cardiovascular-agents and Chest-Pain

Ischaemic heart disease is a major cause of death and disability worldwide, while angina represents its most common symptom. It is estimated that approximately 9 million patients in the USA suffer from angina and its treatment is challenging, thus the strategy to improve the management of chronic stable angina is a priority. Angina might be the result of different pathologies, ranging from the "classical" obstruction of a large coronary artery to alteration of the microcirculation or coronary artery spasm. Current clinical guidelines recommend antianginal therapy to control symptoms, before considering coronary artery revascularization. In the current guidelines, drugs are classified as being first-choice (beta-blockers, calcium channel blockers, and short-acting nitrates) or second-choice (ivabradine, nicorandil, ranolazine, trimetazidine) treatment, with the recommendation to reserve second-line modifications for patients who have contraindications to first-choice agents, do not tolerate them, or remain symptomatic. However, such a categorical approach is currently questioned. In addition, current guidelines provide few suggestions to guide the choice of drugs more suitable according to the underlying pathology or the patient comorbidities. Several other questions have recently emerged, such as: is there evidence-based data between first- and second-line treatments in terms of prognosis or symptom relief? Actually, it seems that newer antianginal drugs, which are classified as second choice, have more evidence-based clinical data that are more contemporary to support their use than what is available for the first-choice drugs. It follows that actual guidelines are based more on tradition than on evidence and there is a need for new algorithms that are more individualized to patients, their comorbidities, and pathophysiological mechanism of chronic stable angina.

Topics: Adrenergic beta-Antagonists; Angina, Stable; Calcium Channel Blockers; Cardiovascular Agents; Chest Pain; Humans; Ivabradine; Nicorandil; Patient Selection; Practice Guidelines as Topic; Ranolazine; Treatment Outcome; Trimetazidine

Angina pectoris is the consequence of an inequality between the demand and supply of blood to the heart. Angina manifests itself as chest pain or discomfort and is a common complaint of patients in the hospital and in the clinic. There are, in fact, roughly half a million new cases of angina per year. Chest pain, while having many etiologies, is generally considered to be most lethal when related to a cardiac cause. In this review, the authors outline the current medical and surgical therapies that are used in the management of angina. Highlights of the various clinical trials that have assisted in the investigation of these therapies are summarized also. Then, the authors provide a focused review of the novel therapy options for angina that are currently being explored. From new medical treatments to revised surgical techniques to the discovery of stem cell therapy, many innovative options are being investigated for the treatment of angina.

Topics: Angina Pectoris; Animals; Cardiovascular Agents; Chest Pain; Clinical Trials as Topic; Humans; Stem Cell Transplantation

Cardiac syndrome X is a heterogeneous entity, both clinically and pathophysiologically, encompassing a variety of pathogenic mechanisms. Management of this syndrome represents a major challenge to the treating physician. They often seek medical care because of recurring and disabling chest pain, which may imply repetitive and costly invasive and non-invasive investigations. A careful patient evaluation for underlying pathophysiologic mechanism and exclusion of other causes of chest pain along with attention to various psychological aspects is helpful in reducing the stress and suffering of these patients. This article reviews the available literature on the pathophysiology and current controversies surrounding the management of this difficult to treat condition.

Topics: Animals; Cardiovascular Agents; Chest Pain; Humans; Microvascular Angina; Risk Reduction Behavior

Anginal chest pain is one of the most common complaints in the outpatient setting. While much of the focus has been on identifying obstructive atherosclerotic coronary artery disease (CAD) as the cause of anginal chest pain, it is clear that microvascular coronary dysfunction (MCD) can also cause anginal chest pain as a manifestation of ischemic heart disease, and carries an increased cardiovascular risk. Epicardial coronary vasospasm, aortic stenosis, left ventricular hypertrophy, congenital coronary anomalies, mitral valve prolapse, and abnormal cardiac nociception can also present as angina of cardiac origin. For nonacute coronary syndrome (ACS) stable chest pain, exercise treadmill testing (ETT) remains the primary tool for diagnosis of ischemia and cardiac risk stratification; however, in certain subsets of patients, such as women, ETT has a lower sensitivity and specificity for identifying obstructive CAD. When combined with an imaging modality, such as nuclear perfusion or echocardiography testing, the sensitivity and specificity of stress testing for detection of obstructive CAD improves significantly. Advancements in stress cardiac magnetic resonance imaging enables detection of perfusion abnormalities in a specific coronary artery territory, as well as subendocardial ischemia associated with MCD. Coronary computed tomography angiography enables visual assessment of obstructive CAD, albeit with a higher radiation dose. Invasive coronary angiography remains the gold standard for diagnosis and treatment of obstructive lesions that cause medically refractory stable angina. Furthermore, in patients with normal coronary angiograms, the addition of coronary reactivity testing can help diagnose endothelial-dependent and -independent microvascular dysfunction. Lifestyle modification and pharmacologic intervention remains the cornerstone of therapy to reduce morbidity and mortality in patients with stable angina. This review focuses on the pathophysiology, diagnosis, and treatment of stable, non-ACS anginal chest pain.

Topics: Age Factors; Angina Pectoris; Cardiovascular Agents; Chest Pain; Coronary Disease; Diagnosis, Differential; Diagnostic Imaging; Electrocardiography; Exercise Test; Female; Humans; Male; Myocardial Revascularization; Risk Factors; Sex Factors; Syndrome

Angina pectoris, the pain of myocardial ischemia, is the major initial and subsequent presentation of coronary disease in women. Angina in women is associated with more adverse morbidity, mortality, and quality-of-life outcomes than for men, despite women having less obstructive coronary artery disease and better left ventricular function. Women with chest pain and myocardial ischemia, in the absence of significant obstructive disease of the coronary arteries, have prominent morbidity and mortality outcomes; the postulated mechanism is microvascular disease. Women also have more non-chest pain manifestations of myocardial ischemia than men. These variables must be incorporated in assessments of optimal diagnostic and therapeutic strategies for myocardial ischemia in women.

Topics: Angina Pectoris; Cardiovascular Agents; Chest Pain; Coronary Disease; Coronary Vessels; Female; Humans; Myocardial Ischemia; Prognosis; Quality of Life; Risk Factors; United States

Topics: Adolescent; Adult; Algorithms; Angioplasty, Balloon, Coronary; Benzodiazepines; Cardiovascular Agents; Chest Pain; Cocaine; Cocaine-Related Disorders; Combined Modality Therapy; Coronary Circulation; Diagnostic Imaging; Disease Management; Evidence-Based Medicine; Female; Humans; Male; Myocardial Infarction; Platelet Aggregation Inhibitors; Smoking; Sympathomimetics; Thrombophilia; Vasoconstrictor Agents

In the fibrinolytic era, several studies have suggested that the rate of atrioventricular block (AVB) in the setting of acute myocardial infarction (MI) is high and is associated with increased short-term mortality. We sought to delineate predictors of AVB and determine long-term mortality of patients developing AVB in the setting of ST-segment elevation MI (STEMI) treated with thrombolytic therapy.. We combined data on patients from 4 similar studies of STEMI. We identified independent predictors of AVB and compared the 6-month and 1-year mortality rates of patients with AVB (5251) to the rates of patients without AVB (70 742).. The incidence of AVB was 6.9%. Significant independent predictors of AVB included inferior MI, older age, worse Killip class at presentation, female sex, enrollment in the United States, current smoking, hypertension, and diabetes. Adjusted mortality was significantly higher in patients with AVB than in patients without AVB within 30 days (OR 3.2, 95% CI 2.7-3.7), 6 months (OR 1.6, 95% CI 1.5-1.8), and 1 year (OR 1.5, 95% CI 1.3-1.6). For patients with AVB and inferior MI, mortality odds ratios (ORs) were 2.2 (95% CI 1.7-2.7), 2.6 (95% CI 2.4-2.9), and 2.4 (95% CI 2.2-2.6) within 30 days, 6 months, and 1 year, respectively. For patients with AVB and anterior MI, mortality ORs were 3.0 (95% CI 2.2-4.1), 3.5 (95% CI 3.1-3.8), and 3.3 (95% CI 3.0-3.7) within 30 days, 6 months, and 1 year, respectively.. In the thrombolytic era, AVB in the setting of STEMI is common and associated with higher mortality. Future studies should focus on determining therapies that are effective at reducing mortality rates in such patients.

Topics: Aged; Cardiovascular Agents; Chest Pain; Comorbidity; Databases, Factual; Electrocardiography; Female; Fibrinolytic Agents; Follow-Up Studies; Heart Block; Humans; Incidence; Male; Middle Aged; Mortality; Myocardial Infarction; New Zealand; Odds Ratio; Randomized Controlled Trials as Topic; Recombinant Proteins; Risk Factors; Streptokinase; Survival Analysis; Tenecteplase; Thrombolytic Therapy; Tissue Plasminogen Activator; United States

There are two types of acute coronary syndromes : those with or without ST-segment elevation. The former require urgent therapeutic measures to reopen the culprit artery (intravenous thrombolysis or primary percutaneous coronary intervention). For the latter, risk stratification is essential and is based upon clinical and biochemical markers. Among them, recent and repeated anginal attacks, ST-segment modifications on admission electrocardiogram, and increased markers of myonecrosis (particularly increased troponin levels) are strong predictors of untoward outcome. According to the risk profile, the initial management is based upon an invasive strategy with powerful antithrombotic medications and urgent angiography, or upon a non-invasive strategy using stress testing, preferably coupled with myocardial imaging techniques. In all instances, secondary prevention measures are determinant to try and stop the progression of the atherosclerotic disease.

Topics: Acute Disease; Adult; Aged; Biomarkers; Cardiovascular Agents; Case Management; Chest Pain; Coronary Angiography; Coronary Disease; Electrocardiography; Humans; Middle Aged; Myocardial Revascularization; Prognosis; Thrombolytic Therapy

Many advances have been made in the treatment of acute coronary syndromes. Patients with intermediate-risk or high-risk features should receive treatment with the newer pharmacologic agents--enoxaparin, statins and, in selected cases, clopidogrel--in addition to established standard therapies (i.e., aspirin, beta-blockers, nitroglycerin, and oxygen). Use of GpIIb-IIIa inhibitors should also be strongly considered, especially in an early invasive approach. However, there is no substitute for a good physician who has the big picture and knows the individual patient in totality. This physician can best judge the dangers of the patient's acute cardiac condition against the comorbidities that may be exacerbated by revascularization procedures. The ability to weigh the risks of the patient's acute coronary syndrome against the risks of an aggressive invasive approach ultimately provides the best care for each patient.

Topics: Adrenergic beta-Antagonists; Angina, Unstable; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Chest Pain; Clinical Protocols; Hematologic Agents; Humans; Myocardial Infarction; Nitrates

Topics: Cardiovascular Agents; Chest Pain; Diagnosis, Differential; Heart Diseases; Humans; Physical Examination; Risk Assessment

To evaluate the impact of comorbidities on the management and outcomes of acute coronary syndrome (ACS) patients without chest pain/discomfort (i.e. ACS without typical presentation).. Of the 11,458 ACS patients, enrolled by the International Survey of Acute Coronary Syndrome in Transitional Countries (ISACS-TC; ClinicalTrials.gov: NCT01218776), 8.7% did not have typical presentation at the initial evaluation, and 40.2% had comorbidities. The odds of atypical presentation increased proportionally with the number of comorbidities (odds ratio [OR]: 1, no-comorbid; OR: 1.64, 1 comorbidity; OR: 2.52, 2 comorbidities; OR: 4.57, ≥3 comorbidities).. Stratifying the study population by the presence/absence of comorbidities and typical presentation, we found a decreasing trend for use of medications and percutaneous intervention (OR: 1, typical presentation and no-comorbidities; OR: 0.70, typical presentation and comorbidities; OR: 0.23, atypical presentation and no-comorbidities; OR: 0.18, atypical presentation and comorbidities). On the opposite, compared with patients with typical presentation and no-comorbidities (OR: 1, referent), there was an increasing trend (p<0.001) in the risk of death (OR: 2.00, OR: 2.52 and OR: 4.83) in the above subgroups. However, after adjusting for comorbidities, medications and invasive procedures, atypical presentation was not a predictor of in-hospital death. Independent predictors of poor outcome were history of stroke (OR: 2.04), chronic kidney disease (OR: 1.57), diabetes mellitus (OR: 1.49) and underuse of invasive procedures.. In the ISACS-TC, atypical ACS presentation was often associated with comorbidities. Atypical presentation and comorbidities influenced underuse of in-hospital treatments. The latter and comorbidities are related with poor in-hospital outcome, but not atypical presentation, per se.

Topics: Acute Coronary Syndrome; Aged; Aged, 80 and over; Cardiovascular Agents; Chest Pain; Comorbidity; Female; Hospital Mortality; Humans; Male; Middle Aged; Odds Ratio; Percutaneous Coronary Intervention; Registries; Risk Factors

Slow flow, no reflow and distal embolization often occur during primary angioplasty in ST segment elevation myocardial infarction (STEMI), compromising optimal myocardial reperfusion.. This study aimed at assessing the impact of deferred stenting (DS) on periprocedural events as compared to immediate stenting (IS). The second objective was to gather the reasons advocated by the physicians for deferring stenting.. All consecutive patients referred for primary angioplasty were included between September 2010 and November 2011. Physicians were free to choose the strategy between DS and IS but had to justify their choice. DS patients underwent a coronary angiogram control in a delay > 24h.. Ninety-eight patients were included. Forty patients underwent DS and 58 IS. DS strategy involved thrombus management by thromboaspiration (33 patients 82.5%) and by the use of AntiGpIIbIIIa (23 patients 62.2%). This strategy could be achieved with a low complication rate. In particular, one patient had a reocclusion leading to a rapid reintervention and one had a distal embolization. In comparison, 11 periprocedural events occurred in the IS subgroup. In addition, among DS patients, 7 were treated medically because of a non-significant stenosis. The major criteria considered by the operator to prefer DS in the presence of a TIMI 3 flow concerned thrombotic load.. This mono-centric experience confirmed the feasibility and the safety of DS. On top of reducing periprocedural events, it may allow for other treatment options in selected STEMI patients, e.g. surgery or medical treatment. The reasons leading physicians to choose DS were large thrombus burden on top of resolution of chest pain and normalization of the ECG. These criteria could help selecting situations in which DS may be of particular value as compared to IS.

Topics: Adult; Aged; Aged, 80 and over; Cardiac Catheterization; Cardiovascular Agents; Chest Pain; Comorbidity; Coronary Angiography; Coronary Thrombosis; Electrocardiography; Embolism; Feasibility Studies; Female; Heart Arrest; Hemorrhage; Hospital Mortality; Humans; Male; Middle Aged; Motivation; Myocardial Infarction; No-Reflow Phenomenon; Percutaneous Coronary Intervention; Physicians; Risk Factors; Shock, Cardiogenic; Stents; Thrombectomy; Time Factors

Non-cardiac chest pain (NCCP) is an extremely debilitating condition of uncertain origin which is difficult to treat and consequently has a high psychological morbidity. Hypnotherapy has been shown to be effective in related conditions such as irritable bowel syndrome where its beneficial effects are long lasting.. This study aimed to assess the efficacy of hypnotherapy in a selected group of patients with angina-like chest pain in whom coronary angiography was normal and oesophageal reflux was not contributory.. Twenty eight patients fulfilling the entry criteria were randomised to receive, after a four week baseline period, either 12 sessions of hypnotherapy or supportive therapy plus placebo medication over a 17 week period. The primary outcome measure was global assessment of chest pain improvement. Secondary variables were a change in scores for quality of life, pain severity, pain frequency, anxiety, and depression, as well as any alteration in the use of medication.. Twelve of 15 (80%) hypnotherapy patients compared with three of 13 (23%) controls experienced a global improvement in pain (p = 0.008) which was associated with a significantly greater reduction in pain intensity (p = 0.046) although not frequency. Hypnotherapy also resulted in a significantly greater improvement in overall well being in addition to a reduction in medication usage. There were no differences favouring hypnotherapy with respect to anxiety or depression scores.. Hypnotherapy appears to have use in this highly selected group of NCCP patients and warrants further assessment in the broader context of this disorder.

Topics: Anxiety; Cardiovascular Agents; Chest Pain; Depressive Disorder; Female; Gastroesophageal Reflux; Humans; Hypnosis; Male; Middle Aged; Proton Pump Inhibitors; Quality of Life; Single-Blind Method; Treatment Outcome

Topics: Aged; Cardiovascular Agents; Chest Pain; Clinical Decision-Making; Computed Tomography Angiography; Conservative Treatment; Coronary Angiography; Coronary Vessel Anomalies; Coronary Vessels; Electrocardiography; Exercise Test; Humans; Image Processing, Computer-Assisted; Male; Multimodal Imaging; Sinus of Valsalva

Topics: Aorta, Thoracic; Aortic Diseases; Cardiovascular Agents; Chest Pain; Computed Tomography Angiography; Conservative Treatment; Coronary Angiography; Diagnosis, Differential; Electrocardiography; Fibrin Fibrinogen Degradation Products; Hematoma; Humans; Male; Middle Aged; Nitroglycerin; Telmisartan; Treatment Outcome

Topics: Adult; Anti-Inflammatory Agents; Antineoplastic Combined Chemotherapy Protocols; Arsenic Trioxide; Cardiovascular Agents; Chest Pain; Drug Substitution; Echocardiography; Electrocardiography; Humans; Idarubicin; Leukemia, Promyelocytic, Acute; Male; Myocarditis; Pericarditis; Remission Induction; Tretinoin

Takayasu arteritis (TA), a systemic vasculitis typically occurring in female patients aged ≤40, can affect coronary arteries and cause ischemic heart disease (IHD). In this study, we investigated the prevalence of TA in young women presenting with IHD in the Emergency Department.. We evaluated hospital records of 158,860 consecutive female patients aged <40, who accessed the Emergency Department of our institution over 8 consecutive years (2007-2015). The prevalence of different etiologies of IHD was determined. Diagnosis of TA was established based on the 1990 ACR criteria.. Overall, 1950 women aged <40 presented to the Emergency Department with chest pain, dyspnea, palpitations, angina, heart failure, or cardiac arrest; 40 had acute IHD. The etiology was 'classic' atherosclerosis in 24 cases (60%), TA in 4 cases (10%), vasospasm and sympathomimetic drug abuse in 3 cases each (7.5%), coronary artery dissection and microvascular angina in 2 cases each (5%), Takotsubo and radiation-induced cardiomyopathy in 1 case each (2.5%).. Although a diagnosis of TA is likely to be overlooked, TA is not infrequent in younger females presenting with acute IHD, a finding relevant to the diagnosis and management of these patients.

Topics: Acute Disease; Adult; Cardiovascular Agents; Chest Pain; Emergency Medical Services; Female; Humans; Myocardial Ischemia; Prevalence; Takayasu Arteritis

Peripartum cardiomyopathy (PPCM) is a left ventricular systolic dysfunction failure emerges during the antepartum or puerperal period, and can result in maternal death. Reported incidences are increasing and differing globally. Echocardiography is the cornerstone for the diagnosis. The immediate goals in acute management are the stabilization of the hemodynamic state, providing symptomatic relief, and ensuring fetal wellbeing. Emergency physicians should be aware of PPCM at the differential diagnosis of dyspnea in pregnancy related emergencies and play role in early diagnosis.

Topics: Adrenergic beta-1 Receptor Antagonists; Adult; Anticoagulants; Cardiomyopathies; Cardiovascular Agents; Chest Pain; Drug Therapy, Combination; Dyspnea; Echocardiography; Emergency Service, Hospital; Female; Hemodynamics; Humans; Metoprolol; Puerperal Disorders; Radiography; Ventricular Dysfunction, Left

Topics: Angina, Stable; Cardiovascular Agents; Chest Pain; Coronary Angiography; Humans; Myocardial Perfusion Imaging; Practice Guidelines as Topic; Primary Health Care; Referral and Consultation

We evaluated the clinical value of a single measurement of high-sensitivity C-reactive protein (hs- CRP) in patients presenting to the emergency department with chest pain. We screened 408 consecutive patients of whom 292 comprised the final cohort for this study. Hs-CRP measured in the emergency department (ED) in patients presenting with chest pain and admitted for evaluation of acute myocardial infarction was neither sensitive nor specific in predicting acute myocardial infarction, myocardial ischemia on SPECT imaging, need for coronary revascularization, or cardiovascular or all-cause rehospitalization at 30 days. In addition, use of a specific CRP cut off >1 was not associated with an increase in all-cause rehospitalization at 30 days.

Topics: Acute Disease; Aged; C-Reactive Protein; Cardiovascular Agents; Chest Pain; Comorbidity; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Myocardial Infarction; Myocardial Ischemia; Patient Readmission; Percutaneous Coronary Intervention; Sensitivity and Specificity; Severity of Illness Index

Topics: Cardiovascular Agents; Chest Pain; Dyspnea; Humans; Myocardial Ischemia; Myocardial Revascularization; Prognosis; Quality of Life; Surveys and Questionnaires; Symptom Assessment

Takotsubo cardiomyopathy (TC) is increasingly recognised in patients presenting with features of acute coronary syndrome. We present a single centre experience of TC with medium term follow up.. Fifty-two consecutive patients presenting with a diagnosis of TC were included. The clinical presentation, complications, baseline and follow-up echocardiograms and cardiac magnetic resonance imaging were analysed.. Fifty-one patients were female. A stressful event preceded presentation in 37 (71%) patients. Chest pain was the most common symptom (83%). Two patients presented with an out-of-hospital cardiac arrest. ST segment elevation (40%) and global T wave inversion (44%) were the most frequent electrocardiogram changes. Left ventricular assessment demonstrated typical apical ballooning in 41 patients and 11 patients demonstrated the mid-wall variant. In-hospital complications occurred in 11 patients (21%) and included acute pulmonary oedema (n = 2), cardiogenic shock (n = 5); two of whom had a significant left ventricular outflow gradient, atrial fibrillation (n = 1), left ventricular thrombus (n = 2) and a cerebrovascular event (n = 2). Left ventricular function at presentation and follow up was compared in 40 patients. The mean ejection fraction in this group at presentation was 47% (20-70%) compared with that at follow up of 63% (44-76%). There were no significant complications or recurrences at follow up.. While TC is a reversible condition with low rates of complications and recurrence at follow up it is, as demonstrated in our cohort, associated with significant in-hospital morbidity in a proportion of patients.

Topics: Acute Coronary Syndrome; Adult; Aged; Aged, 80 and over; Atrial Fibrillation; Cardiac Catheterization; Cardiovascular Agents; Chest Pain; Diagnosis, Differential; Electrocardiography; Female; Follow-Up Studies; Heart Arrest; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Platelet Aggregation Inhibitors; Pulmonary Edema; Queensland; Shock, Cardiogenic; Stress, Psychological; Stroke Volume; Takotsubo Cardiomyopathy; Ultrasonography; Ventricular Dysfunction, Left

To evaluate the long-term prognostic impact of baseline symptoms in a cohort of hypertrophic cardiomyopathy (HCM) patients.. We considered 84 HCM patients symptomatic at diagnosis: 26 (31%) with heart failure (group 1), 34 (40%) with syncope/palpitations (group 2) and 24 (29%) with chest pain (group 3). During a median follow-up of 102 (53-187) months, 25 (30%) patients died/underwent heart transplant (HTx), 14 of 26 (54%) in group 1, 10 of 34 (29%) in group 2 and one of 24 (4%) in group 3. At 12, 60 and 120 months, HTx-free survival rates were 100, 79 and 52% in group 1, vs. 100, 97 and 69% in group 2, vs. 96, 96 and 96% in group 3, respectively (P = 0.008). At multivariate analysis, heart failure [hazard ratio (HR) 2.59, confidence interval (CI) 95% 1.09-6.17, P = 0.032] and left atrium diameter (HR 1.83, CI 95% 1.16-2.89, P = 0.009) emerged as independent predictors of death/HTx, with incremental prognostic power with respect to echo Doppler variables of left ventricular systolic and diastolic dysfunction [area under the curve (AUC) of receiver operating characteristics (ROC) curves at 5 years: 0.90 vs. 0.78, respectively, P = 0.03].. Clinical presentation emerged as a relevant prognostic tool in HCM patients symptomatic at onset, as heart failure was associated with a particularly poor outcome. Heart failure and left atrium diameter at diagnosis showed incremental prognostic power compared with echo Doppler assessment of left ventricular systolic and diastolic dysfunction.

Topics: Adolescent; Adult; Aged; Arrhythmias, Cardiac; Cardiomyopathy, Hypertrophic; Cardiovascular Agents; Chest Pain; Chi-Square Distribution; Child; Child, Preschool; Disease-Free Survival; Echocardiography, Doppler; Female; Heart Atria; Heart Failure; Heart Transplantation; Humans; Infant; Italy; Kaplan-Meier Estimate; Male; Middle Aged; Multivariate Analysis; Predictive Value of Tests; Prognosis; Proportional Hazards Models; Registries; Risk Factors; Syncope; Time Factors; Ventricular Function, Left; Young Adult

Apical ballooning syndrome mimics acute coronary syndromes and it is characterized by reversible left ventricular apical ballooning in the absence of angiographically significant coronary artery stenosis.. This is a case of a 40-year-old Caucasian male without any health related problems that was submitted to an urgent coronary angiography because of acute chest pain and marked precordial T-wave inversions suggestive of acute myocardial ischemia. Coronary angiography showed no significant stenosis of the coronary arteries. Left ventriculography showed systolic apical ballooning with mild basal hypercontraction.. Physicians should be aware of the presentation of apical ballooning syndrome, and the chest pain after following acute stress should not be readily attributed to anxiety.

Topics: Acute Coronary Syndrome; Adult; Cardiovascular Agents; Chest Pain; Coronary Angiography; Coronary Stenosis; Diagnosis, Differential; Humans; Male; Predictive Value of Tests; Risk Factors; Stress, Psychological; Takotsubo Cardiomyopathy; Unemployment

Topics: Aged; Atrioventricular Block; Cardiac Pacing, Artificial; Cardiovascular Agents; Chest Pain; Coronary Angiography; Drug Therapy, Combination; Electrocardiography; Female; Humans; Middle Aged; Pacemaker, Artificial; Sick Sinus Syndrome; Takotsubo Cardiomyopathy; Treatment Outcome

The diagnosis and management of pericardial disease are very challenging for clinicians. The evidence base in this field is relatively scarce compared with other disease entities in cardiology. In this article, we outline a unified, stepwise pathway-based approach for the management of pericardial disease. We used the "CHASER" acronym to define the entry points into the pathway. These include chest pain, hypotension or arrest, shortness of breath, echocardiographic or other imaging finding of pericardial effusion, and right-predominant heart failure. We propose a score for the assessment of pericardial effusion that is composed of the following 3 parameters: the etiology of the effusion, the size of the effusion, and the echocardiographic assessment of hemodynamic parameters. The score is applied to clinically stable patients with pericardial effusion to quantify the necessity of pericardial effusion drainage. A stepwise, pathway-based approach to the management of pericardial disease is intended to provide guidance for clinicians in decision-making and a patient-tailored evidence-based approach to medical and surgical therapy for pericardial disease. The pathway for the management of pericardial disease is the ninth project to be incorporated into the "Advanced Cardiac Admission Program" at Saint Luke's Roosevelt Hospital Center of Columbia University in New York. Further studies should focus on the validation of the feasibility, efficacy, and reliability of this pathway.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Cardiac Tamponade; Cardiovascular Agents; Chest Pain; Clinical Protocols; Critical Pathways; Disease Management; Echocardiography; Electrocardiography; Evidence-Based Practice; Heart Failure; Hemodynamics; Humans; Hypotension; Pericardial Effusion; Pericardiocentesis; Pericardium; Program Evaluation; Severity of Illness Index

Patients with persistent chest pain and no obstructive coronary artery disease are often labeled as having noncardiac pain and not offered further cardiologic testing or treatment. Diagnostic uncertainty for persistent chest pain is associated with adverse quality of life, morbidity, and health care costs. Two underdiagnosed cardiac causes for persistent chest pain include microvascular coronary disease and abnormal cardiac nociception. Microvascular coronary disease is associated with an increased risk of adverse cardiovascular events such as myocardial infarction, congestive heart failure, and sudden cardiac death, and treatment directed at improving endothelial function can improve outcomes. Abnormal cardiac nociception is also a cause for persistent chest pain caused by heightened coronary pain perception. Coronary reactivity testing allows for direct measurement of blood flow characteristics in response to vasoactive agents for the diagnoses of microvascular coronary disease and can be a useful tool to differentiate causes of chest pain. Coronary reactivity testing is an invasive method for assessing coronary vascular function, with current evidence suggesting that its associated risk is relatively low compared with the adverse prognosis associated with microvascular coronary dysfunction. Accurate diagnosis in patients with persistent chest pain and normal coronary arteries can be challenging and deserves adequate investigation in light of the associated morbidity, mortality, and health care costs.

Topics: Adult; Blood Flow Velocity; Cardiovascular Agents; Chest Pain; Coronary Circulation; Coronary Vasospasm; Diagnosis, Differential; Diagnostic Techniques, Cardiovascular; Female; Humans; Imipramine; Microvascular Angina; Middle Aged; Nociceptors; Pain Measurement; Radiography, Interventional; Transcutaneous Electric Nerve Stimulation; Vasodilator Agents

Topics: Angina Pectoris; Animals; Blood Flow Velocity; Cardiovascular Agents; Chest Pain; Coronary Circulation; Coronary Disease; Diagnosis, Differential; Humans; Mibefradil; Quality of Life; Randomized Controlled Trials as Topic; Rest; Vasodilator Agents

Topics: Administration, Cutaneous; Administration, Oral; Angina Pectoris, Variant; Aspirin; Cardiovascular Agents; Chest Pain; Coronary Angiography; Coronary Vasospasm; Diltiazem; Drug Therapy, Combination; Electrocardiography; Follow-Up Studies; Humans; Male; Middle Aged; Nitrates; Platelet Aggregation Inhibitors; Time Factors

An electrophysiological study and a provocative test of coronary artery spasm was attempted in a 68-year-old man who was having syncopal attacks and chest pain. His electrocardiogram had the characteristics of Brugada syndrome and ventricular fibrillation (VF) was induced by programmed electrical stimulation. ST-segment elevation became exaggerated by procainamide, which could not prevent the induction of VF. Coronary angiography revealed no stenotic lesions, and spasm in the left coronary artery was induced by intracoronary administration of acetylcholine with similar chest pain to that experienced before. Under treatment with diltiazem and flecainide, which suppressed the induction of VF, the patient experienced no recurrence of symptoms despite persistent ST-segment elevation. No previous reports have described coronary spasm associated with Brugada-type ECG abnormalities, and patients with syncope should be evaluated carefully.

Topics: Acetylcholine; Aged; Anti-Arrhythmia Agents; Calcium Channel Blockers; Cardiovascular Agents; Chest Pain; Coronary Angiography; Coronary Vasospasm; Diagnosis, Differential; Diltiazem; Electric Stimulation; Electrocardiography; Electrophysiology; Flecainide; Humans; Male; Syncope; Syndrome; Vasodilator Agents; Ventricular Fibrillation

The impact of coronary heart disease (CHD) on elderly patients' functional abilities is of growing interest because of the increasing number of people that survive the disease. The aim of our study was, firstly, to describe functional abilities among elderly CHD patients and, secondly, to analyze the relationships between physical disability and the severity of chest pain or dyspnea. The third aim was to assess whether there is an independent association between physical disability and CHD. The study was carried out at the health center of the municipality of Lieto, southwestern Finland. From a population of 1196 community-dwelling persons aged > or = 64 years, 89 men and 73 women with CHD (angina pectoris and/or a past myocardial infarction) were selected along with 178 male and 146 female sex- and age-matched controls without CHD. Physical functioning was assessed by means of interviewer-based questionnaires, compared between patients and controls and described in relation to the severity of chest pain and dyspnea among patients. The associations between dependence or difficulties in mobility, ADL (activities of daily living) and IADL (instrumental activities of daily living) and CHD, age, smoking, comorbidities, drug therapy and clinical characteristics were assessed by logistic regression analyses. On items representing mobility and managing in IADL, patients reported more difficulties or dependence than controls. Among female patients, more severe chest pain was associated with poor managing in IADL and tended to be associated with poor mobility. More severe dyspnea was associated with poor mobility among both male and female patients, and with poor managing in IADL among male patients. Logistic regression analyses failed to show that CHD was associated independently with physical disability among the elderly. However, physical disability was associated with the use of cardiovascular drugs in the models among both genders, which probably indirectly indicated an association between physical disability and CHD. Several confounding factors, such as higher age, depression, cancer and the use of psychotropic drugs, contributed to the decline in functional abilities even among persons with CHD. In conclusion, elderly CHD patients have greater limitations in their functional ability than matched controls, which may depend on the severity of the disease. Especially male patients' limitations in physical abilities may be influenced by the fact that men with C

Topics: Activities of Daily Living; Age Factors; Aged; Aged, 80 and over; Cardiovascular Agents; Case-Control Studies; Chest Pain; Coronary Disease; Disability Evaluation; Dyspnea; Female; Humans; Logistic Models; Male; Middle Aged; Smoking

A total of 502 patients presenting in Utsunomiya city and its suburbs during a 10-year period were studied to determine the clinical features of ischemic heart disease and to identify coronary risk factors. The male/female ratio was 1.21, but the ratio decreased with increasing age. The duration of chest pain showed a continuous spectrum between angina and infarction, with a short duration of chest pain not being useful for excluding the diagnosis of myocardial infarction. Hypertension was more common than hypercholesterolemia in this study, although the prevalence of the latter increased slightly with time, along with the shift towards a modernized occupational pattern. Smoking was a more important risk factor for ischemic heart disease in younger individuals than in the elderly, and diabetes mellitus was highly associated with the development of myocardial infarction. The incidence of radiologically diagnosed cardiac hypertrophy and aortic calcification decreased over time. These changes may have resulted in part from improved blood pressure control and the development of new anti-hypertensive and cholesterol-lowering agents.

Topics: Age Factors; Alcohol Drinking; Aortic Diseases; Arteriosclerosis; Calcinosis; Cardiomegaly; Cardiovascular Agents; Chest Pain; Comorbidity; Death, Sudden, Cardiac; Diabetes Mellitus; Female; Humans; Hypercholesterolemia; Hypertension; Japan; Male; Morbidity; Myocardial Ischemia; Occupations; Risk Factors; Smoking; Urban Population

The aim of this study was to compare the outcome for men and women with chest pain or other symptoms suggestive of acute myocardial infarction (AMI) and a normal ECG on admission.. All patients who presented to our emergency room over a 21-month period with chest pain or other symptoms suggestive of AMI were prospectively followed for 1 year, whether they were hospitalised or not.. Of 5201 registered patients a normal ECG was found in 2691, of whom 700 men and 559 women were hospitalised while 752 men and 680 women were not hospitalised. As many women (45%) as men (48%) were hospitalised, but fewer women were admitted to the coronary care unit in the first instance (8.6% versus 15.2%; P < 0.001). More men than women (9.3% versus 2.7%; P < 0.001) who were hospitalised developed AMI during hospitalisation, but there was no difference during 1 year between men and women who were not hospitalised regarding AMI development (1.5% versus 1.4%; NS). There was no difference in in-hospital complications between men and women. Mortality for men and women during hospitalisation (1.6% versus 1.1%) or during 1 year (4.2% versus 4.5% for hospitalised and 1.2% versus 1.2% for not hospitalised patients) did not differ.. Among patients with suspected AMI and a normal ECG on admission women were less often admitted to the coronary care unit and less often developed AMI during hospitalisation than men. Men and women had the same mortality during hospitalization and during 1 year.

Topics: Adult; Aged; Cardiovascular Agents; Chest Pain; Coronary Care Units; Electrocardiography; Female; Hospitalization; Humans; Male; Middle Aged; Myocardial Infarction; Myocardial Revascularization; Retrospective Studies; Sex Factors; Survival Rate

Topics: Angina Pectoris; Cardiovascular Agents; Chest Pain; Chlordiazepoxide; Dipyridamole; Electrocardiography; Geriatrics; Humans; Pentaerythritol Tetranitrate; Prenylamine