RESUMO
A 26-year-old woman, a well-trained runner, had a sudden cardiac arrest just before crossing the finish line of a marathon. She was rapidly resuscitated and was later found to have an ectopic origin of the left coronary artery. This anomaly was surgically repaired by translocating the ostium from the right to the left sinus of Valsalva. Her difficult postoperative course prompted further coronary evaluation, which revealed severe stenosis of the neoostium. The patient underwent a second operation: this time, the stenosis was bypassed via a left internal mammary artery-to-left anterior descending coronary artery (LAD) graft. Hypoplasia of the LAD and spasm during manipulation caused the graft to fail, necessitating double-stent angioplasty of the left main ostium and the LAD 2 months later. At the patient's 6-month follow-up examination, she had no further evidence of functional ischemia, and she resumed jogging. Because the mode and mechanism of the patient's condition and events were documented in unusual detail, this case furthers our understanding of sudden cardiac arrest in athletes who have rare coronary anomalies. We conclude that ectopia of a coronary artery does not itself cause potentially fatal ischemia. Rather, these events are due to the ectopic artery's intramural proximal course within the aortic media, which might result in critical stenosis by means of hypoplasia or lateral compression of the artery.
Assuntos
Anomalias dos Vasos Coronários , Morte Súbita Cardíaca/etiologia , Isquemia Miocárdica , Enxerto Vascular/métodos , Vasoconstritores/uso terapêutico , Fibrilação Ventricular , Adulto , Reanimação Cardiopulmonar/métodos , Angiografia Coronária/métodos , Anomalias dos Vasos Coronários/complicações , Anomalias dos Vasos Coronários/diagnóstico por imagem , Anomalias dos Vasos Coronários/fisiopatologia , Anomalias dos Vasos Coronários/cirurgia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/cirurgia , Eletrocardiografia/métodos , Circulação Extracorpórea/métodos , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Imageamento por Ressonância Magnética/métodos , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/etiologia , Isquemia Miocárdica/fisiopatologia , Isquemia Miocárdica/cirurgia , Seio Aórtico/diagnóstico por imagem , Seio Aórtico/cirurgia , Esportes , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Fibrilação Ventricular/diagnóstico , Fibrilação Ventricular/etiologia , Fibrilação Ventricular/fisiopatologia , Fibrilação Ventricular/terapiaRESUMO
OBJECTIVES: Patients with ST elevation (STE) in ≥ 2 leads or ST depression (STD) confined to V1-V4 are defined as potential STE myocardial infarction (STEMI). We evaluated the incidence of missed STEMI over an 11-month period. METHODS: Consecutive patients with a discharge diagnosis of non STEMI were retrospectively evaluated. Clinical data, ECG and angiographic data were reviewed. RESULTS: Of the 198 patients screened, 140 were included. Forty-nine patients (35%) met the STEMI criteria: 6 (12%) had STD confined to V1-V3, 20 (41%) had STD in V1-V6, 7 (14%) had STE in V1-V3, 2 (4%) had STE in I and aVL, 11 (22%) had STE in inferior leads, and 6 (12%) had STE in V4-V6. CONCLUSIONS: A significant percentage of patients met STEMI ECG criteria. A large number of patients with STD in V1-V6 had angiographic evidence compatible with inferolateral (posterior) STEMI equivalent.
Assuntos
Erros de Diagnóstico/prevenção & controle , Erros de Diagnóstico/estatística & dados numéricos , Eletrocardiografia/estatística & dados numéricos , Infarto do Miocárdio/diagnóstico , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Fatores de Risco , Sensibilidade e Especificidade , Texas/epidemiologiaRESUMO
Current guidelines state that patients with compatible symptoms and ST-segment elevation (STE) in ≥2 contiguous electrocardiographic leads should undergo immediate reperfusion therapy. Aggressive attempts at decreasing door-to-balloon times have led to more frequent activation of primary percutaneous coronary intervention (pPCI) protocols. However, it remains crucial to correctly differentiate STE myocardial infarction (STEMI) from nonischemic STE (NISTE). We assessed the ability of experienced interventional cardiologists in determining whether STE represents acute STEMI or NISTE. Seven readers studied electrocardiograms of consecutive patients showing STE. Patients with left bundle branch block or ventricular rhythms were excluded. Readers decided if, based on electrocardiographic results, they would have activated the pPCI protocol. If NISTE was chosen, readers selected from 12 possible explanations as to why STE was present. Of 84 patients, 40 (48%) had adjudicated STEMI. The percentage for which readers recommended pPCI varied (33% to 75%). Readers' sensitivity and specificity ranged from 55% to 83% (average 71%) and 32% to 86% (average 63%), respectively. Positive and negative predictive values ranged from 52% to 79% (average 66%) and 67% to 79% (average 71%), respectively. Broad inconsistencies existed among readers as to the chosen reasons for NISTE classification. In conclusion, we found wide variations in experienced interventional cardiologists in differentiating STEMI with a need for pPCI from NISTE.
