Myocardial scintigraphy in the evaluation of cardiac events in patients without typical symptoms.

BACKGROUND: Cardiovascular disease is a leading cause of death in the world and in Brazil. Myocardial scintigraphy is an important noninvasive method for detecting ischemia in symptomatic patients, but its use in asymptomatic ones or those with atypical symptoms is yet to be defined. OBJECTIVE: To verify the presence of major cardiac events in asymptomatic patients or those with atypical symptoms (atypical chest pain or dyspnea) that underwent myocardial scintigraphy (MS), over a period of 8 years. Secondary objectives were to identify cardiac risk factors associated with myocardial scintigraphy abnormalities and possible predictors for major cardiac events in this group. METHODS: This was a retrospective, observational study using the medical records of 892 patients that underwent myocardial scintigraphy between 2005 and 2011 and who were followed until 2013 for assessment of major cardiac events and risk factors associated with myocardial scintigraphy abnormalities. Statistical analysis was performed by Fisher's exact test, logistic regression and Kaplan-Meyer survival curves, with statistical significance being set at p ≤ 0.05. RESULTS: Of the total sample, 52.1% were men, 86.9% were hypertensive, 72.4% had hyperlipidemia, 33.6% were diabetic, and 12.2% were smokers; 44.5% had known coronary artery disease; and 70% had high Framingham score, 21.8% had moderate and 8% had low risk. Of the myocardial scintigraphies, 58.6% were normal, 26.1% suggestive of fibrosis and 15.3% suggestive of ischemia. At evolution, 13 patients (1.5%) had non-fatal myocardial infarction and six individuals (0.7%) died. The group with normal myocardial scintigraphy showed longer period of time free of major cardiac events, non-fatal myocardial infarction (p = 0.036) and death. Fibrosis in the myocardial scintigraphy determined a 2.4-fold increased risk of non-fatal myocardial infarction and five-fold higher risk of death (odds ratio: 2.4 and 5.7, respectively; p = 0.043). CONCLUSION: The occurrence of major cardiac events in 8 years was small. Patients with fibrosis at MS had more major events, whereas patients with normal MS result had fewer major cardiac events, with higher survival.

Miocardiopatía hipertrófica. Reporte de caso / Hypertrophic cardiomyopathy. Case report / Cardiomiopatia hipertrófica. Relato de caso

Resumen: La miocardiopatía hipertrófica (MCH) es una enfermedad hereditaria común que ocurre en 1 de cada 500 individuos y afecta a ambos sexos. Se presenta con hipertrofia ventricular izquierda (HVI) en ausencia de otra enfermedad cardíaca o sistémica capaz de explicarla. Sus manifestaciones clínicas son variadas, desde la HVI asintomática o la insuficiencia cardíaca progresiva hasta la muerte súbita cardíaca. Los síntomas comunes incluyen disnea, dolor torácico, palpitaciones, presíncope y síncope. La mayoría de las veces la HVI se evidencia durante la adolescencia o la juventud. Se describe el caso de un paciente de 43 años que presentó una urgencia hipertensiva sin historia previa de hipertensión arterial sistémica. Por medio de exámenes complementarios, se diagnosticó MCH medioapical sin obstrucción del tracto de salida del ventrículo izquierdo.

Summary: Hypertrophic cardiomyopathy is a common inherited disease, which occurs in 1 in 500 individuals and affects both sexes. It presents with left ventricular hypertrophy in the absence of another cardiac or systemic disease capable of producing an increase in the thickness of the left ventricle wall. The clinical manifestations of hypertrophic cardiomyopathy are varied, from asymptomatic left ventricular hypertrophy or progressive heart failure to sudden cardiac death. Common symptoms include dyspnea, chest pain, palpitations, pre-syncope and syncope. Most of the time, left ventricular hypertrophy is evident during adolescence or youth. We describe the case of a male patient of 43 years, who presented a hypertensive emergency without previous history of systemic arterial hypertension. Through complementary exams, hypertrophic middle-apical myocardiopathy was diagnosed without obstruction of the left ventricular outflow tract.

Resumo: A cardiomiopatia hipertrófica é uma doença hereditária comum que ocorre em 1 em 500 indivíduos e afeta ambos os sexos. Apresenta-se com hipertrofia ventricular esquerda na ausência de outra doença cardíaca ou sistêmica capaz de explica-la. Suas manifestações clínicas são variadas, desde hipertrofia ventricular esquerda assintomática ou insuficiência cardíaca progressiva até morte súbita cardíaca. Os sintomas mais comuns incluem dispnéia, dor torácica, palpitações, pré-síncope e síncope. Na maioria das vezes, a hipertrofia ventricular esquerda é evidente durante a adolescência ou juventude. Descrevemos o caso de um paciente masculino de 43 anos, que apresentou uma urgência hipertensiva sem história prévia de hipertensão arterial sistêmica. Por meio de exames complementares, diagnosticou-se cardiomiopatía hipertrófica medio-apical sem obstrução da via de saída do ventrículo esquerdo.

Myocardial Scintigraphy in the Evaluation of Cardiac Events in Patients without Typical Symptoms / Cintilografia Miocárdica na Avaliação de Eventos Cardíacos em Pacientes sem Sintomas Cardíacos Típicos

AbstractBackground:Cardiovascular disease is a leading cause of death in the world and in Brazil. Myocardial scintigraphy is an important noninvasive method for detecting ischemia in symptomatic patients, but its use in asymptomatic ones or those with atypical symptoms is yet to be defined.Objective:To verify the presence of major cardiac events in asymptomatic patients or those with atypical symptoms (atypical chest pain or dyspnea) that underwent myocardial scintigraphy (MS), over a period of 8 years. Secondary objectives were to identify cardiac risk factors associated with myocardial scintigraphy abnormalities and possible predictors for major cardiac events in this group.Methods:This was a retrospective, observational study using the medical records of 892 patients that underwent myocardial scintigraphy between 2005 and 2011 and who were followed until 2013 for assessment of major cardiac events and risk factors associated with myocardial scintigraphy abnormalities. Statistical analysis was performed by Fisher’s exact test, logistic regression and Kaplan-Meyer survival curves, with statistical significance being set at p ≤ 0.05.Results:Of the total sample, 52.1% were men, 86.9% were hypertensive, 72.4% had hyperlipidemia, 33.6% were diabetic, and 12.2% were smokers; 44.5% had known coronary artery disease; and 70% had high Framingham score, 21.8% had moderate and 8% had low risk. Of the myocardial scintigraphies, 58.6% were normal, 26.1% suggestive of fibrosis and 15.3% suggestive of ischemia. At evolution, 13 patients (1.5%) had non-fatal myocardial infarction and six individuals (0.7%) died. The group with normal myocardial scintigraphy showed longer period of time free of major cardiac events, non-fatal myocardial infarction (p = 0.036) and death. Fibrosis in the myocardial scintigraphy determined a 2.4-fold increased risk of non-fatal myocardial infarction and five-fold higher risk of death (odds ratio: 2.4 and 5.7, respectively; p = 0.043).Conclusion:The occurrence of major cardiac events in 8 years was small. Patients with fibrosis at MS had more major events, whereas patients with normal MS result had fewer major cardiac events, with higher survival.

ResumoFundamento:A doença cardiovascular é uma das principais causas de óbito no Brasil e no mundo. A cintilografia miocárdica tem papel estabelecido na detecção de isquemia de pacientes sintomáticos, mas sua indicação em assintomáticos ou naqueles com sintomas atípicos ainda não está definida.Objetivo:Identificar eventos maiores em pacientes assintomáticos ou com sintomas atípicos (dor torácica atípica ou dispneia) que realizaram cintilografia miocárdica, em até 8 anos. Como objetivos secundários, citamos identificar os fatores de risco associados às alterações na cintilografia miocárdica e os possíveis preditores para eventos maiores nesse grupo.Métodos:Estudo retrospectivo, observacional, por revisão de prontuário, de 892 pacientes que realizaram cintilografia miocárdica entre 2005 e 2011, com seguimento até 2013, para avaliação de eventos maiores e análise dos fatores de risco associados à cintilografia miocárdica alterada. A análise estatística foi realizada por testes de Fisher, regressão logística e curva de sobrevida de Kaplan-Meier, com p significativo se ≤ 0,05.Resultados:Do total dos pacientes da amostra, 52,1% eram homens, 86,9% hipertensos, 72,4% dislipidêmicos, 33,6% diabéticos, e 12,2% tabagistas; 44,5% tinham doença arterial coronária conhecida; e 70% apresentavam escore de Framingham alto, 21,8% moderado e 8% baixo risco. Das cintilografias miocárdicas, 58,6% foram normais; 26,1%, sugestivas de fibrose; e 15,3%, de isquemia. Na evolução, 13 pacientes (1,5%) apresentaram infarto do miocárdio não fatal e 6 pacientes (0,7%) foram a óbito. O grupo com cintilografia miocárdica normal apresentou maior tempo livre de eventos maiores, infarto do miocárdio não fatal (p = 0,036) e morte (p = 0,019). A fibrose determinou risco 2,4 vezes maior de infarto do miocárdio não fatal e cinco vezes maior de morte (odds ratio: 2,4 e 5,7, respectivamente; p = 0,043).Conclusão:A ocorrência de eventos maiores em até 8 anos no grupo estudado foi pequena. Pacientes com fibrose na cintilografia miocárdica apresentaram mais eventos maiores. Pacientes com cintilografia miocárdica normal apresentaram menos eventos maiores, com sobrevida maior.

Síndrome de Lance-Adams depois de parada cardiorrespiratória prolongada: relato de caso / Lance-Adams syndrome post longtime cardiac arrest: case report

JUSTIFICATIVA E OBJETIVOS: A síndrome de Lance-Adams (SLA) é caracterizada por mioclonias pós-hipóxicas crônicas, podendo surgir dias, semanas ou meses após grave lesão isquêmica ao sistema nervoso central. Sua incidência é muito baixa, sendo uma doença rara, com poucos casos descritos na literatura mundial. O objetivo desse estudo foi relatar um caso de SLA após parada cardiorrespiratória, discutindo algumas hipóteses de sua fisiopatologia e terapêutica. RELATO DO CASO: Paciente do sexo feminino, 50 anos, evoluiu com parada cardiorrespiratória por 30 minutos, durante a recuperação pós-anestésica, após submeter-se à gastroplastia redutora. Evoluiu em coma profundo por um mês, ficando em estado vegetativo persistente por quatro meses apresentando mioclonias generalizadas de difícil controle que melhoravam apenas durante o sono. Sua recuperação neurológica era evidente, escala de coma de Glasgow 11, quando evoluiu a óbito por hipertermia de origem central não responsiva as medicações, após 120 dias de internação. CONCLUSÃO: A SLA ainda possui fisiopatologia desconhecida, as medicações atuais podem como no presente caso, não atenuar os movimentos involuntários. Com a melhora das manobras de reanimação cardiorrespiratória podem ocorrer mais casos de SLA, exigindo maior conhecimento clínico desta doença.

BACKGROUND AND OBJECTIVES: The Lance-Adams syndrome (LAS) is characterized by a chronic myoclonus state after central nervous system hypoxemia that appears days, weeks or months after the insult. Its incidence is very low, being a rare disease, with few cases report in the world-wide literature. The aim of this study is to report a case of LAS after cardiac arrest, discussing some therapeutics hypotheses and physiopathological pathways.CASE REPORT: Female patient, 50 years old, presented a thirty minutes cardiac arrest during post-anesthetic recovery after a successful gastric bypass. Evolved into a deep coma for a month, progressing to vegetative persistent state for four months, during which she presented chronic generalized myoclonus, difficult to control with classical pharmacological agents. His neurological recovery was evident, Glasgow coma score 11 when she evolved to death by central origin hyperthermia unresponsive to medications, after 120 days of hospitalization. CONCLUSION: The Lance-Adams syndrome has yet an unknown pathophysiology mechanism that impairs our clinical approaches. Classical pharmacological agents may be ineffective, as in our case, does not alleviate completely the involuntary movements. With the improvement of cardiopulmonary resuscitation techniques, more cases of LAS should be faced, requiring more clinical knowledge of this disease.