Acute coronary syndrome of paradoxical origin.

We describe a rare case of acute myocardial infarction secondary to paradoxical embolism complicating acute pulmonary embolism. A 44-year-old woman presented to the emergency department with chest pain. The physical examination was unremarkable except for oxygen saturation of 75%, and the electrocardiogram showed ST-segment elevation in the inferior leads. Urgent coronary angiography showed a distal occlusion of the right coronary artery and multiple thrombi were aspirated. Despite relief of chest pain and electrocardiogram normalization, her oxygen saturation remained low (90%) with high-flow oxygen by mask. The transthoracic echocardiogram showed a mass in the left atrium and dilatation of the right chambers, while the transesophageal echocardiogram showed a thrombus attached to the interatrial septum in the region of the foramen ovale. Color flow imaging was consistent with a patent foramen ovale. Thoracic computed tomography angiography documented thrombi in both branches of the pulmonary trunk. After five days on anticoagulation, the patient underwent surgical foramen ovale closure.

Special program to reduce cardiology consultation waiting lists: report on an innovatory experience.

The problem of waiting lists has been widely debated in the Portuguese society. In this paper, the authors report the first results of a prioritization approach, started in March 2000. In this program cardiologists and general practitioners work in close proximity, coordinating efforts in order to improve the establishment of clinical priorities, and consequently optimize hospital referral. Working as cardiology consultants, the authors were able to reduce the number of first consultation requests by 77.9% (December 2002). For the first time it was possible to match the number of requests with the available consultation times, halting the growth of the waiting list.