Cardiovascular and noncardiovascular conditions are commonly encountered in the emergency department. While the majority of patients have underlying cardiovascular aetiologies, such as acute myocardial infarction, congestive heart failure, aortic dissection and pulmonary embolism, a small subset of patients have underlying noncardiovascular conditions, although they present with similar symptoms of chest pain, dyspnoea, cough, haemoptysis and haematemesis. This article aims to describe the imaging findings in common noncardiovascular conditions of the chest that are frequently encountered in the emergency department, with a review of the existing literature.
Chest Pain ; diagnosis ; etiology ; Diagnosis, Differential ; Diagnostic Imaging ; Emergencies ; Humans ; Myocardial Infarction ; complications ; diagnosis ; Pulmonary Embolism ; complications ; diagnosis

Noncardiac chest pain (NCCP) is defined as recurring, angina-like, retrosternal chest pain of noncardiac origin. Although patients with NCCP have excellent long-term prognosis, most suffer persistently from their symptoms. Several pathophysiological mechanisms have been suggested, including gastroesophageal reflux disease (GERD), esophageal motility disorder, esophageal hypersensitivity, and psychological comorbidity. Among them, GERD is the most common cause of NCCP. Therefore, GERD should first be considered as the underlying cause of symptoms in patients with NCCP. Empirical proton pump inhibitor (PPI) treatment with a preferably double dose for more than 2 months could be cost-effective. PPI test can also be used for diagnosis of GERD-related NCCP, but it should be considered for patients with NCCP occurring at least weekly and its duration should be at least 2 weeks. However, upper endoscopy and esophageal pH monitoring are necessary when the diagnosis of GERD is uncertain. Esophageal impedance-pH monitoring could further improve the diagnostic yield. Patients with GERD-related NCCP should preferably be treated with a double dose PPI until symptoms remit (may require more than 2 months of therapy for optimal symptom control), followed by dose tapering to determine the lowest PPI dose that can control symptoms. However, treatment of patients with non-GERD-related NCCP is challenging. An empirical treatment of antidepressants could be considered. If there are specific esophageal motility disorders, smooth muscle relaxants or endoscopic treatment may be considered in selected cases. If none of these traditional treatments is effective, a psychology consultation for cognitive behavioral therapy should be considered.
Chest Pain/*diagnosis/etiology ; Esophageal pH Monitoring ; Gastroesophageal Reflux/complications/*diagnosis/drug therapy ; Humans ; Manometry ; Proton Pump Inhibitors/therapeutic use

Esophageal pain that manifests as heartburn or chest pain, is a prevalent problem. Esophageal chest pain is most often caused by gastroesophageal reflux disease (GERD), but can also result from inflammatory processes, infections involving the esophagus, and contractions of the esophageal muscle. The mechanisms and pathways of esophageal chest pain are poorly understood. Vagal and spinal afferent pathways carry sensory information from the esophagus. Recently, esophageal hypersensitivity is identified as an important factor in the development of esophageal pain. A number of techniques are available to evaluate esophageal chest pain such as endoscopy and/or proton-pump inhibitor trial, esophageal manometry, a combined impedance-pH study, and esophageal ultrasound imaging. Proton pump inhibitors (PPIs) have the huge success in the treatment of GERD. Other drugs such as imipramine, trazadone, sertraline, tricyclics, and theophylline have been introduced for the control of esophageal chest pain in partial responders to PPI and the patients with esophageal hypersensitivity. Novel drugs which act on different targets are anticipated to treat esophageal pain in the future.
Chest Pain/*etiology ; Esophageal pH Monitoring ; Gastroesophageal Reflux/*diagnosis/drug therapy/ultrasonography ; Humans ; Manometry ; Proton Pump Inhibitors/therapeutic use

OBJECTIVE: We aimed to assess the feasibility and superiority of machine learning (ML) methods to predict the risk of Major Adverse Cardiovascular Events (MACEs) in chest pain patients with NSTE-ACS. METHODS: Enrolled chest pain patients were from two centers, Beijing Anzhen Emergency Chest Pain Center Beijing Bo'ai Hospital, China Rehabilitation Research Center. Five classifiers were used to develop ML models. Accuracy, Precision, Recall, F-Measure and AUC were used to assess the model performance and prediction effect compared with HEART risk scoring system. Ultimately, ML model constructed by Naïve Bayes was employed to predict the occurrence of MACEs. RESULTS: According to learning metrics, ML models constructed by different classifiers were superior over HEART (History, ECG, Age, Risk factors, & Troponin) scoring system when predicting acute myocardial infarction (AMI) and all-cause death. However, according to ROC curves and AUC, ML model constructed by different classifiers performed better than HEART scoring system only in prediction for AMI. Among the five ML algorithms, Linear support vector machine (SVC), Naïve Bayes and Logistic regression classifiers stood out with all Accuracy, Precision, Recall and F-Measure from 0.8 to 1.0 for predicting any event, AMI, revascularization and all-cause death ( vs. HEART ≤ 0.78), with AUC from 0.88 to 0.98 for predicting any event, AMI and revascularization ( vs. HEART ≤ 0.85). ML model developed by Naïve Bayes predicted that suspected acute coronary syndrome (ACS), abnormal electrocardiogram (ECG), elevated hs-cTn I, sex and smoking were risk factors of MACEs. CONCLUSION Compared with HEART risk scoring system, the superiority of ML method was demonstrated when employing Linear SVC classifier, Naïve Bayes and Logistic. ML method could be a promising method to predict MACEs in chest pain patients with NSTE-ACS.
Humans ; Acute Coronary Syndrome/epidemiology* ; Bayes Theorem ; Feasibility Studies ; Risk Assessment/methods* ; Chest Pain/etiology* ; Myocardial Infarction/diagnosis*

BACKGROUND/AIMS: Esophageal perforation is a rare but often a life-threatening condition. However, the incidence and clinical features of esophageal perforation caused by ingested foreign body are unknown. This study investigated the incidence of esophageal perforation caused by ingested foreign body and evaluated the clinical features and outcome of patients with esophageal perforation. METHODS: Among a total of 196 adult patients with confirmed esophageal foreign body and complained of at least one of the related symptoms at the emergency department between January 2000 and July 2008, 18 patients with esophageal perforation due to esophageal foreign body ingestion were included in the study. Data were collected by retrospectively reviewing the electric medical records. RESULTS: The incidence of esophageal foreign body and esophageal perforation in adults was 19.4% (196/1,009) and 1.8% (18/1,009), respectively. Chest pain was the most common symptom and fishbone was the most common foreign body causing esophageal perforation. Mediastinitis or mediastinal abscess occurred in 13 patients (13/18, 72.2%). About half (8/18) of the patients were admitted to the intensive care unit but there was no in-hospital mortality. CONCLUSIONS: The incidence of esophageal perforation in patients with foreign body ingestion was low but it increased up to 9.2% in patients with esophageal foreign body. However, prognosis was favorable with timely proper treatment. Chest pain can be an ominous sign indicating the presence of esophageal perforation in patients with esophageal foreign body.
Aged ; Chest Pain/etiology ; Emergency Medical Services ; Esophageal Perforation/*diagnosis/epidemiology/etiology ; Female ; Foreign Bodies/*complications ; Humans ; Incidence ; Intensive Care Units ; Male ; Middle Aged ; Prognosis ; Retrospective Studies

OBJECTIVETo analyze the diagnosis, treatment and prognosis of spontaneous pneumomediastinum (SPM) in children.

METHODA retrospective analysis of the clinical data of 18 children diagnosed with SPM in Yuying Children's Hospital Affiliated to Wenzhou Medical University from December 2007 to February 2013 was performed. Information of the sequelae and recurrence of SPM was obtained by telephone follow-up. SPM was diagnosed according to Versteegh's standard. SPM cases due to mechanical ventilation, trauma, inhaled foreign body or as a result of the underlying disease were not included. Also cases of secondary pneumothorax pneumomediastinum and neonatal mediastinal emphysema were excluded.

RESULTFifteen of 18 cases were boys and 3 were girls, the range of age was from 9 to 17 years. Predisposing factors included sport activities, severe cough or without a known cause. Clinical manifestations included chest pain, chest tightness, dyspnea, neck pain, back pain, foreign body sensation or pain on swallowing, throat pain of swelling. Chest CT of 18 cases showed pneumomediastinum, 8 cases displayed varied degrees of air in neck, chest; 18 cases of SPM responded well to bed rest, oxygen, antitussive and anti-infection treatment. Fifteen cases received chest CT or X-ray inspection after therapy, showing that the pneumomediastinum disappeared or significantly absorbed, 3 cases improved in clinical symptom. Among 18 patients, telephone follow-up of 14 were successful and 4 cases were lost. An average follow-up time was (24 ± 17) months. None of the cases had any serious consequences, and recurrence happened in one case.

CONCLUSIONChildren's spontaneous pneumomediastinum is a benign disease. When a child has chest pain or chest tightness, SPM should be considered after excluding the common diseases. SPM can be diagnosed in association with clinical feature and chest CT examination. Patients respond well to conservative therapy and most of them had no severe sequelae.

Adolescent ; Chest Pain ; diagnosis ; etiology ; Child ; Dyspnea ; diagnosis ; etiology ; Female ; Follow-Up Studies ; Humans ; Male ; Mediastinal Emphysema ; complications ; diagnosis ; therapy ; Oxygen Inhalation Therapy ; Prognosis ; Radiography, Thoracic ; Recurrence ; Subcutaneous Emphysema ; diagnosis ; etiology ; Tomography, X-Ray Computed

BACKGROUND: Although patients may present with typical chest pain and exhibit ischemic changes on the cardiac stress test, they are frequently found to have a normal coronary angiogram. Thus, we wanted to determine which procedures should be performed in order to make an adequate diagnosis of the cause of chest pain. METHODS: 121 patients (males: 42, 34.7%) who had a normal coronary angiogram with typical chest pain were included in this study. All the patients underwent upper endoscopy, Bernstein's test and esophageal manometry. RESULTS: Among the 121 patients, clinically stable angina was noted in 107 (88.4%). Stress testing was done in 82 (67.8%); it was positive in 52 (63.4%). Endoscopic findings were erosive gastritis in 18 (14.8%), gastric ulcer in 4 (3.3%), duodenal ulcer in 5 (4.1%), and reflux esophagitis in 16 (13.2%). Positive results were observed on Berstein's test for 68 patients (56.2%); 59 (86.8%) of them had non-erosive reflux disease. On the esophageal manometry, 35 (28.9%) of these patients had motility disorders. Nutcracker esophagus was observed in 27 patients (22.3%), nonspecific esophageal motility disorder was observed in 5 (4.1%), and hypertensive lower esophageal sphincter was observed in 3 (2.5%). Among the 52 patients with positive cardiac stress testing and a negative coronary angiogram (this clinically corresponded to microvascular angina), 46 patients (85.1%) showed abnormal findings on the gastro-esophageal studies. CONCLUSIONS: In our study, 85.1% of the patients with microvascular angina revealed positive results of gastric or esophageal disease. In spite of any existing evidence of microvascular angina or cardiac syndrome X, it would be more advisable to perform gastro-esophageal studies to adequately manage chest pain.
Stomach Diseases/*complications/epidemiology ; Retrospective Studies ; Middle Aged ; Male ; Incidence ; Humans ; Female ; Esophageal Diseases/*complications/epidemiology ; Coronary Angiography ; Chest Pain/diagnosis/*etiology/radiography ; Aged ; Adult

A 53-yr-old man underwent radiofrequency ablation to treat persistent atrial flutter. After the procedure, the chest pain was getting worse, and the electrocardiogram showed ST-segment elevation in inferior leads with reciprocal changes. Immediate coronary angiography showed total occlusion with thrombi at the distal portion of the right coronary artery, which was very close to the ablation site. Intervention with thrombus aspiration and balloon dilatation was successful, and the patient recovered without any kind of sequelae. Although the exact mechanism is obscure, the most likely explanation is a thermal injury to the vascular wall that ruptured into the lumen and formed thrombus. Vasospasm and thromboembolism can also be other possibilities. This case raise the alarm to cardiologists who perform radiofrequency ablation to treat various kinds of cardiac arrhythmias, in that myocardial infarction has been rarely considered one of the complications.
Acute Disease ; Angioplasty, Balloon, Coronary ; Atrial Flutter/*surgery ; Catheter Ablation/*adverse effects ; Chest Pain/etiology ; Coronary Occlusion/etiology ; Coronary Vessels/radiography ; Humans ; Male ; Middle Aged ; Myocardial Infarction/*diagnosis/etiology/therapy ; Thrombosis/surgery

PURPOSE: Spontaneous pneumomediastinum (SPM) is a rare entity, with only a few cases reported, especially in adolescents. We aimed to analyze the clinical characteristics of SPM in adolescents and the diagnostic implications of computed tomography (CT) and esophagography therein. MATERIALS AND METHODS: This retrospective descriptive study was conducted as a review of medical records of 416 adolescents (10-18 years of age) with chest pain from March 2005 to June 2013. Information on clinical presentation, methods of diagnosis, hospital stay, and outcomes were collected and analyzed. RESULTS: Among adolescents complaining of chest pain, 11 patients had SPM (11/416, 2.64%). All patients presented with pleuritic chest pain, and 54.5% reported neck pain as the most common associated complaint. Clinical findings were nonspecific, and initial chest X-ray assessment was diagnostic only in three of 11 patients. However, reassessment of chest X-ray revealed diagnostic findings of SPM in five of the remaining eight patients. CT was diagnostic in all patients, while esophagography and echocardiogram were uninformative. Symptomatic improvement was noted within 2.45+/-1.2 hours (range, 0.5 to 4) after supportive care; mean hospital stay was 4.54+/-0.99 days (range, 2 to 6). No recurrence was observed. CONCLUSION: SPM is a rare disease that should be considered in adolescent patients with pleuritic chest pain. Careful reading of initial chest X-rays is important to avoiding further unnecessary investigations. SPM is self-limited and treatment is supportive; nevertheless, if there are no indications of esophageal rupture, urgent esophagography is not recommended.
Adolescent ; Analgesics/*therapeutic use ; Chest Pain/diagnosis/*etiology ; Child ; Female ; Follow-Up Studies ; Humans ; Length of Stay ; Male ; Mediastinal Emphysema/complications/*diagnosis/*therapy ; Medical Records ; *Oxygen Inhalation Therapy ; Rare Diseases ; Retrospective Studies ; Risk Factors ; Tomography, X-Ray Computed ; Treatment Outcome

About one-third of patients with suspected gastro-oesophageal reflux disease (GERD) do not respond symptomatically to proton pump inhibitors (PPIs). Many of these patients do not suffer from GERD, but may have underlying functional heartburn or atypical chest pain. Other causes of failure to respond to PPIs include inadequate acid suppression, non-acid reflux, oesophageal hypersensitivity, oesophageal dysmotility and psychological comorbidities. Functional oesophageal tests can exclude cardiac and structural causes, as well as help to confi rm or exclude GERD. The use of PPIs should only be continued in the presence of acid reflux or oesophageal hypersensitivity for acid reflux-related events that is proven on functional oesophageal tests.
Chest Pain ; etiology ; Esophagus ; drug effects ; Gastroenterology ; methods ; Gastroesophageal Reflux ; diagnosis ; drug therapy ; Heartburn ; diagnosis ; drug therapy ; Humans ; Hydrogen-Ion Concentration ; Life Style ; Primary Health Care ; Proton Pump Inhibitors ; therapeutic use ; Surveys and Questionnaires