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El infarto agudo de miocardio en ausencia de enfermedad coronaria obstructiva (MINOCA) representa un reto diagnóstico en la práctica clínica. En su abordaje diagnóstico se incluye la documentación de un sustrato isquémico, con un tratamiento que debe ser específico según la etiología identificada. Un grupo de estos pacientes presenta isquemia secundaria a una alteración en la relación aporte/ demanda de oxígeno. Se presenta el caso de una paciente de sexo femenino y mediana edad, con hipertiroidismo severo y tirotoxicosis, que debuta con un síndrome coronario agudo, con troponina T marcadamente elevada y arterias coronarias sin lesiones significativas en la coronariografía. El tratamiento fue dirigido a manejar la causa desencadenante, de manera inicialmente farmacológica y posteriormente quirúrgica, con resolución total del cuadro, mejoría sintomática de la paciente y disminución de los biomarcadores cardíacos.

The diagnosis of ischemic cardiomyopathy is not well established. Our objective is to determine predictive variables of coronary disease in unselected patients with ventricular dysfunction. This study is a retrospective cohort study of consecutive patients with left ventricular dysfunction and no known history of ischemic heart disease. We analyse the demographic variables, clinical data, electrocardiogram, and echocardiogram that are associated with the presence of coronary stenosis on coronary angiography. A total of 536 patients with left ventricular dysfunction were studied, with 135 (25.2%) of them having significant coronary lesions. In the multivariate logistic regression analysis, age ≤ 50 years, female gender, and the presence of atrial fibrillation on the electrocardiogram (ECG) were predictors of the absence of coronary lesions. Diabetes, hypercholesterolemia, the existence of Q waves in the ECG, and segmental alterations in contractility in the echocardiogram were predictors of coronary heart disease (C-Statistics 0.771, 95% CI 0.727 to 0.814). The information obtained from the clinical history, the ECG, and the echocardiogram of patients with ventricular dysfunction allows us to select subjects in whom coronary angiography has shown poor performance in diagnosing coronary disease.

Kounis syndrome is defined as the coincidental occurrence of allergic reaction and acute coronary syndrome secondary to vasospasm. Anti-inflammatory drugs are included as one of the multiple causes. Current data available about this syndrome come from case reports. We present the case of a patient who suffered Kounis syndrome with cardiogenic shock and asystole after intravenous infusion of Metamizole, and in which no lesions were observed in coronariography. Resumo: A síndrome de Kounis é definida como a ocorrência concomitante de reação alérgica e síndrome coronariana aguda secundária ao vasoespasmo. Os medicamentos anti-inflamatórios estão incluídos como uma das múltiplas causas. Os dados atuais disponíveis sobre essa síndrome são provenientes de relatos de casos. Apresentamos o caso de um paciente que apresentou síndrome de Kounis com choque cardiogênico e assistolia após infusão intravenosa de metamizol, e no qual não foram observadas lesões na coronariografia. Keywords: Kounis syndrome, Metamizole, Cardiogenic shock, Asystole, Palavras-chave: Síndrome de Kounis, Metamizol, Choque cardiogênico, Assistolia

La punción percutánea de la arteria radial para la realización de procedimientos por cateterismo ha ganado mayor aceptación en los últimos tiempos. Esto sucedió como consecuencia de haber alcanzado resultados similares a los obtenidos mediante el acceso femoral, con los beneficios de una menor tasa de complicaciones y mayor confort de los pacientes. Recientemente, su utilización tomó un impulso adicional, por estar asociada a mejor pronóstico en síndromes coronarios agudos. En el presente trabajo hemos evaluado si la factibilidad, resultados y ventajas relacionadas al acceso percutáneo de la arteria radial en procedimientos por cateterismo, se aplican también a quienes presentan disección previa de la arteria humeral. Sobre un total de 1 356 accesos radiales percutáneos, 53 fueron en pacientes con disección previa de la arteria humeral, obteniéndose éxito del acceso en el 96.2% (51/53) de las punciones. A través de estos accesos se realizaron 71 procedimientos por cateterismo, con 93.6% (44/47) de éxito del procedimiento en las intervenciones diagnósticas y 100% (24/24) en las terapéuticas. En este grupo no ocurrieron complicaciones mayores. Las complicaciones menores sucedieron en el 1.4% (1/71) de los casos y no se registraron nuevas complicaciones en el seguimiento a siete días. Si bien el grupo es pequeño, consideramos que resulta suficiente para mostrar que las punciones percutáneas de la arteria radial para la realización de procedimientos por cateterismo, en pacientes con disección previa de la arteria humeral, son factibles y permiten elevadas tasas de éxito con baja frecuencia de complicaciones.The percutaneous punction of the radial artery for catheterization procedures has gained acceptance lately. This was a consequence of achieving results similar to the femoral approach, with the benefits of a lower rate of complications and increased comfort for the patients post procedure. Recently it has gained an additional impulse with the better prognosis obtained in acute coronary syndromes. In this trial we have evaluated if the feasibility, results and advantages related with the use of the radial artery percutaneous approach to perform catheterization procedures, continues when used in patients who have had a previous brachial artery cutdown. Out of a total of 1356 percutaneous radial accesses, 53 were in patients with previous brachial artery cutdown. Through this access 71 catheterization procedures were performed, achieving access success in 96.2% (51/53) of the punctions. Once the access success was obtained, 93.6% (44/47) of the diagnostic procedures and 100% (24/24) of the therapeutics procedures were successful. During hospitalization, in this group of patients, no major adverse cardiac events occurred and there was a 1.4% (1/71) rate of minor events. At seven days follow up, no new complications were recorded. Although this is a small group, we believe that it is enough to show that percutaneous punctions of the radial artery to perform catheterization procedures, in patients with previous brachial artery cutdown, are feasible, allowing high access and procedure success rates, with a low frequency of complications.

El síndrome coronario agudo con elevación de ST (SCACEST) es una entidad clínica que rara vez se observa en mujeres embarazadas, pero cuya manifestación constituye una situación de alto riesgo materno-fetal. El manejo farmacoterapéutico de estas pacientes es difícil y requiere una atención individualizada por parte de un equipo multidisciplinar, puesto que muchos de los tratamientos estándar se incluyen dentro de las categorías de teratogenicidad C o D de la Food and Drug Administration, y es escasa la experiencia con técnicas como la angioplastia coronaria con colocación de stent. Se describe el caso de una mujer de 32 años, gestante de 11 semanas y diagnosticada de SCACEST, así como el abordaje terapéutico de la misma. Además se revisa la información disponible sobre la epidemiología, etiología y fisiopatología del SCACEST durante el embarazo y el papel específico de las opciones de tratamiento disponibles actualmente. ST segment elevation acute coronary syndrome is a clinical condition that is rarely observed in pregnant women. However, its manifestation is a situation of high maternal-fetal risk. Pharmacotherapeutical management of these patients is difficult and requires individualized care by a multidisciplinary team since many of the standard treatments are included within the categories of teratogencity C or D of the Food and Drug Administration and experience with techniques such as coronary angioplasty with stent placement is scarce. The case of a 32-year woman who was 11 weeks pregnant and diagnosed of acute coronary syndrome with ST segment and its therapeutic approach are described. Furthermore, the information available on epidemiology, etiology and pathophysiology of acute coronary syndrome with ST segment during pregnancy and the specific role of the currently available treatment options are reviewed.

Coronary aneurysms are uncommon. The most frequent etiologies are atherosclerotic and congenital, although there are several other rare causes. Myocardial infarction and sudden death may be the initial manifestations which are usually a consequence of aneurysm complications such as rupture or distal embolization. Although coronariography is the gold standard diagnostic technique, coronary aneurysm may also be detected by non-invasive methods such as ultrasonography and nuclear magnetic resonance. We report the case of a young male with hypercholesterolemia who presented cardiac arrest as the first clinical manifestation. Ultrasonography and MRI revealed the presence of multiple coronary aneurysm. This case illustrates the usefulness of non-invasive techniques for the diagnosis of coronary aneurysm.

INTRODUCTION AND OBJECTIVES An angiographic algorithm of clinical utility, applicable to conventional coronariography, is proposed to establish different patterns of coronary distribution depending on the characteristics of the myocardial perfusion, considering the starting point as the segmentary classification of the arterial irrigation of the left ventricle. METHODS To validate this system of classification, 30 hearts coming from necropsy were studied, through anatomical and angiographical analysis. The average age of the population studied was of 69.8 +/- 14.6 years. The range was between 26 and 91 years. To study them, the hearts were unrolled and after a coronariography and a dissection of the coronary arterial tree, the identification of the perfusion mode--exclusive or shared--of every left ventricle segment was done. Then an algorithm based on the type of division of the left main branch, and on the type of perfusion of the left ventricle inferobasal segment was applied to the angiographic frames. There was statistical analysis of the data obtained in the anatomic and angiographic studies. To verify the applicability of the algorithm, it was employed to successive series of 100 coronariographies in vivo, and these were then compared to the results obtained with the necropsy series. RESULTS The statistical comparison between the percentages of the classification obtained from both analyses of the necropsy series showed no significant differences. The statistical comparison of the percentages of the classification obtained between the in vivo and post-mortem analyses did not show any significant difference either. CONCLUSIONS The angiographical algorithm developed allows to classify the myocardial perfusion of the left ventricle, by the conventional coronary arteriography, in three groups of clinical interest. The classification is based on the predominance of the left ventricular segments exclusively irrigated by: the anterior interventricular artery (type I), the circumflex artery (type II), or a balance between both arteries (type III). The angiographic projections in left anterior oblique with caudal angulation and right anterior oblique are important for its application. The classification of the ventricular perfusion established with the developed algorithm can be validated as being equivalent to the one obtained through the anatomical series.

Resumen —Presentamos un paciente de 55 anos, de sexo masculino, al que le aparecieron dos placas de aspecto poiquilodermico a ambos lados del costado derecho, tras la practica de dos angioplastias percutaneas y coronariografia debido a enfermedad isquemica coronaria. (Actas Dermosifiliogr 2001;92:291-293).

Aneurysm of the left main coronary artery is a rare angiographic finding, with few cases described in the international literature. We report the case of a 42-year-old male with a previous history of acute myocardial infarction, whose coronariography indicated triple vessel coronary disease and an aneurysm of the left main coronary artery. A review of the etiology, clinical aspects, and surgical management of coronary arterial aneurysm is presented.

OJBETIVOS: Demonstrar nossa experiência com o implante da artéria torácica interna, para revascularização do miocárdio, procedimento proposto por Vineberg, em 1946. CASUÍSTICA E MÉTODO: De agosto de 1994 a setembro de 1998, foram operados 10 pacientes nos quais foi implantada a artéria torácica interna esquerda na parede ântero-lateral do ventrículo esquerdo. Em todos esses pacientes também foi feito enxerto de safena aorto-coronária. A idade dos pacientes variou de 42 a 73 anos, tendo sexo masculino prevalecido (60%). Todos os pacientes apresentavam doença coronária arterosclerótica difusa, mas com miocárdio viável. A indicação para o implante de artéria torácica interna foi feita durante a operação, devido a impossibilidade de fazer enxerto ou endarterectomia. RESULTADOS: Todos os pacientes estavam muito bem no pós-operatório imediato. O reestudo angiográfico foi feito em 9 pacientes entre 45 dias e 23 meses de pós-operatório, mostrando patência da artéria implantada e uma vasta rede que se comunicava com a coronária nativa. CONCLUSÃO: O implante de artéria torácica interna em miocárdio viável pode ter lugar no arsenal terapêutico da revascularização miocárdica, em casos especiais. Agora, baseados nos erros do passado, podemos selecionar os pacientes e obter melhores resultados. É uma técnica pouco estudada, que deveria ser mais usada, assim possibilitando uma avaliação mais precisa de sua eficácia. OBJECTIVE: To demonstrate our experience with the myocardial revascularization using the implantation of left internal mammary artery. This procedure was proposed by Vineberg, in 1946. MATERIAL AND METHODS: From August 1994 to September 1998, 10 patients were operated on, all of them had the left internal mammary artery implanted in the anterolateral part of the wall of the left ventricle and all of them had a saphenous vein bypass graft. The age of the patients ranged from 42 years to 73 years with the prevalence of males. All patients had a diffuse and severe coronary artery disease mainly of the interventricular (descending) anterior artery, but with myocardial viability. The indication for internal mammary implantation was made during the procedure, because the techniques as saphenous vein bypass or endarterectomy were not considered applicable to these cases. RESULTS: All the patients were very well in the post operative period; from 45 days to 23 months, coronariography study were performed on nine patients, showing the implanted internal mammary artery arborizing and communicating with the native coronary arteries. CONCLUSION: The internal mammary artery implanted in a viable myocardium should have its place on myocardial revascularization treatment, in selected cases. Nowadays, observing the misinterpretation on the past papers, we can select the patients with appropriate indication for this technique, obtained good results. The Vineberg technique needs more experience to define the evaluation of its real effectiveness.

OBJETIVO: Avaliar o efeito da cirurgia de revascularização miocárdica (CRM) sobre episódios isquêmicos assintomáticos (EIA). MÉTODOS: Foram estudados 28 homens, com angina estável (idade média 57,3±9,6) anos sem condições relacionadas a alterações de microcirculação e que, após retirada da medicação, apresentaram EIA à eletrocardiografia ambulatorial (ECGA). No pré-operatório e 4 meses após a cirurgia foram analisados os comportamentos dos EIA, segundo sua freqüência, e o de suas freqüências cardíacas (FC). A revascularização miocárdica foi completa em 75% dos casos. RESULTADOS: O número dos EIA foi reduzido de 162 (9 sintomáticos) no pré-operatório para, apenas, 4 no pós-operatório (p

Investigação qualitativa exploratória com o objetivo de identificar o conhecimento dos pacientes que se submetem a coronariografia no Laboratório de Hemodinâmica de um Hospital Público. Após aprovação do Comitê de Ética e Pesquisa, efetivou-se a coleta de dados por entrevista semi-estruturada com os pacientes maiores de 18 anos, portadores de cardiopatias encaminhados pela primeira vez para realização eletiva de coronariografia. O número de participantes totalizou 15 (quinze), determinado por saturação dos dados. Na Análise Temática, foram explorados os temas desconhecimento dos pacientes sobre o exame coronariografia e importância da orientação prévia no conhecimento dos pacientes. Concluiu-se que os profissionais de enfermagem necessitam revigorar a sua capacidade de comunicação com os pacientes. Pode-se corroborar que a orientação adequada minimizaria o desconhecimento dos pacientes acerca do exame coronariografia. Há necessidade de estudos que validem modos de efetivar orientações articulados à diminuição da ansiedade e insegurança do paciente e das complicações do procedimento.

To analyze the related assistance times to transfer patients with STEMI referred to another hospital with a hemodynamics unit (HU) for performing emergency catheterization (primary or rescue PCI).