Cases reported "Chest Pain"

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1/34. Importance of posterior chest leads in patients with suspected myocardial infarction, but nondiagnostic, routine 12-lead electrocardiogram.

    Criteria for reperfusion therapy in acute myocardial infarction require the presence of ST elevation in 2 contiguous leads. However, many patients with myocardial infarction do not show these changes on a routine 12-lead electrocardiogram and hence are denied reperfusion therapy. Posterior chest leads (V7 to V9) were recorded in 58 patients with clinically suspected myocardial infarction, but nondiagnostic routine electrocardiogram. ST elevation >0.1 mV or Q waves in > or =2 posterior chest leads were considered to be diagnostic of posterior myocardial infarction. Eighteen patients had these changes of posterior myocardial infarction. All 18 patients were confirmed to have myocardial infarction by creatine phosphokinase criteria or cardiac catheterization. Of the 17 patients who had cardiac catheterization, 16 had left circumflex as the culprit vessel. We conclude that posterior chest leads should be routinely recorded in patients with suspected myocardial infarction and nondiagnostic, routine electrocardiogram. This simple bedside technique may help proper treatment of some of these patients now classified as having unstable angina or non-Q-wave myocardial infarction.
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2/34. Spontaneous pneumomediastinum in an 18-year-old black Sudanese high school student.

    Spontaneous pneumomediastinum (SPM) is defined as pneumomediastinum in the absence of an underlying lung disease. It is the second most common cause of chest pain in young, healthy individuals (< 30 years) necessitating hospital visits. It is surpassed in frequency in this setting only by spontaneous pneumothorax. These two conditions may coexist in 18% of patients. The incidence of spontaneous pneumomediastinum varies in different communities and generally is relatively uncommon. Inhalational drug use (cocaine and cannabis) have been associated with a significant number of cases, although cases with no apparent etiologic or incriminating factors are well recognized. Also its recurrence, though uncommon, is worthy of note. It is a benign clinical condition with diverse clinical presentations. physicians' knowledge of the presentation, treatment, and prognosis of SPM will guard against the need for expensive radiologic and laboratory tests. The differential diagnosis of chest pain, shortness of breath, and dysphagia include cardiac, pulmonary, and esophageal diseases. The tendency to pursue these entities may lead to laboratory investigations such as electrocardiograms, arterial blood gases, ventilation/perfusion scans, and contrast radiographic studies of the esophagus.
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3/34. pneumopericardium mimicking acute myocardial ischemia after laparoscopic cholecystectomy.

    pneumopericardium occurred after laparoscopic cholecystectomy in a 57-year-old woman. The patient had chest pain accompanied by T-wave inversion on electrocardiogram, with signs and symptoms suggestive of acute myocardial ischemia. Evaluation for myocardial infarction, however, was negative and clinical findings resolved spontaneously. Although pneumopericardium after laparoscopic procedures has been previously reported, this case illustrates how associated findings may mimic those of acute myocardial ischemia or infarction.
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4/34. Right bundle branch block-induced Q waves simulating anterior myocardial infarction extension.

    A concept generally accepted in clinical electrocardiography is the assumption that a right bundle branch block (RBBB) does not alter significantly the initial portion of the QRS complex and because the left bundle branch is intact, the septum is activated normally in a left-to-right direction. We report a woman with an acute anterior myocardial infarction (MI) in which a small R wave was present in leads V1 and V4, but with the development of RBBB associated with PR-interval prolongation, these R waves were replaced by Q waves. Subsequently, the electrocardiographic features of anterior MI disappeared concomitantly with the loss of RBBB. The clinical and electrophysiologic implications of these findings are discussed.
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5/34. Langerhans' cell histiocytosis presenting with a para-aortic lesion and heart failure.

    Langerhans' cell histiocytosis (LCH) is an uncommon disease with variable manifestations. We report a case of LCH with the unusual initial presentations of chest pain and progressive heart failure in a 5-year-old boy. Chest radiography revealed a wide mediastinum with cardiomegaly. electrocardiography showed first-degree atrioventricular block and an inverted T wave over V4-V6. echocardiography, computed tomography, and magnetic resonance imaging of the chest all showed an infiltrating lesion that enveloped the entire heart, great vessels, and coronary arteries. Pathologic examination of the biopsy specimen revealed LCH. Chemotherapy, which included prednisolone, vincristine, methotrexate, and 6-mercaptopurine, had only a minimal effect on the tumor. After the addition of etoposide, the lesion decreased in size, and the symptoms and signs of heart failure and chest pain were ameliorated.
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6/34. Unusual presentation of a left ventricular aneurysm.

    We report on a case of left ventricular aneurysm in a 42-year-old woman presenting with atypical chest pains. The resting electrocardiogram showed abnormal Q and T negative waves in leads II, III, and aVF. Transthoracic echocardiography revealed an aneurysm on the posterior wall of the left ventricle. thallium myocardial tomoscintigraphy confirmed the presence of a persistent defect with uneven uptake in the posterior wall, and coronary arteriography showed perfectly normal coronary arteries. A left ventricular aneurysm associated with normal coronary arteries and transient ischemia was diagnosed following a comparison with one of the patient's old electrocardiograms.
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7/34. Electrocardiographic T-wave inversion: differential diagnosis in the chest pain patient.

    Inverted T waves produced by myocardial ischemia are classically narrow and symmetric. T-wave inversion (TWI) associated with an acute coronary syndrome (ACS) is morphologically characterized by an isoelectric ST segment that is usually bowed upward (ie, concave) and followed by a sharp symmetric downstroke. The terms coronary T wave and coved T wave have been used to describe these ischemic TWIs. Prominent, deeply inverted, and widely splayed T waves are more characteristic of non-ACS conditions such as juvenile T-wave patterns, left ventricular hypertrophy, acute myocarditis, wolff-parkinson-white syndrome, acute pulmonary embolism, cerebrovascular accident, bundle branch block, and later stages of pericarditis.
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8/34. acute coronary syndrome in patients with human immunodeficiency virus disease.

    With more effective prophylactic treatment and an increased time of survival, noninfectious conditions associated with human immunodeficiency virus (hiv) disease are being recognized with increasing frequency in hiv patients. Cardiac involvement in hiv-infected patients varies from clinically silent to a fatal disease with a direct cardiac cause of mortality estimated at 1% to 6%. pericardial effusion, pericarditis, myocarditis, cardiomyopathy, endocarditis, and pulmonary hypertension are known cardiac manifestations associated with hiv infection. coronary artery disease (CAD) has not been a recognized complication of hiv disease, although some recent case reports have suggested occurrence of premature CAD and accelerated atherogenesis in hiv-infected patients. The role of protease inhibitors have been suggested in the development of this complication. After reviewing records of the last 7 years, the authors found 10 cases of acute coronary syndrome in hiv-infected patients who had no other risk factor for CAD except smoking. The presence of CAD was confirmed by angiography or autopsy. The mean CD4 count was 380 cells/mm3, and the mean duration between the diagnosis of hiv infection and CAD was 7.5 years. Four patients had single-vessel disease, 1 patient had 2-vessel disease, and 5 patients had 3-vessel disease. Three patients underwent coronary bypass surgery and 1 patient died of cardiogenic shock. CAD may be associated with hiv disease.
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9/34. Increasing myocardial 123I-BMIPP uptake in non-ischemic area in a patient with acute myocardial ischemia.

    The subject was a 65-year-old woman with chest pain. An electrocardiogram revealed T-wave-inversion in leads III, aVF, V1-V5. 99mTc-tetrofosmin myocardial SPECT showed mildly reduced uptake in the anteroseptal wall and the apex. These findings suggested acute myocardial ischemia. coronary angiography did not show any stenotic lesions, but diffuse coronary ectasia was noted in three vessels. Coronary flow velocity was remarkably reduced on coronary angiography. Epicardial coronary spasm was not provoked by ergonovine loading test. Left ventriculography showed diffuse hypokinesis. 123I-BMIPP myocardial SPECT showed mildly reduced uptake in the anteroseptal wall and the apex on the early images. But 4-hour delayed images showed an increase of 8% in myocardial 123I-BMIPP uptake. We treated this patient with ticlopidine and nicorandil. After drug therapy her symptoms and left ventriculography improved. 123I-BMIPP myocardial SPECT findings on the early images improved, whereas delayed images showed a decrease of 28% in myocardial 123I-BMIPP uptake after two weeks and 36% after four weeks. These dynamic changes in 123I-BMIPP findings might be a reflection of myocardial fatty acid metabolism in patients with acute myocardial ischemia. Delayed 123I-BMIPP myocardial SPECT images are useful for the assessment of fatty acid metabolism.
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10/34. hypercalcemia due to vitamin d intoxication with clinical features mimicking acute myocardial infarction.

    We report a case of hypercalcemia in an elderly patient due to vitamin d intoxication with clinical features and electrocardiogram (ECG) findings mimicking acute myocardial infarction. A 78-year-old man was referred to our department with symptoms of general fatigue, anorexia and chest pain. The ECG demonstrated ST elevation in leads V1 to V3 and diffuse T wave flattening, resulting in myocardial infarction being suspected. However, his symptoms, including chest pain, gradually improved and the ECG returned to normal in accordance with a fall in his serum calcium level. We introduce the use of QaTc interval shortening in differentiating ST-T changes of hypercalcemia from those of true myocardial ischemia.
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