Síndrome coronariana aguda em paciente jovem com sintomas atípicos

Evaluation of acute chest pain can be extremely difficult and challenging. This diagnosis comprehends several causes, including benign and potentially lethal causes.Most of the time, the diagnosis can be done with the history and ordinary tests such as electrocardiogram, chest x-ray and myocardial enzymes. The coronary angiotomography is a new tool that can safely rule out acute coronary syndrome, beingperformed in patients with low to middle probability of acute coronary syndrome.The present report describes a young woman that presented to the emergency unit with atypical chest pain and myocardial enzyme elevation. Miocarditis was the initial diagnosisThe patient was submited to a coronary angiotomography with late enhancement research. The coronary angiotomography demonstrated zero calcium score with a high degree stenosis in the coronary descending artery and late enhancement inanterior wall demonstrating myocardial necrosis. It was performed coronary catheterization and angioplasty afterwards.O diagnóstico da dor torácica aguda no setor de emergência pode ser difícil e desafiador, incluindo diversos diagnósticos diferenciais, dentre eles: causas benignas a causas potencialmente fatais. O diagnóstico na maioria das vezesé estabelecido através do quadro clínico e de exames complementares como: marcadores de necrose miocárdica, eletrocardiograma e radiografia de tórax.A angiotomografia coronariana tem sido utilizada nos casos de dor torácica aguda com baixa ou intermediária probabilidade de síndrome coronariana aguda, permitindo sua exclusão e conseqüente alta precoce dos pacientes. Apresentamosrelato de caso de uma paciente jovem com dor precordial atípica e marcadores de necrose miocárdica discretamente elevados. Considerando-se a epidemiologia e o quadro clínico da paciente, foi feita hipótese diagnóstica inicial de miocardite. A angiotomografia cardíaca com pesquisa de realce tardiofoi solicitada. Apesar do escore de cálcio ter sido zero, foi diagnosticada lesão estenosante grave no terço médio da artéria coronária descendente anterior com realce tardio na parede anterior do ventrículo esquerdo, compatível comnecrose miocárdica. A paciente foi submetida a cateterismo com angioplastia da lesão

Increase in mortality due to myocardial infarction in the Brazilian city of São Paulo during winter

OBJECTIVE: To study the seasonal variation in mortality due to myocardial infarction in the city of São Paulo. METHODS: We analyzed the database of PROAIM (Programa de Aprimoramento de Informações de Mortalidade) containing the registrations of the certificates of deaths due to myocardial infarction (International Classification of Diseases, 10th edition, classification I21) of the residents of the municipality of São Paulo during 12 months (from December 1996 to November 1997). The number of deaths was corrected for a standard period of 90 days and then it was divided by the corresponding population to obtain the event rate per 10 thousand inhabitants. The magnitude of the seasonal variation, which was defined by the difference of the relative risks between the seasons with higher and lower mortality, was estimated. RESULTS: A total of 5,615 deaths due to myocardial infarction were included in the study. Sixty-one per cent occurred in the male sex, and the mean age was 68 years. The mortality rate during winter was always higher and that during summer was lower than that during the other seasons (P<0.01), independent from age and sex. Seasonal variations in deaths due to myocardial infarction was 30% in the general group, being 23% in individuals who died younger than 75 years, and 44% in the older ones. CONCLUSION: A marked seasonal variation in mortality due to myocardial infarction was observed in the city of São Paulo, with a significant increase in its magnitude and age distribution during the winter, similar to those reported in regions of North America and Europe with temperate climates

Acute coronary syndrome in young patients with atypical symptoms

Evaluation of acute chest pain can be extremely difficult and challenging. This diagnosis comprehends several causes, including benign and potentially lethal causes. Most of the time, the diagnosis can be done with the history and ordinary tests such as electrocardiogram, chest x-ray and myocardial enzymes. The coronary angiotomography is a new tool that can safely rule out acute coronary syndrome, being performed in patients with low to middle probability of acute coronary syndrome. The present report describes a young woman that presented to the emergency unit with atypical chest pain and myocardial enzyme elevation. Miocarditis was the initial diagnosis The patient was submited to a coronary angiotomography with late enhancement research. The coronary angiotomography demonstrated zero calcium score with a high degree stenosis in the coronary descending artery and late enhancement in anterior wall demonstrating myocardial necrosis. It was performed coronary catheterization and angioplasty afterwards

Escore de cálcio para avaliar dor torácica na sala de emergência

Alguns autores têm sugerido que um escore de cálcio (CAC) igual à zero pode ser usado para descartar o diagnóstico de síndrome coronariana aguda. Objetivo do estudo é avaliar a precisão do diagnóstico de um CAC zero quando comparado com a angiotomografia coronária (ATC) no Pronto-Socorro. 135 pacientes sintomáticos sem doença arterial coronariana (DAC) prévia atendidos no Pronto-Socorro, foram submetidos ao CAC e à ATC para descartar a DAC. Todos os pacientes tinham eletrocardiograma e marcadores cardíacos normais e apresentaram escore de risco TIMI de 0 a 2. A ATC foi considerada positiva no caso de identificação de qualquer lesão obstrutiva (> 50%). A média de idade era de 51,7 ± 13,6 anos, com 50,6% de homens. Setenta e três (54,1%) pacientes apresentaram um escore zero de cálcio. Desses, 3 (4,1%) tiveram uma obstrução > 50% e foram submetidos a angiografia coronária invasiva. O escore de cálcio mostrou uma sensibilidade de 92,9%, especificidade de 75,3% e valores preditivos positivos e negativos de, respectivamente, 62,9% e 95,9%. As razões de verossimilhança positiva e negativa foram respectivamente de 3,7 e 0,09 para a detecção de lesões maiores do que 50% na ATC. A razão de verossimilhança negativa de 0,09 é muito boa para descartar a maioria dos casos de obstrução coronária significativa em estudos epidemiológicos. No entanto, é importante entender que em um cenário clínico, todas as evidências, incluindo histórico, exame clínico, dados de biomarcadores miocárdicos e do eletrocardiograma, devem ser interpretados em conjunto. Em nosso estudo, três casos com um escore CAC zero tinham obstrução coronariana superior a 50% na ATC

Aortic dissection-induced acute flaccid paraplegia treated with cerebrospinal fluid drainage

Acute aortic dissection is a life-threatening event in which prompt and correctdiagnosis is associated with better outcomes. In most cases, there is chestor back pain. However, in rare cases, patients have little or no pain andother symptoms are more conspicuous at presentation. The autors reportsthe case of a 47-year-old female patient who sought medical attention forsudden-onset paraplegia. The physical examination was normal except forbilateral lower limb flaccid paralysis, with abolition of deep tendon reflexes andparaesthesia in both feet. Computed tomography showed aortic dissection,with partial thrombosis of the false lumen, starting after the emergence of theleft subclavian artery and extending, toward the bifurcation of the aorta, to theleft iliac artery. After cerebrospinal fluid drainage, the evolution was favorable

Espessura do Tecido Subcutâneo como Preditor Independente de \ud Ruído em Imagem de TC Cardíaca

Background: Few data on the definition of simple robust parameters to predict image noise in cardiac computed \ud tomography (CT) exist.\ud Objectives: To evaluate the value of a simple measure of subcutaneous tissue as a predictor of image noise in cardiac CT.\ud Methods: 86 patients underwent prospective ECG-gated coronary computed tomographic angiography (CTA) and coronary \ud calcium scoring (CAC) with 120 kV and 150 mA. The image quality was objectively measured by the image noise in the \ud aorta in the cardiac CTA, and low noise was defined as noise < 30HU. The chest anteroposterior diameter and lateral \ud width, the image noise in the aorta and the skin-sternum (SS) thickness were measured as predictors of cardiac CTA noise. \ud The association of the predictors and image noise was performed by using Pearson correlation.\ud Results: The mean radiation dose was 3.5 ± 1.5 mSv. The mean image noise in CT was 36.3 ± 8.5 HU, and the mean \ud image noise in non-contrast scan was 17.7 ± 4.4 HU. All predictors were independently associated with cardiac CTA noise. \ud The best predictors were SS thickness, with a correlation of 0.70 (p < 0.001), and noise in the non-contrast images, with a \ud correlation of 0.73 (p < 0.001). When evaluating the ability to predict low image noise, the areas under the ROC curve for \ud the non-contrast noise and for the SS thickness were 0.837 and 0.864, respectively.\ud Conclusion: Both SS thickness and CAC noise are simple accurate predictors of cardiac CTA image noise. Those parameters \ud can be incorporated in standard CT protocols to adequately adjust radiation exposure.Fundamento: Há poucos dados sobre a definição de parâmetros simples e robustos para predizer artefato de imagem \ud em tomografia computadorizada (TC) cardíaca.\ud Objetivos: Avaliar o valor da simples medida da espessura do tecido subcutâneo (espessura pele-esterno) como preditor \ud de artefato de imagem em TC cardíaca.\ud Métodos: O estudo avaliou 86 pacientes submetidos a angiotomografia computadorizada cardíaca (ATCC) com \ud sincronização prospectiva com ECG e avaliação de escore de cálcio coronário com 120 kV e 150 mA. A qualidade da \ud imagem foi medida objetivamente pelo artefato de imagem na aorta em ATCC, sendo ‘artefato baixo’ definido como \ud aquele < 30 UH. Os diâmetros torácicos anteroposterior e laterolateral, o artefato de imagem na aorta e a espessura \ud pele-esterno foram medidos como preditores de artefato em ATCC. A associação de preditores e artefato de imagem foi \ud avaliada usando-se correlação de Pearson.\ud Resultados: A dose média de radiação foi 3,5 ± 1,5 mSv. O artefato de imagem médio na ATCC foi de 36,3 ± 8,5 UH, \ud sendo o artefato de imagem médiona fase sem contraste do exame de 17,7 ± 4,4 UH. Todos os preditores foram \ud independentemente associados com artefato em ATCC. Os melhores preditores foram espessura pele-esterno, com \ud correlação de 0,70 (p < 0,001), e artefato de imagem na fases em contraste,com correlação de 0,73 (p < 0,001). \ud Ao avaliar a habilidade de predizer artefato de imagem baixo, as áreas sob a curva ROC para o artefato de imagem na \ud fases em contraste e para a espessura pele-esterno foram 0,837e 0,864, respectivamente.\ud Conclusão: Tanto espessura pele-esterno quanto artefato de escore de cálcio são preditores simples e precisos de \ud artefato de imagem em ATCC. Tais parâmetros podem ser incorporados aos protocolos de TC padrão para ajustar \ud adequadamente a exposição à radiação