Chest Pain – ABC CARDIOL

IJCS

Original Article

Acute Coronary Syndrome Patient Profile in Emergency Department: A cross-sectional study

Riza Fikriana et al. Al Afik Randy Eka Prasetya

Abstract

Background:

Acute Coronary Syndrome (ACS) remains one of the leading causes of high morbidity and mortality worldwide. Psychological factors are considered important contributors to increasing recurrence rates in patients.

Objective:

This study aimed to analyze the association between stress, chest pain complaints, electrocardiographic changes, and cardiac enzyme levels.

Methods:

A cross-sectional design was employed. A sample of 105 ACS patients presenting to the hospital emergency department was selected using an accidental sampling technique. Variables measured included stress scores, chest pain, electrocardiographic findings, troponin, and CK-MB levels. Data were analyzed using the Spearman rank test and linear regression, with a significance level set at p < 0.05.

Results:

Stress scores were significantly associated with chest pain (p < 0.001), electrocardiographic changes (p < 0.001), troponin levels (p < 0.001), and CK-MB levels (p < 0.001). ECG findings showed that most STEMI patients (68.9%) experienced severe pain. Linear regression analysis indicated that troponin and CK-MB levels were significantly influenced by chest pain (p < 0.001).

Conclusions:

Stress is positively correlated with chest pain in ACS patients and is reflected in ECG changes and elevated cardiac enzymes (troponin and CK-MB).

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ABCIC

Case Report

Rare Presentation of an Anatomical Congenital Anomaly of the Coronary Arteries on Computed Tomography Angiography

Marcello Zapparoli et al. Alexandre Alessi Franco Camargo Zapparoli Mateus Rodrigues Alessi

Introduction

Anomalous origin of the coronary arteries represents a heterogeneous group of alterations in the origin and course of these vessels, ranging from the most common, asymptomatic and low risk, to the rarest and highest risk, which may eventually be symptomatic or have sudden death as their first manifestation.^, Their prevalence corresponds to 1.3% of patients undergoing coronary angiography, but this number may be higher depending on the diagnostic method and the population selected, representing the second leading cause of sudden death in young athletes, behind only hypertrophic cardiomyopathy.^,

Within this group, coronary anomalies with a single ostium are present in a smaller proportion of the population, approximately 0.004% to 0.098%. They are most often asymptomatic, but they may manifest with chest pain, dyspnea, palpitation, myocardial infarction, and sudden death.^, The presentation of this anomaly has worse prognosis in the presence of an interarterial vessel course (between the aorta and pulmonary trunk), an acute angle of origin, and atherosclerotic plaque; the latter change has a higher incidence in anomalous vessels on account of the greater stress on the arterial wall.^, In addition to presenting in isolation, they may also be associated with other alterations such as cardiac fistulas or a bicuspid aortic valve.

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ABCIC

Review Article

My Approach To CAD-RADS 2.0 in the Assessment of Coronary Artery Disease by CT Angiogram

Bruno Maeda Fuzissima et al. Roberto Vitor Almeida Torres Renata Muller Couto Lucas de Pádua Gomes de Farias … Bernardo Salgado Pinto Oliveira José de Arimatéia Batista Araújo Filho

Abstract

Coronary artery disease (CAD) is a common cause of chest pain, frequently seen in emergency departments and during elective consultations, and remains the leading cause of death worldwide. Coronary computed tomography angiography (CCTA) has become an established diagnostic tool for evaluating stable angina and acute chest pain in patients with low or intermediate risk. In this setting, CAD-RADS (Coronary Artery Disease-Reporting and Data System) was introduced as a CCTA reporting model, first published in 2016 and updated in 2022, with the aim of standardizing the description of imaging findings, improving communication between imaging specialists and clinicians, and providing guidance on patient management. This article reviews the CAD-RADS classification categories, which are based on the degree of stenosis, atherosclerotic plaque burden, and other modifying findings related to coronary abnormalities while also addressing certain exceptional situations. Through clinical cases, examples of structured reports, and recommendations for clinical management in different scenarios, we examine the objectives, benefits, limitations, and future potential of this classification, which remains underutilized in clinical practice.

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ABC

Editorial

The Importance of Characterizing Chest Pain in the Management of Unstable Angina

Daniela do Carmo Rassi et al. Aguinaldo Figueiredo Freitas Jr. Salvador Rassi

Unstable angina is a clinical entity of great complexity and whose correct diagnosis is essential for appropriate management. This terminology, unstable angina, tends to fall into disuse. As advocated by the latest European Guideline for the Management of Acute Coronary Syndrome of 2020, it would be encompassed under the name Acute Coronary Syndrome (unstable angina, acute myocardial infarction with and without ST elevation). Its diagnosis is essentially clinical, with nonspecific changes on the electrocardiogram and without plasma elevation of markers of myocardial necrosis.

In Acute Coronary Syndrome, when we have electrocardiographic changes and documentation of myocardial injury, there is already an established approach that would be early catheterization and coronary intervention, if applicable. In the absence of these markers, we do not yet have an established approach.

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ABC

Editorial

Index of Systemic Immunoinflammation and Ischemia in Patients with Non-Obstructive Coronary Arteries

Henrique Tria Bianco

Cardiovascular disease is the leading cause of death worldwide and coronary artery disease (CAD) is the most common type of cardiovascular disease. However, a significant portion of patients who present with characteristic chest discomfort do not demonstrate obstructive CAD, defined as ≥50% stenosis in at least one coronary artery on angiography. These patients are generally diagnosed with non-cardiological conditions, such as gastrointestinal disorders or psychosomatic disorders. It is speculated that coronary vascular dysfunction appears to be the underlying cause of ischemia in a large proportion of these cases. Therefore, standardization of diagnostic criteria for ischemic symptoms due to coronary microvascular dysfunction (CMD) is necessary for further investigation of patients presenting with anginal chest pain consistent with “microvascular angina”.

Historically, the only practical methods available for assessment have been invasive, such as intracoronary Doppler or thermodilution. This probably hindered the objective assessment of CMD in patients presenting with chest pain without obstructive CAD. Thus, treatment has often been studied in imprecise clinical entities such as cardiac syndrome distinct.^, Furthermore, the lack of consensus on diagnostic criteria and nomenclature has further obscured the evidence that sought to objectively define microvascular angina as a distinct clinical entity.

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ABC

Original Article

Critical Assessment of the Management of Unstable Angina in a Specialized Cardiology Emergency Room

Mateus Arantes Prata et al. Louis Nakayama Ohe Kelvin Henrique Vilalva Lucas Ferreira Marcondes Lemos Paola Emanuela Poggio Smanio

Abstract

Background:

The management of unstable angina (UA) presents a challenge due to its subjective diagnosis and limited representation in randomized clinical trials that inform current practices.

Objectives:

This study aims to identify key factors associated with the indication for invasive versus non-invasive stratification in this population and to evaluate factors associated with stratification test results.

Methods:

This retrospective cohort study included patients hospitalized with UA over a consecutive 20-month period. To assess factors associated with stratification strategies, patients were divided into invasive stratification (coronary angiography) and non-invasive stratification (other methods) groups. For the analysis of factors related to changes in stratification tests, patients were categorized into groups with or without obstructive coronary artery disease (CAD) or ischemia, as per the results of the requested tests. Comparisons between groups and multiple logistic regression analyses were performed, with statistical significance set at a 5% level.

Results:

A total of 729 patients were included, with a median age of 63 years and a predominance of males (64.6%). Factors associated with invasive stratification included smoking (p = 0.001); type of chest pain (p < 0.001); "crescendo" pain (p = 0.006); TIMI score (p = 0.006); HEART score (p = 0.011). In multivariate analysis, current smokers (OR 2.23, 95% CI 1.13-4.8), former smokers (OR 2.19, 95% CI 1.39-3.53), and type A chest pain (OR 3.39, 95% CI 1.93-6.66) were independently associated. Factors associated with obstructive CAD or ischemia included length of hospital stay (p < 0.001); male gender (p = 0.032); effort-induced pain (p = 0.037); Diamond-Forrester score (p = 0.026); TIMI score (p = 0.001). In multivariate analysis, only chest pain (type B chest pain: OR 0.6, 95% CI 0.38-0.93, p = 0.026) and previous CAD (OR 1.42, 95% CI 1.01-2.0, p = 0.048) were independently associated.

Conclusion:

The type of chest pain plays a crucial role not only in the diagnosis of UA but also in determining the appropriate treatment. Our results highlight the importance of incorporating pain characteristics into prognostic scores endorsed by guidelines to optimize UA management.

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Editorial

The “Value of 0”: Is There an Added Value in Using the Calcium Score in the Stratification of Symptomatic Individuals with a Zero Score?

Catarina Ferreira

Coronary calcium score (CCS) is a good marker of cardiovascular risk, with an independent prognostic value that is incremental over traditional clinical risk factors.^– It is performed using non-contrast computed tomography with very low radiation exposure to patients.

Its use is now recommended in selected asymptomatic individuals to refine risk assessment and help initiate or prolong preventive pharmacotherapies.

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Original Article

Predicting Significant Coronary Obstruction in a Population with Suspected Coronary Disease and Absence of Coronary Calcium: CORE-64 / CORE320 Studies

Anderson C. Armstrong et al. Rodrigo Cerci Matthew B. Matheson Tiago Magalhães … Satoru Kishi Jeff Brinker Melvin E. Clouse Carlos E. Rochitte Christopher Cox João A. C. Lima Armin Arbab-Zadeh

Abstract

Background

Coronary artery calcium (CAC) scanning can be performed using non-contrast computed tomography to predict cardiovascular events, but has less value for risk stratification in symptomatic patients.

Objective

To identify and validate predictors of significant coronary obstruction (SCO) in symptomatic patients without coronary artery calcification.

Methods

A total of 4,258 participants were screened from the CORE64 and CORE320 studies that enrolled patients referred for invasive angiography, and from the Quanta Registry that included patients referred for coronary computed tomography angiography (CTA). Logistic regression models evaluated associations between cardiovascular risk factors, CAC, and SCO. An algorithm to assess the risk of SCO was proposed for patients without CAC. Significance level of 5% was used in the analyses.

Results

Of the 509 participants of the CORE study, 117 (23%) had zero coronary calcium score; 13 (11%) patients without CAC had SCO. Zero calcium score was related to younger age, female gender, lower body mass index, no diabetes, and no dyslipidemia. Being a current smoker increased ~3.5 fold the probability of SCO and other CV risk factors were not significantly associated. Considering the clinical findings, an algorithm to further stratify zero calcium score patients was proposed and had a limited performance in the validation cohort (AUC 58; 95%CI 43, 72).

Conclusion

A lower cardiovascular risk profile is associated with zero calcium score in a setting of high-risk patients. Smoking is the strongest predictor of SCO in patients without CAC.

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ABC

Original Article

Diagnostic Performance of Coronary Tomography Angiography and Serial Measurements of Sensitive Cardiac Troponin in Patients With Chest Pain and Intermediate Risk for Cardiovascular Events

Alexandre de Matos Soeiro et al. Bruno Biselli Tatiana C.A.T. Leal Aline Siqueira Bossa … Maria Cristina César Sérgio Jallad Priscila Gherardi Goldstein Patrícia Oliveira Guimarães Carlos Vicente Serrano Jr Cesar Higa Nomura Débora Nakamura Carlos Eduardo Rochitte Paulo Rogério Soares Múcio Tavares de Oliveira Jr.

Abstract

Background

Coronary tomography angiography (CTA) has been mainly used for chest pain evaluation in low-risk patients, and few data exist regarding patients at intermediate risk.

Objective

To evaluate the performance of serial measures of sensitive troponin and CTA in intermediate-risk patients.

Methods

A total of 100 patients with chest pain, TIMI risk scores of 3 or 4, and negative troponin were prospectively included. All patients underwent CTA and those with coronary stenosis ≥ 50% were referred to invasive coronary angiography. Patients with coronary lesions <50% were discharged and contacted 30 days later by a telephone call to assess clinical outcomes. Outcomes were hospitalization, death, and myocardial infarction at 30 days. The comparison between methods was performed by Kappa agreement test. The performance of troponin measures and CTA for detecting significant coronary lesions and clinical outcomes was calculated. Results were considered statistically significant when p < 0.05.

Results

Coronary stenosis ≥ 50% on CTA was found in 38% of patients and significant coronary lesions on coronary angiography were found in 31 patients. Two clinical events were observed. Kappa agreement analysis showed low agreement between troponin measures and CTA in the detection of significant coronary lesions (kappa = 0.022, p = 0.78). The performance of CTA for detecting significant coronary lesions on coronary angiography or for predicting clinical events at 30 days was better than sensitive troponin measures (accuracy of 91% versus 60%).

Conclusion

CTA performed better than sensitive troponin measures in the detection of significant coronary disease in patients with chest pain and intermediate risk for cardiovascular events.

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ABC

Editorial

Role of Computed Tomography in Excluding Acute Coronary Syndrome: is Anatomy the Way?

Nuno Bettencourt

Chest pain is one of the most common reasons for admission to the emergency room (ER). Although only a small minority of these correspond to an acute coronary syndrome (ACS), the potential severity of a misdiagnosis or a non-diagnosis implies using systematic protocols to confirm or exclude coronary artery disease (CAD) as a cause of symptoms. In recent years, the sequential blood testing of high-sensitive troponin (cTnI-hs) levels has become a safe and effective method in this context and is commonly applied worldwide.^– However, this approach is associated with prolonged times in the ER and is not error-free, as some patients with unstable angina may not be correctly identified.

New approaches using imaging methods to exclude CAD gained relevance and have generated interest from the scientific community. Cardiac CT angiography (CTA), due to its high diagnostic performance, is assumed to be the main candidate to change the status-quo of the current approach based on serial blood testing. It is a simple, fast and robust test with a high negative predictive value – which makes it particularly suitable in ER, where it is essential to quickly and effectively exclude the presence of CAD. The ROMICAT studies were among the first to document the advantages of CTA in this context and to emphasize its additive prognostic value concerning the TIMI risk score (TIMI RS). However, like the vast majority of studies that used CTA in the context of hospital ER, their results mostly apply to low-risk populations.^,

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IJCS

Case Report

Exercise-Induced Bronchoconstriction: A Frequent, but Neglected Cause of Chest Pain

Renata Rodrigues Teixeira de Castro et al. João Giffoni Silveira Neto Adalgiza Mafra Moreno Marco Orsini

Introduction

Chest pain is one of the most common complaints in emergency departments, and internal medicine and cardiology clinics. Patients’ comorbidities and the clinical characterization of chest pain are cornerstones to guide symptom differentiation. Information about pain intensity, duration, localization, changes with posture/movement, and its reaction to nitroglycerin helps diagnose cardiac chest pain. Typical angina pectoris is the presence of substernal chest pain or discomfort provoked by exertion or emotional stress, and is relieved by rest and nitroglycerin. Angina pectoris is attributed to myocardial ischemia due to the unbalance between myocardial oxygen supply and myocardial oxygen demand elicited during exercise or emotional stress.

The diagnosis and treatment workup in patients with moderate to high cardiovascular risk presenting angina pectoris is quite straight-forward. Nevertheless, exertional chest pain in a young man can be challenging and yield a common but overlooked diagnosis, as in the present case report.

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ABCIC

Case Report

Left Ventricular Longitudinal Strain Echocardiogram and Handgrip: A Useful Tool for Detecting Ischemia in the Emergency Room

Ana Paula Torres Guimarães de Freitas et al. Natalia Marcusso Massoni Rodrigo Bellio de Mattos Barretto

Introduction

Acute coronary syndrome is among the greatest diagnostic challenges for emergency room physicians. Non-invasive imaging tests such as echocardiography (ECHO) are useful in the etiological diagnosis of chest pain. In cases of suspected ischemia, when electrocardiography (ECG) and myocardial necrosis markers (MNM) are inconclusive, ECHO can be performed at the time of pain or immediately after. The use of advanced techniques such as myocardial deformation analysis (strain) provides greater accuracy in identifying the coronary artery disease territory.

This report describes a case of a patient with chest pain without segmental changes on initial ECHO in the emergency room. Significant coronary artery disease (CAD) changes were evident on additional tools (handgrip, strain, and postsystolic peak) as showed on the subsequent coronary angiography.

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ABCIC

Case Report

Young Patient with Chagas Disease Presenting Initially as Acute Chest Pain and Treated for Acute Coronary Syndrome

Jakson Ferreira Neto et al. Dannyl Roosevelt de Vasconcelos Lima Pedro Vinicius Amorim de Medeiros Patriota João Helbert Costa e Silva … Antônio Marconi Leandro da Silva Anderson da Costa Armstrong

Introduction

Chagas disease, a chronic and endemic condition in 21 countries within the Americas, affects approximately 6 million people. The northeast region has always been particularly important for the disease. According to data from the Mortality Information System (Sistema de Informação sobre Mortalidade), between 1980 and 2007, Brazil registered 156,224 deaths from Chagas disease; of them, 20,472 were in the northeast region and 3,144 occurred in Pernambuco.

Classic symptoms of Chagas disease can include chest pain, commonly typical for angina. Records of Chagas patients usually relate typical acute anginal pain to superimposed coronary artery disease. However, microcirculation disease has also been suggested as a chest pain trigger. Despite the high prevalence of Chagas heart disease in inland northeastern Brazil, coronary artery disease remains the main cause of heart failure and acute coronary syndromes.

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ABCIC

Case Report

Rare Cause of Chest Pain in Young Patient: Left Ventricular Myxoma

Gustavo Henrique Belarmino Góes et al. José Candido de Souza Ferraz Neto Ivaldo Pedrosa Calado Filho Ricardo de Carvalho Lima Dário Celestino Sobral Filho

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ABCIC

Case Report

Multimodality Evaluation in Cardiovascular Imaging in the Diagnosis of Atypical Cases of Chest Pain: Myasthenia Gravis

Roberta de Alvarenga Batista et al. Alexandre Henrique Cobucci Santana Roberto Luiz Marino Bárbara Campos Abreu Marino

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ABCIC

Image

Suprasternal echocardiogram: an essential tool in emergency room

Inês Almeida et al. Hélder Santos Hugo Miranda Catarina Sousa

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ABCIC

Case Report

A Young Patient with Chest Pain: Going Beyond the Obvious

Sebastian Gallo Bernal et al. Azucena Martínez Juan F Vasquez-Rodriguez Nicolás Isaza … Daniel Isaza Camilo A Calixto Claudia Jaimes

Abstract

Background

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is diagnostically and therapeutically challenging for clinicians, as a large spectrum of causes may result in this clinical condition, multiple entities can mimic it, and there are relatively few evidence-based recommendations for its assessment.

Discussion

Accurate diagnosis of the underlying etiology of MINOCA requires a systematic and dynamic evaluation of the clinical history and work-up of each patient, as well as the use of additional diagnostic tools that allow more in-depth characterization of the cardiac anatomy and coronary function, such as cardiac magnetic resonance imaging, coronary vascular imaging (intravascular ultrasound, optical coherence tomography), and coronary functional assessments. The prognosis of MINOCA highly depends on its underlying cause, and therefore, an accurate diagnosis of its etiology is necessary.

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Case Report

Spontaneous Coronary Artery Dissection and Diagnosis by Computed Tomography Angiography: a Case Report

Mathias Silvestre de Brida et al. Georgia Pergher Postingher Fábio Vieira Caovilla Juarez Neuhaus Barbisan

Introduction

Spontaneous coronary artery dissection (SCAD), defined as separation of the layers of the coronary wall unrelated to trauma, iatrogenesis, or atherosclerosis, often occurs in young women without cardiovascular risk factors. First described almost a century ago, it was poorly understood for some time, known only to be associated with the peripartum and pregnancy periods. SCAD is a rare cause of acute coronary syndrome (ACS), and despite technological advances in invasive or non-invasive imaging tests increasing our understanding of its pathophysiology and treatment, it remains underdiagnosed. This report describes the case of an ACS patient without obstructive lesions on coronary angiography in which coronary computed tomography angiography (CCTA) was an indispensable tool in the diagnosis of SCAD with an unusual location, highlighting its growing importance based on the current scientific literature.

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ABC

Original Article

Accuracy of Post-thrombolysis ST-segment Reduction as an Adequate Reperfusion Predictor in the Pharmaco-Invasive Approach

Henrique Tria Bianco et al. Rui Povoa Maria Cristina Izar Braulio Luna Filho … Flavio Tocci Moreira Edson Stefanini Henrique Andrade Fonseca Adriano Henrique Pereira Barbosa Claudia Maria Rodrigues Alves Adriano Mendes Caixeta Iran Gonçalves Jr Pedro Ivo de Marqui Moraes Renato Delascio Lopes Angelo Amato Vincenzo de Paola Dirceu Almeida Valdir Ambrosio Moises Francisco A. H. Fonseca

Abstract

Background

Primary percutaneous coronary intervention is considered the “gold standard” for coronary reperfusion. However, when not available, the drug-invasive strategy is an alternative method and the electrocardiogram (ECG) has been used to identify reperfusion success.

Objectives

Our study aimed to assess ST-Segment changes in post-thrombolysis and their power to predict recanalization and using the angiographic scores TIMI-flow and Myocardial Blush Grade (MBG) as an ideal reperfusion criterion.

Methods

2,215 patients with ST-Segment Elevation Myocardial Infarction (STEMI) undergoing fibrinolysis [(Tenecteplase)-TNK] and referred to coronary angiography within 24 h post-fibrinolysis or immediately referred to rescue therapy were studied. The ECG was performed pre- and 60 min-post-TNK. The patients were categorized into 2 groups: those with ideal reperfusion (TIMI-3 and MBG-3) and those with inadequate reperfusion (TIMI and MBG 50%. A p-value <0.05 was considered for the analyses, with bicaudal tests.

Results

The ECG reperfusion criterion showed a positive predictive value of 56%; negative predictive value of 66%; sensitivity of 79%; and specificity of 40%. There was a weak positive correlation between ST-Segment reduction and ideal reperfusion angiographic data (r = 0.21; p <0.001) and low diagnostic accuracy, with an AUC of 0.60 (95%CI: 0.57-0.62).

Conclusion

The ST-Segment reduction was not able to accurately identify patients with adequate angiographic reperfusion. Therefore, even patients with apparently successful reperfusion should be referred to angiography soon, to ensure adequate macro and microvascular coronary flow.

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IJCS

Case Report

Takotsubo Cardiomyopathy and Myocardial Perfusion Image: Unusual Binomial in the Investigation of Acute Coronary Syndrome without Obstructive Lesions

Mathias Silvestre de Brida et al. Raphael Boesche Guimaraes Leonardo Rothlisberger Matheus Patricio

Introduction

Takotsubo cardiomyopathy (TC), also known as broken heart syndrome or stress-induced cardiomyopathy, was primarily described in Japan in 1990, is named after its morphological similarity to the vase used by Asian people to catch octopuses, which has a rounded bottom and a narrow bottleneck. This condition is characterized by transient left ventricular (LV) systolic dysfunction, commonly preceded by physical or emotional stress, mimicking the presentation of acute myocardial infarction. In the present article, we describe a case of TC focusing on its updated approach, highlighting the applicability of myocardial perfusion scintigraphy (MPS) in the acute phase of chest pain and presenting images rarely described in this scenario.

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Image

Pulmonary Arterial Intramural Hematoma Due to Acute Aortic Dissection

Lucas de Pádua Gomes de Farias et al. Ana Cristina Favaretto Luciana de Pádua Silva Baptista Gustavo Borges da Silva Teles

A 54-year-old male patient, who was a smoker, was admitted to the emergency room with acute chest pain and dyspnea. Investigation was initiated by means of computed tomography angiography of the chest, which showed extensive dissection of the thoracic aorta, beginning in the ascending segment (Stanford type A), associated with intramural hematoma of the pulmonary artery trunk and its main branches. It was more evident on the right, which determines local pulmonary luminal reduction, in addition to a small para-aortic and subaortic mediastinal hematoma. There were no signs of pulmonary thromboembolism, and the evaluation of the parenchyma showed no signs of pulmonary hemorrhage ( and ).

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Original Article

Does Advanced Age Reduce the Typicality of Clinical Presentation in Patients with Acute Chest Pain Related to Coronary Artery Disease?

Pedro Henrique Correia Filgueiras et al. Antônio Maurício Cerqueira Junior Gabriela Oliveira Bagano Vitor Calixto de Almeida Correia … Fernanda Oliveira de Andrade Lopes Thiago Menezes Barbosa de Souza Leticia Lara Fonseca Lara Queiroz Kertzman Yasmin Falcon Lacerda Marcia Noya Rabelo Luis Claudio Lemos Correia

Abstract

Background

According to traditional diagnosis thinking, very elderly individuals are more predisposed to develop atypical symptoms in acute coronary syndromes.

Objective

To test the hypothesis that very elderly individuals are more predisposed to atypical chest pain manifestations due to obstructive coronary artery disease (CAD).

Methods

The Registry of Thoracic Pain includes patients admitted with acute chest pain. Firstly, the typicality index of this clinical manifestation was constructed: the sum of 12 symptom characteristics (8 typical and 4 atypical symptoms). In the subgroup of patients with coronary etiology, the typicality index was compared between octogenarian and non-octogenarian individuals. Statistical significance was defined by p<0.05.

Results

958 patients were included in the registry, and 486 (51%) had a supposedly coronary etiology. In this group, 59 (12%) octogenarians (age 84±3.5, 50% men) were compared to 427 patients aged <80 (60±12 years, 71% men). The typicality index in octogenarians was 3.42±1.92, which is similar to that of non-octogenarians (3.44±1.74; p=0.92 in univariate analysis and p=0.80 after adjustment for sex by analysis of variance — ANOVA). There was also no statistically significant difference when the sample was divided into median age (62 years; 3.41±1.77 vs. 3.49 ± 1.77; p=0.61). There was no statistically significant linear association between age and typicality index (r=- 0.05; p=0.24). Logistic regression analysis for prediction of CAD in the general sample of 958 patients showed no interaction of typicality index with numeric age (p=0.94), octogenarians (p=0.22) or age above median (p=0.74).

Conclusion

In patients with acute chest pain of coronary etiology, advanced age does not influence the typical clinical presentation.

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Editorial

Precordial Pain and Infarction in the Elderly. It´S no so Elementary, My Dear Watson!

Ricardo Wang et al. José Carlos da Costa Zanon Fernando Carvalho Neuschwander

In Medical School, we learn the traditional way to conduct the investigative process in order to reach a diagnosis. This process is traditionally based on the collection of anamnesis and clinical exams, clinical reasoning, the generation of a hypothesis, and tests with complementary exams. In general, we follow the the Occam’s razor principle: “the simplest answer is usually the correct answer,” or as William Osler’s aphorism: “Where you hear hoofs, you don´t think of zebras”. However, in this investigative process, the clinical reasoning is challenged in an elderly population over 80 years of age, and not always is the simplest answer the most correct. In this age group, the presence of comorbidities is quite common and can interfere, changing the perception of cardiovascular symptoms (depression, dementia, medications that interfere in the central nervous system, diabetes, analgesics, etc.), or even modify the symptomatology. The presence of atypical symptoms, such as dyspnea, sudoresis, vomiting, diarrhea, epigastric pain, and mental confusion can all mask the cardiovascular pathology.^,

Many studies have shown the difficulty in diagnosing acute myocardial infarction (AMI) in this population, which clearly entails delays in or the lack of treatment. Even when the diagnosis and early treatment of AMI is established, the mortality rate remains high in this population. The under-treatment or lack of treatment contribute to the increase in mortality in this age group.^– Understanding the factors that make the diagnosis difficult is of utmost importance in establishing protocols directed toward the older age elderly patient.

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Spontaneous Pneumomediastinum

Luísa Gonçalves et al. Inês Pires João Santos Joana Correia Davide Moreira

Case

A 31-year-old male athlete presented with acute chest pain that was aggravated with swallowing after completing a marathon. Physical examination findings and his vital signs were normal. Electrocardiography revealed showed sinus rhythm, an incomplete right bundle block, and a negative T wave in V1-V2. A blood analysis showed normal D-dimer values and a slightly elevated troponin-I level (maximum at 72 hours: 0.52 ng/mL; normal, <0.07 ng/mL) with fluctuations. Chest X-ray, echocardiography, and coronary angiography findings were normal. Cardiac computed tomography (CT) revealed small gas collections on the superior and middle mediastinum compatible with spontaneous pneumomediastinum (SP). ( and ) SP is rare, usually benign, and often underdiagnosed. Intense physical exercise is a recognized cause. Cardiac CT assesses the extension, causative factors, and pathologies and discloses the diagnosis of SP when chest X-ray findings are normal.

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