Rationale: Coronary chest pain is usually ischemic in etiology and has various electrocardiographic presentations. Lately, it has been recognized that myocardial bridging (MB) with severe externally mechanical compression of an epicardial coronary artery during systole may result in myocardial ischemia. Such a phenomenon can be associated with chronic angina pectoris, acute coronary syndromes (ACS), coronary spasm, ventricular septal rupture, arrhythmias, exercise-induced atrioventricular conduction blocks, transient ventricular dysfunction, and sudden death. Patient concerns: We report the case of a 58-year-old woman presenting with recurrent episodes of constrictive chest pain during exercise within the last 2 weeks. Except for obesity, general and cardiovascular clinical examination on admission were normal. Diagnoses: The resting 12 lead electrocardiogram (ECG) revealed changes typically for Wellens syndrome. High-sensitive cardiac troponin I was normal. We established the diagnosis of low-risk non-ST-segment elevation acute coronary syndrome with a Global Registry of Acute Coronary Events risk score of 92 points. Interventions: The patient underwent coronary angiography, who showed subocclusive dynamic obstruction of the left anterior descending artery due to MB. Outcomes: The patient was managed conservatively. Her hospital course was uneventful and she was discharged on pharmacological therapy (clopidogrel, bisoprolol, amlodipine, atorvastatin, and metformin) with well-controlled symptoms on followup. Lessons: MB is an unusual cause of myocardial ischemia. Wellens syndrome is an unusual presentation of ACS. We present herein a rare case of Wellens syndrome caused by MB. This case highlights the importance of subtle and frequently overseen ECG findings when assessing patients with chest pain and second, the importance of considering nonatherosclerotic causes for ACS.

Tracheal stenosis is a rare complication of tracheal intubation, which usually becomes symptomatic after some time after detubation, with typical superior airway obstruction signs and symptoms. This is a case of a 62-yearold female with post intubation tracheal stenosis, with interesting problems of differential diagnosis until the final diagnostic was found. Clinical and imagistic investigations led us to our final diagnosis of iatrogenic post intubation tracheal stenosis.

Objectives: Objectives: Wellens syndrome has been described as a clinical and electrocardiographic complex that identifies a subset of patients with unstable angina (UA) at an impending risk of myocardial infarction (MI) and death in studies published almost four decades ago, before the wide use of cardiac biomarkers such as troponins. The clinical implications of Wellens sign in a contemporary cohort of patients with non-ST elevation acute coronary syndromes (NSTEACS) is yet to be defined.Materials and methods: We performed a prospective analysis of patients with acute coronary syndrome (ACS) and Wellens sign who underwent coronary angiography between January 2018 and December 2019. Patients follow-up visits were at one month and at six months. Clinical, electrocardiographic, biological and echocardiographic data were recorded at both follow-up visits.Results: A total of 79 patients were included in the statistical analysis, of whom 16 (20.25%) had pure Wellens syndrome (normal myocardial necrosis biomarkers). The prevalence of type A Wellens sign was higher than previously reported (45.6%). The culprit coronary artery was most frequently LAD (49 pts, 62.03%), followed by LM (10 patients, 12.66%), right coronary artery (RCA) (eight pts, 10.13%), instent restenosis (three pts, 3.8%), left circumflex artery (LCX) (two pts, 2.53%) and bypass graft (one pt, 1.27%). Ischaemic reccurence rate within six months was 18,99%. The rate of reccurent percutaneous revascularization procedures was 11.54% and the rate of repeat target vessel revascularization (TVR) was 5.77% at six months. All-cause mortality rate at six months was 7.59%, with 5.06% cardiovascular deaths.Conclusions: Early recognition of subtle ECG changes resembling Wellens sign in patients with chest pain is crucial as it reflects a large area of myocardium at risk. In our study, the culprit coronary artery was most frequently LAD (62.03%), with 36.7% proximal LAD culprit lesion, followed by LM (12.66%). Wellens syndrome should be considered a high risk condition that makes the conventional methods for risk assesment using risk scores unnecessary, useless and potentially deleterious. In our study, according to GRACE 1.0 risk score, 70.89% of patients were in the low risk group (1-108 points, estimated in-hospital death risk < 1%). No patient died during the initial hospitalization. All-cause mortality rate at six months was 7.59%, with 5.06% cardiovascular deaths.

Objective: The importance of the NT-proBNP value in detecting patients at risk of developing heart failure (HF) and its importance in guiding medical management to prevent the development of HF. Material and methods: The study is a prospective study and includes 314 patients who was presented at the Bagdasar-Arseni Emergency Hospital for cardiology consultation, by appointment, for a period of 3 years. The inclusion criteria were as follows: essential hypertension (diagnosed more than 5 years before), diabetes mellitus (insulin-deficient or under treatment with oral ant diabetics diagnosed more than 5 years before), ischemic heart disease, mild or moderate valvulopathy (mild or moderate mitral regurgitation and large or moderate aortic stenosis) and permanent or paroxysmal atrial fibrillation. Exclusion criteria were as follows: a previous diagnosis of heart failure or left ventricular systolic dysfunction, and the presence of signs or symptoms of heart failure at the time of enrollment in the study. Patients were randomized into 2 groups, a control group and a intervention group. Patients in the intervention group were managed according to the NT-proBNP value, and patients in the control group received the conventional intervention. Patients were monitored for 3 years and the following objectives were pursued: new diagnosis of heart failure, systolic or diastolic dysfunction of the left ventricle and hospitalization for cardiovascular pathology. Results: After 3 years, in the control group there were 40 patients (25.5%) who developed HF, compared to 28 patients (17.8%) in the intervention group. In the control group, 60 patients (38.2%) were diagnosed with left ventricular systolic dysfunction, compared to 43 patients (27.4%) in the intervention group. Regarding left ventricular diastolic dysfunction, in the control group there were 98 patients (62.4%), and in the intervention group there were 80 patients (51.0%). Also, the rate of hospitalizations for cardiovascular pathology was higher in the control group, 56 patients (35.7%), compared to 33 patients (21.0%) in the intervention group. Discussions: The incidence of heart failure, left ventricular systolic or diastolic dysfunction, or hospitalizations for cardiovascular events, was lower in the intervention group, in which patients were managed according to the NT-proBNP value, compared to patients in the control group who received conventional intervention. Conclusions: The NT-proBNP biomarker may be useful in the medical management of patients for the prevention of heart failure.