gifft ◽

...

Keyword(s):

Myocardial Infarction ◽

Left Ventricular ◽

Retrospective Case ◽

St Segment Elevation ◽

Coronary Syndrome ◽

Segment Elevation Myocardial Infarction ◽

Lv Dysfunction ◽

St Segment ◽

Artery Disease ◽

Control Study

Background: Acute coronary syndrome (ACS) from non-ST-segment elevation myocardial infarction (NSTEMI) and Takotsubo (TK) cardiomyopathy present with similar initial clinical features and can result in left ventricular (LV) dysfunction and acute heart failure. Methods: This study was a retrospective case-control study that identified patients aged 18 years and older who presented with ACS and underwent cardiac catheterization. Results: There were a total of 321 patients in the TK group and 1031 patients in the NSTEMI group. There was significantly worse LV dysfunction in the TK group with average ejection fraction (EF) of 44.35% (±15.11%) versus NSTEMI with an average EF of 47.36% (±13.5%) ( P < .001). The presence of TK yielded of an odds ratio (OR) of 2.373 (95% confidence interval [CI]: 1.165-3.618) and presence of peripheral artery disease (PAD) yielded an OR of 2.053 (95% CI: 1.165-3.618). Conclusions: The presence of TK cardiomyopathy and PAD were independent predictors of patients who had LVEF of <35% and elevated B-type natriuretic peptide levels.

Download Full-text