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LETTER TO EDITOR
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 174-175

An unusual case of recurrent chest pain


Department of Cardiology, Eugene Clinic, Coimbatore, Tamil Nadu, India

Date of Web Publication13-Dec-2018

Correspondence Address:
Dr. Arunkumar Panneerselvam
Eugene Clinic, 6, Agraharam, Mettupalayam, Coimbatore, Tamil Nadu 641301
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IHJI.IHJI_6_18

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How to cite this article:
Panneerselvam A. An unusual case of recurrent chest pain. Indian Heart J Interv 2018;1:174-5

How to cite this URL:
Panneerselvam A. An unusual case of recurrent chest pain. Indian Heart J Interv [serial online] 2018 [cited 2019 Sep 16];1:174-5. Available from: http://www.ihji.org/text.asp?2018/1/2/174/247456



Dear Editor,

A 41-year-old male, nonsmoker, presented with recurrent paroxysmal episodes of retrosternal chest discomfort, not related to exertion, and lasting for few minutes. His clinical examination during the episode was normal except for tachycardia and sweating. The electrocardiogram showed sinus tachycardia with a heart rate of 128 beats per minute (bpm). No ST-T changes were observed. Serial troponin T levels were normal. Baseline blood investigations including lipid profile were normal. He was subjected to treadmill exercise electrocardiogram to ascertain the cause of chest pain. He exercised very well on treadmill, achieving 12 metabolic equivalents. Although he complained of nonspecific pricking pain during the exercise, no ST-T changes were observed [Figure 1]. Echocardiography showed normal left ventricular systolic function with no wall motion abnormality. In view of no major cardiovascular risk factors, atypical nature of chest pain, and normal exercise stress test, he was treated with antacid and anxiolytics. However, despite treatment, he continued to have similar episodes with significant chest discomfort. In view of recurrent episodes of undiagnosed chest discomfort, he was subjected to a coronary angiogram. During coronary angiography, immediately after radial access, he started having chest discomfort with sinus tachycardia. Coronary angiogram was performed, which revealed grade III[1] mid-left anterior descending coronary artery myocardial bridging [Figure 2] and [Figure 3]. No plaque was observed. He was started on extended-release metoprolol and dose was titrated to 100mg/day to achieve a resting heart rate of 60–70 bpm. After initiation of the beta-blocker therapy, he became completely asymptomatic.
Figure 1: Peak exercise electrocardiogram showing no ST-T changes

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Figure 2: Coronary angiogram diastolic frame showing normal left anterior descending coronary artery

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Figure 3: Systolic frame showing grade III mid-left anterior descending artery bridging

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Myocardial bridging is a condition where a segment of coronary artery travels through the myocardium. This can be diagnosed noninvasively by multidetector computed tomogram. But more often, it is an incidental finding in coronary angiogram and does not require treatment in asymptomatic patients. In symptomatic patients, beta-blockers and calcium channel blockers are cornerstone of the therapy. If the patient has refractory symptoms, then myotomy is the treatment of choice if feasible. In our case, it was odd that the patient did not develop any chest discomfort or ST-T changes during the exercise test, despite achieving very good level of exercise. Yet, he continued to have significant symptoms on minimal exertion or even at rest. This case suggests that myocardial bridge should be one of the differential diagnoses in cases of atypical, recurrent, and unexplained chest pain.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Noble J, Bourassa MG, Petitclerc R, Dyrda I. Myocardial bridging and milking effect of the left anterior descending coronary artery: Normal variant or obstruction? Am J Cardiol 1976;1:993-9.  Back to cited text no. 1
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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