Chest pain: if it is not the heart, what is it?

Introduction: Chest pain is one of the most common reasons for presenting in the emergency room, but noncardiac causes are often difficult to diagnose, which may be pulmonary, musculoskeletal, gastrointestinal and psychiatric disorders. Among the emergency room presentations, the noncardiac chest pain one ranges between 20 and 55% in literature.

Methods: We present the case of a 75 year old pati-ent admitted on the cardiology department for inter-mittent resting chest pain, posterior irradiation, 5/10 intensity and general condition alteration, 2 day on-set and progressively aggravated symptomatology. No documented pathological history.: Clinical examina-tion at presentation shows a moderately altered gene-ral condition, afebrile, normally colored teguments, BP=90/60 mmHg, regulat heart sounds with HR=95 bpm, no cardiac murmurs, soft abdomen, slightly pa-infull at the palpation to the epigastric area, no signs of petioneal irritation, mild hepatomegaly. Biological samples show acute inflammatory syndrome, severe thrombocytopenia, hepatic cytolysis, nitrate retention, hypokalemia, negative myocardial necrosis enzymes in dynamics. Echocardiography reveals normal dimensi-ons of the left ventricle with preserved systolic function (55% EF) with no segmental kinetic changes, normal right chambers with preserved systolic function, nor-mal aorta, and normal pericardium.

Results: Electrocardiogram: sinus tachycardia, no ter-minal changes, similar in dynamics. The abdominal ul-trasound showed a mass in the hepatic left lobe of 5.2/4 cm with irregular contours and a non-homogeneous structure, hypoecogenic with 2-3 mm transonic areas inside of it, without free fluid in the peritoneal cavity. An abdominal computer tomography is performed that detects in the II-III hepatic segments a spontane-ous intense hyperdense linear image with a suggesti-ve appearance of a foreign body, and adjacent to this a pseudonodular, hypodensial, hypocaptant area with a suggestive appearance of hepatic abscess. Thus, clinical and paraclinical investigations invalidate the cardiac origin of the pain and therefore sepsis with multiple or-gan failure is considered and antibiotic treatment, pla-telet transfusion and hydroelectrolytic rebalancing are initiated. Evolution was favorable with hemodynamic stability. Surgery consult is requested and then the pati-ent is transferred in order to receive the specialty treat-ment. It was performed a laparoscopic surgery and the video-inspection shows a fluctuating tumor formation which was punctured in order to remove the pus; the remaining cavity is explored and a foreign body with dimensions of about 3/0.3 cm with bone aspect is visu-alized. P ostoperative the patient has a favorable evo-lution under antibiotic and anti-inflammatory therapy. Conclusions: In conclusion, we presented a patient who was admitted to the cardiology department with suspicion of acute coronary syndrome, which, following the investigations, we found a gastrointestinal cause of the chest pain, namely a hepatic abscess with a foreign body. It is vital that when we have a patient presenting with chest pain in the emergency room it is recommen-ded to be thoroughly evaluated clinically and the elec-trocardiogram must be done as quickly as possible. In case of patients with non-cardiac chest pain we have to maintain a high level of suspicion and often require effective collaboration between several specialties.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)
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