Protocolos de diagnóstico acelerado basados en troponina de alta sensibilidad en el diagnóstico del dolor torácico: una revisión sistemática / Accelerated Diagnostic Protocols Based on High-Sensitivity Troponin in the Diagnosis of Thoracic Pain: A Systematic Review

RESUMEN Introducción: Los protocolos de diagnóstico acelerado de dolor torácico, con el avance de la troponina de alta sensibilidad, permiten identificar a los pacientes que ingresan al servicio de urgencias con dolor torácico de bajo riesgo para un evento cardiovascular adverso mayor, que podrían ser dados de alta de forma temprana y segura, con ahorro de tiempo y recursos. Objetivo: Evaluar ensayos clínicos que utilicen protocolos de diagnóstico acelerado basados en troponina de alta sensibilidad. Material y métodos: se realizó una búsqueda de ensayos clínicos aleatorizados que evaluaran protocolos de diagnóstico acelerado basados en troponina de alta sensibilidad en los servicios de urgencias, en las bases de datos MEDLINE/Ovid, Cochrane y EMBASE utilizando los criterios de evaluación del manual Cochrane y la estrategia PRISMA Resultados: Tras una tamización de 3509 estudios se incluyeron 5 ensayos clínicos que incluyeron 1513 pacientes; se identificaron 409 (27%) altas tempranas, el 91% para el protocolo 0/3 h ESC, 72% para el 0/1 h, 48% para el EDACS, 40% para el HEART, 19 y 32% para ADAPT y 8 y 18% para el cuidado usual. El valor predictivo negativo fue alto, en un rango de 99,1 al 100% La duración media de la estancia hospitalaria fue más baja para los protocolos 0/1 h y 0/3 h ESC, con 4,6 y 5,6 horas respectivamente. Conclusiones: Los protocolos de diagnóstico acelerado en dolor torácico que implementan el uso de troponina de alta sensibilidad permiten lograr alta proporción de altas tempranas con baja tasa de eventos cardiovasculares mayores, con disminución del tiempo de estancia y recursos consumidos.

ABSTRACT Background: Accelerated diagnostic protocols for chest pain, with the advancement of high-sensitivity troponin, make it possible to identify patients admitted to the emergency department with chest pain and low risk for a major adverse cardiovascular event, who could be discharged immediately, early and safely, saving time and resources. Objective: The aim of this study was to assess clinical trials using accelerated diagnostic protocols based on high-sensitivity troponin. Methods: A search of randomized clinical trials evaluating accelerated diagnostic protocols based on high-sensitivity troponin in emergency services was carried out in MEDLINE/Ovid, Cochrane and EMBASE database, using the assessment criteria of the Cochrane manual and the PRISMA strategy. Results: After screening 3509 studies, 5 clinical trials, including 1513 patients, were analyzed. Early discharges were identified in 409 (27%) of patients, in 91% of cases for ESC 0/3-h protocols, 72% for 0/1-h, 48% for EDACS, 40% for HEART, 19% and 32% for ADAPT and 8% and 18% for standard care protocols. The negative predictive value was high, in the 99.1-100% range. Mean length of hospital stay was lower for the 0/1-h and ESC 0/3-h protocols, with 4.6 and 5.6 hours, respectively. Conclusions: Accelerated diagnostic protocols in chest pain using high-sensitivity troponin allow a higher proportion of early discharges with a low rate of major cardiovascular events, with reduction in length of hospital stay and resources used.

Caracterización del dolor torácico agudo en pacientes del Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez Hernández. Matanzas / Characterization of acute chest pain in patients of the Teaching Clinic- Surgical Hospital Comandante Faustino Perez Hernandez. Matanzas

RESUMEN Introducción: el dolor torácico agudo es una sensación dolorosa que se manifiesta entre el diafragma y la base del cuello. En Cuba, constituye una de las causas más frecuentes de consulta médica. La provincia de Matanzas muestra un comportamiento similar. Objetivo: caracterizar el perfil clínico de los pacientes con dolor torácico agudo en la Unidad de Cuidados Intensivos Emergentes, del Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez Hernández, de Matanzas. Materiales y métodos: se realizó un estudio transversal descriptivo con las historias clínicas de 418 pacientes que acudieron a la Unidad de Cuidados Intensivos Emergentes, refiriendo dolor torácico agudo, de enero a diciembre de 2019. Resultados: el rango de edad más afectado fue el de 50 a 59 años, para un 30,38 %. Predominó el sexo masculino con el 30,08 %. El ejercicio físico intenso elevó el riesgo de aparición de dolor torácico. Las primeras causas de dolor torácico agudo fueron, en orden de frecuencia, la osteocondritis esternocostal, la bursitis del hombro y el síndrome coronario agudo. Conclusiones: se evidenció que en la mayoría de los casos el origen del dolor fueron causas no cardiovasculares, afectando más al sexo masculino. Existió asociación estadística significativa entre la actividad física intensa y el inicio del dolor torácico agudo. Egresaron vivos de la unidad el 71,53 % de los pacientes. Se recomienda priorizar la atención de los pacientes que refieren dolor torácico agudo, para una correcta clasificación y atención en el menor tiempo posible (AU).

ABSTRACT Introduction: acute chest pain is a painful sensation perceptible between the diaphragm and the base of the neck. It is one of the most frequent causes of medical consultation in Cuba. It shows a similar behavior in the province of Matanzas. Objective: to characterize the clinical profile of the patients with acute thoracic pain in the Emergency Intensive Care Unit of the Teaching Clinic-Surgical Hospital Comandante Faustino Perez Hernandez, of Matanzas. Materials and methods: a descriptive, cross-sectional study was carried out with the clinical records of 418 patients who attended the Emergency Intensive Care Unit referring acute thoracic pain, from January to December 2019. Results: the most affected age range was the one from 50 to 59 years, for 30.38 %. Male sex predominated, with 30.08 %. Intense physical exercise raised the risk of thoracic pain. The first causes of acute thoracic pain were, in order of frequency, sternocostal osteochondritis, shoulder bursitis, and acute coronary syndrome. Conclusions: It was evidenced that in most of the cases the source of the pain was non-cardiovascular causes, more affecting the male sex. There was significant statistic association between intense physical activity and acute thoracic pain. 71.53 % of the patients was discharged from the unit alive. It is recommended to prioritize the attention of patients referring acute thoracic pain, for their correct classification and care in the shortest possible time (AU).

Hiperglicemia y volumen plaquetario medio como predictores tempranos del síndrome coronario agudo tipo IAM SEST / Hyperglycemia and mean platelet volume as early predictors of acute coronary syndro-me type IAM SEST

Introducción: El objetivo del presente trabajo de investigación es determinar la validez diag-nóstica que tiene la hiperglucemia y el volumen plaquetario medio en el diagnóstico tempra-no de pacientes que acuden al Departamento de Emergencia con dolor torácico y sospecha de infarto agudo de miocardio sin elevación del ST. Materiales y métodos: se realizó un ensayo clínico no controlado para validación de pruebas diagnósticas de 6 meses de duración, en 133 pacientes admitidos en el Departamento de Emergencia del Hospital Carlos Andrade Marín por dolor torácico y sospecha de síndrome coronario agudo. Un punto de cohorte de hiperglu-cemia >140 mg/dl y volumen plaquetario medio ≥ 10,33 fl a la admisión fue considerado tomando en cuenta valores propuestos en la curva ROC (curva operante receptor); así como también, se determinó el rendimiento diagnóstico de las pruebas, regresión univariante y multivariante. Resultados: de los 133 pacientes incluidos en el trabajo, 32 (24,1%) tuvieron infarto agudo de miocardio sin elevación del ST. El rendimiento diagnóstico del volumen plaquetario medio ≥ 10,33 fl (AUC: 0,91; IC 95%: 0,841-0,979; p<0,05) tuvo una sensibili-dad del 81,2%, especificidad de 93,1%, valor predictivo positivo 78,8%, valor predictivo negativo 94%, razón de verosimilitud positivo 11,723 y razón de verosimilitud negativo 0,201. Para la hiperglucemia >140 mg/dl (AUC: 0,923; IC 95%: 0,879-0,967; p<0,05) la sensibilidad fue del 71,9%, especificidad de 90,1%, valor predictivo positivo 69,7%, valor predictivo negativo 91%, razón de verosimilitud positivo 7,259 y razón de verosimilitud negativo 0,312. Conclusiones: la hiperglucemia y el volumen plaquetario medio son biomar-cadores con buena capacidad predictiva para el diagnóstico temprano del infarto agudo de miocardio sin elevación del ST.

Introduction: The aim of this research is to determine the diagnostic validity of hyperglycemia and mean platelet volume in the early diagnosis of patients who come to the Emergency Department with chest pain and suspected acute myocardial infarction without ST elevation. Materials and methods: an uncontrolled clinical trial was conducted to validate diagnostic tests of 6 months in 133 patients admitted to the Emergency Department of the Carlos Andra-de Marín Hospital for chest pain and suspected acute coronary syndrome. A cohort point of hyperglycemia> 140 mg / dl and mean platelet volume ≥ 10.33 fl upon admission was consi-dered taking into account values proposed in the ROC curve (receiver operant curve); as well as, the diagnostic performance of the tests, univariate and multivariate regression was deter-mined. Results: of the 133 patients included in the study, 32 (24.1%) had acute myocardial infarction without ST elevation. The diagnostic yield of mean platelet volume ≥ 10.33 fl (AUC: 0.91, 95% CI: 0.841-0.979, p <0.05) had a sensitivity of 81.2%, specificity of 93.1%, value positive predictive 78.8%, negative predictive value 94%, positive likelihood ratio 11.723 and negative likelihood ratio 0.201. For hyperglycemia> 140 mg / dL (AUC: 0.923, 95% CI: 0.879-0.967, p <0.05) the sensitivity was 71.9%, specificity 90.1%, positive predic-tive value 69.7%, negative predictive value 91%, positive likelihood ratio 7,259 and negative likelihood ratio 0,312. Conclusion: hyperglycaemia and mean platelet volume are biomar-kers with good predictive capacity for the early diagnosis of acute myocardial infarction without ST elevation.

A Rare Extradural Spinal Meningioma with Nocturnal Chest Pain: A Case Report

STUDY DESIGN: Case report. OBJECTIVES: To report a rare case of a spinal extradural meningioma in a patient with longstanding nonspecific thoracic nocturnal pain. SUMMARY OF LITERATURE REVIEW: Meningioma is a frequent intradural extramedullary tumor that is associated with pain, sensory/motor deficits, and sphincter weakness. Spinal meningiomas most commonly occur in the thoracic spine, although they can also be found at other locations. MATERIALS AND METHODS: A 65-year-old woman first visited the cardiac and gastrointestinal departments of our institution due to chest pain 2 years previously. No explanation for the complaint could be found in the heart or other organs. On a computed tomography scan of the thorax, a spinal mass was found a few months before the diagnosis. On magnetic resonance imaging, an extramedullary and extradural mass was observed at T7/8. RESULTS: We performed surgery and found an extradural spinal meningioma upon the histological diagnosis. Postoperatively, the patient could adequately move both legs and feet and the nocturnal chest pain disappeared after surgery without any complications. CONCLUSIONS: Awareness of the rarity and nonspecific symptoms of extradural spinal meningiomas will be beneficial for their accurate diagnosis and proper treatment.

Nineth Rib Syndrome after 10th Rib Resection

The 12th rib syndrome is a disease that causes pain between the upper abdomen and the lower chest. It is assumed that the impinging on the nerves between the ribs causes pain in the lower chest, upper abdomen, and flank. A 74-year-old female patient visited a pain clinic complaining of pain in her back, and left chest wall at a 7 on the 0-10 Numeric Rating scale (NRS). She had a lateral fixation at T12-L2, 6 years earlier. After the operation, she had multiple osteoporotic compression fractures. When the spine was bent, the patient complained about a sharp pain in the left mid-axillary line and radiating pain toward the abdomen. On physical examination, the 10th rib was not felt, and an image of the rib-cage confirmed that the left 10th rib was severed. When applying pressure from the legs to the 9th rib of the patient, pain was reproduced. Therefore, the patient was diagnosed with 9th rib syndrome, and ultrasound-guided 9th and 10th intercostal nerve blocks were performed around the tips of the severed 10th rib. In addition, local anesthetics with triamcinolone were administered into the muscles beneath the 9th rib at the point of the greatest tenderness. The patient's pain was reduced to NRS 2 point. In this case, it is suspected that the patient had a partial resection of the left 10th rib in the past, and subsequent compression fractures at T8 and T9 led to the deformation of the rib cage, causing the tip of the remaining 10th rib to impinge on the 9th intercostal nerves, causing pain.

Schwannoma intratorácico / Intrathoracic schwannoma

El schwannoma (neurilemoma) es un tumor benigno de lento crecimiento originado en la vaina de Schwann, cuya localización en la cavidad torácica es excepcional. En general es asintomático y se descubre en forma incidental, aunque puede ocasionar síntomas cuando la lesión crece o invade estructuras subyacentes. Su importancia radica en la posibilidad de confusión con tumores malignos. Presentamos una paciente con dolor torácico de evolución prolongada causado por un schwannoma. La imagen tomográfica es sugestiva de tumor extrapulmonar, por ello el schwannoma en esta localización debe ser considerado en el diagnóstico diferencial de tumores pleurales metastásicos o primarios como el lipoma, el tumor fibroso solitario y el mesotelioma.

The schwannoma (neurilemmoma) is a slow-growing benign tumor originating from Schwann sheath whose location in the chest cavity is exceptional. It is generally asymptomatic and is discovered incidentally but can cause symptoms when the lesion grows or invade underlying structures. Its importance lies in the possibility of confusion with malignant tumors. We present a patient who complains of chest pain caused by a prolonged course schwannoma. The tomographic image is suggestive of extrapulmonary tumor, so the schwannoma in this location should be considered in the differential diagnosis of metastatic or primary pleural tumors such as lipoma, solitary fibrous tumor and mesothelioma.

Diagnóstico y tratamiento de la acalasia esofágica / Diagnosis and treatment of esophageal achalasia

Esophageal idiopathic achalasia is a complex disease associated with loss of neuronal Auerbach Plexus in the esophagus, and possibly caused by specific anti-neural antibodies, characterized by incomplete relaxation of the lower esophageal sphincter (LES), together with progressive loss of esophageal body motility. Its cardinal symptom is dysphagia which is accompanied by intermittent chest pain and pseudoregurgitation. A barium swallow shows a classic regular obstruction at the esophago-gastric junction and typical manometry features, being incomplete relaxation of LES the essential element. The goal of management is palliation of dysphagia and is based on endoscopic or surgical LES myotomy with the purpose of reducing the obstructive effect of incomplete-relaxing LES. Endoscopic dilation and endoscopic and surgical myotomy procedures are evolving to provide greater efficacy and safety in the management of achalasia, resulting in the lower rate of side effects such as gastro-esophageal reflux. Among these therapies, surgical myotomy is the only one that shows acceptable long-term results, however, late complications such as severe gastro-esophageal reflux, Barrett’s esophagus and esophageal carcinoma should alert about side effects of an effective myotomy.

La acalasia esofágica idiopática es una enfermedad compleja asociada a la pérdida del plexo neuronal de Auerbach en el esófago, posiblemente causada por anticuerpos anti-neurales específicos. Se caracteriza por la relajación incompleta e hipertonía del esfínter esofágico inferior (EEI), junto con pérdida progresiva de la motilidad del cuerpo esofágico. Su síntoma cardinal es la disfagia que se acompaña de dolor torácico intermitente y pseudo-regurgitación. Su diagnóstico de certeza lo aporta un clásico esófago-grama y hallazgos manométricos típicos, siendo la relajación incompleta del EEI un elemento imprescindible. Su manejo busca paliar la disfagia y se basa en procedimientos endoscópicos o quirúrgicos para reducir el efecto obstructivo que causa la anomalía del EEI. Las terapias de dilatación endoscópica, miotomía endoscópica y quirúrgica están en permanente evolución para brindar la mayor eficacia y seguridad en el manejo de la acalasia, causando la menor tasa de efectos colaterales como el RGE. De estas terapias, la miotomía quirúrgica es la única que muestra buenos resultados sostenidos en el largo plazo, pero surge la inquietud de la aparición de complicaciones tardías como reflujo gastroesofágico grave, esófago de Barrett y carcinoma esofágico.

Hemotórax traumático en un período de tres años / Traumatic hemothorax in a three-year period

Introducción: el trauma es en el mundo moderno una de las principales causas de morbilidad y mortalidad. Se estima que del 20 al 25 porciento de las muertes por trauma, son consecuencia de lesiones torácicas. Objetivo: describir el comportamiento del hemotórax traumático en un período de tres años. Métodos: se realizó un estudio descriptivo, retrospectivo y tangencial del hemotórax traumático en el Hospital Docente Dr. Miguel Enríquez en un período de tres años. Se confeccionó una base de datos y se identificaron diferentes variables, que condujeron a un análisis porcentual de los datos obtenidos además se aplicó el estadígrafo chi cuadrado para establecer la significación de la distribución de las frecuencias observadas. Resultados: dentro de las lesiones torácicas el hemotórax traumático se presentó en 104 pacientes (57,7 porceinto). El 91,3 porciento correspondió al sexo masculino y el grupo etario más afectado fue el comprendido entre 20-30 años con 30 lesionados. Las heridas por arma blanca penetrante en tórax se presentaron en el 75 porciento de los casos, seguida por el trauma cerrado. El cuadro clínico que predominó fue el dolor torácico y disnea en 43 pacientes. Se realizó la pleurostomía mínima baja en el 98,5 porciento de los casos. Las complicaciones más frecuentes en relación con la lesión fueron el hemotórax coagulado (8 pacientes) seguido del derrame pleural y el shock hipovolémico. No se reportó mortalidad en nuestra serie. Conclusiones: la pleurostomía mínima baja sigue siendo el método quirúrgico más empleado en el hemotórax traumático reservando la toracotomía de urgencia para pacientes con indicaciones precisas(AU)

Introduction: trauma is considered one of the main causes of morbidity and mortality in the modern world. It is estimated that the 20-25 percent of deaths by trauma are consequences of thoracic lesions. Objective: to describe the behavior of traumatic hemothorax in a three-year period. Methods: a descriptive, retrospective and tangential study of traumatic hemothorax was conducted at Dr. Miguel Enriquez Teaching Hospital in a three-year period. A database was made and different variables were identified, which led to a percentage analysis of the obtained data. Chi2 was also applied to establish the importance of the distribution of the observed frequencies. Results: among the thoracic lesions, the traumatic hemothorax was present in 104 patients (57,7 percent). 91,3 percent were males and the most affected age group corresponded to 20-30 years with 30 injured patients. Penetrating thoracic wound with knife was present in 75 percen t of cases, followed by closed trauma. The predominant clinical manifestations were thoracic pain and dyspnea in 43 patients. Conclusions: Low minimal pleurostomy keeps being the most used surgical procedure for the traumatic hemothorax, reserving the urgent thoracotomy only for specific patients with precise indications(AU)

Disección aórtica toracoabdominal / Thoracoabdominal aortic dissection

Se describe el caso clínico de un paciente de 43 años de edad, presumiblemente saludable, quien acudió al cuerpo de guardia del Hospital Clinicoquirúrgico Docente "Dr. Joaquín Castillo Duany" de Santiago de Cuba por presentar dolor torácico opresivo, desgarrante, súbito e intenso, que se irradiaba hacia la parte superior del abdomen cuando realizaba esfuerzo físico de moderada intensidad. Los exámenes complementarios efectuados confirmaron el diagnóstico de disección aórtica aguda toracoabdominal, por lo cual fue operado en el Cardiocentro de esta ciudad, donde evolucionó satisfactoriamente y egresó sin complicaciones.

The case report of an apparently healthy 43 year-old patient is described, who went to the emergency department of "Dr. Joaquín Castillo Duany" Teaching Clinical Surgical Hospital due to sudden, severe and ripping oppressive thoracic pain irradiating toward the upper abdominal region while he was making a physical effort of moderate intensity. Complementary tests confirmed the diagnosis of thoracoabdominal acute aortic dissection, reason why he underwent surgery at the Cardiology Center of this city, where he made good progress and was discharged without complications.

Aneurisma aorta torácica y falla cardíaca manejado con transplante cardíaco: descripción de un caso clínico / Aorta thoracic aneurysm and cardiac failure treated with cardiac transplant: description of a clinical case

Alrededeor de un 25% de aneurismas aórticos degenerativos afectan a la aorta torácica. En la mayoria de los casos afectan al arco y a la aorta desendente, a diferencia de los luéticosque tienen mayor frecuencia en aorta ascendente. A veces toda la aorta es estásica presentando multiples dilataciones que se extienden a aorta abdominal, dando lugar a aneurisma toracoabdominales. Existen factores predisponentes como la edad, hipertensión sistémica arterial (HTA), anomalias congénitas de la válvula aórtica, transtornos hereditarios del sistema conectivo, traumáticos y otros. Afecta a pacientes entre la quinta y la séptima décadas de la vida, siendo más frecuente en varones (3:1). En menores de 40 años la frecuencia es similar en ambos sexos, debido a la mayor frecuencia en mujeres durante el trecer trimestre del embarazo. La HTA es encontrada en el 80% de los casos, siendo el segundo factor predisponente en importancia.

Around 25% of degenerative aortic aneurysms affect the thoracic aorta. In the majority of cases they affect the arch and the descending aorta, unlike luetic aneurysms, which are more frequent in the ascending aorta. Sometime the entire aorta is in a state of stasis, presenting multiple dilatations that extend to the abdominal aorta giving rise to thoracoabdominal aneurysms. There are predispositional factors, among them systemic arterial hypertension (SAH), congenital anomalies of the aortic valve, hereditary connective system disorders and traumatisms. This condition affects patients in their 50s to 70s and is most frequent in males (3:1). In the under-40s, frequency is similar in both sexes, owing to the higher frequency among women during the third trimester of pregnancy. SAH is found in 80% of cases, being the second most important predispositional factor.

Treatment of a Twelfth Rib Syndrome : A case report

Twelfth rib syndrome is thought to be due to intercostal nerve irritation by a mobile twelfth rib, and presents with upper abdominal pain, or low thoracic pain. This syndrome appears to be a fairly common entity and diagnosis is based on clinical findings. Patients with twelfth rib syndrome can be misdiagnosed when it has been overlooked. We report a case of a 34-year-old male along with a presentation of twelfth rib syndrome. One patient was transferred from urologic clinic to pain clinic due to right flank pain and admitted. The patient had direct tenderness on twelfth rib area and direct tenderness was reproducible. Pain increased when the patient flexed laterally, rotated trunk. There were no specific abnormal findings in laboratory test, electrocardiogram, and radiologic examination. After intercostal nerve block and epidural block, pain decreased and the patient was discharged.

Evaluación de los pacientes con dolor torácico / Assesment of patients with thoracic pain

Las consultas por dolor torácico son frecuentes en el consultorio y en la guardia. Su evaluación representa un desafío, dado el riesgo que representan los síndromes coronarios agudos (SCA) no diagnosticados adecuadamente, siendo la escucha y el interrogatorio el primer paso de la evaluación. Ciertas características del dolor torácico aumentan o disminuyen la probabilidad de SCA, pero usadas en forma aislada, ninguna permite confirmarlo o descartarlo. Es fundamental el entrenamiento en la lectura del electrocardiograma (ECG) ya que los trastornos de la repolarización guían las conductas terapéuticas, debiéndose realizar en forma inmediata y durante los episodios de dolor. El 80% de los pacientes que consultan tienen ECG normales o con cambios inespecíficos, siendo clave la realización de ECG seriados. Cuando la información precedente no resulta definitoria, los marcadores de necrosis miocárdica (CPK-CPK MB y troponinas) permiten identificar pacientes con SCA en curso, siendo necesario el conocimiento de sus características operativas y de su cinética de liberación. Con el objetivo de integrar estas variables y brindar un marco confiable para la evaluación y estratificación del riesgo se elaboraron guía de manejo; siendo las Unidades de Dolor Torácico estrategias de manejo que aplican una sistemática basada en la observación y medición seriada de ECG y marcadores. Estas han mejorado la detección y disminuido el número de pacientes con SCA erróneamenete descartados.

AbstractThoracic pain is a frecuent presenting symptom both in office and emergency settings. Its evaluation represents a challengeto physicians, due to the risk of non detected coronary artery syndrome (CAS). Listening and asking the right questions arefirst steps to differential diagnosis. Certain features of thoracic pain increase or decrease CAS probability, but neither of them are enough to confirm the diag-nosis. Training in ECG reading is essential for guiding therapeutic approaches related to repolarization alterations and ECGmust be drawn inmediately during pain episodes. The majority of patients (80%) presenting with thoracic pain have normalECG or inespecific electrical changes, so it is necesary to draw serial ECGs. When previous information is not conclusive,myocardial necrosis markers (CPK, CPK MB, troponins) allow identification of ongoing CAS, with necesary knowledge oftest opperative characteristics and liberation kinetics. Therapeutic guidelines were developed in order to integrate all the variables and create a trustworthy framework for evalua-tion and risk stratification. Thoracic Pain Units are management strategies which apply observation based sistematics andserial ECG and markers measurement. The use of these approaches has improved detection of CAS and lowered missedcases rate.

Dor torácica na emergência de um hospital geral / Thoracic pain in a general hospital emergency

Introdução: Dentre as doenças cardiovasculares, a condição mais prevalente é a dor torácica aguda não traumática. Objetivo: Identificar a freqüência de dor torácica na emergência e a descrição dos eventos na internação em 6 meses. Métodos: O estudo apresenta duas etapas: estudo transversal e série de casos, em pacientes com dor torácica na emergência, onde foi avaliado o protocolo assistencial. A dor foi classificada nas categorias: infarto agudo do miocárdio (IAM), angina pectoris e dor não-anginosa, de acordo com a clínica, eletrocardiografia e marcadores de necrose miocárdica. O teste ergométrico foi realizado de acordo com protocolo de Bruce. Os eventos em 6 meses foram mensurados. Resultados: No período de novembro de 2004 a janeiro de 2005 foram atendidos 80.184 pacientes na emergência do Hospital Conceição (HNSC). Desses atendimentos, 1.564 (2%) apresentavam dor torácica. Foram avaliados 52 pacientes, 34 (65%) masculino, idade média de 59 anos (dp 14,74), 69% internaram (38% com infarto, 27% angina e 4% dor não-anginosa), 17% realizaram teste ergométrico. Conclusão: Constatou-se uma baixa freqüência (2%) dos atendimentos devido a dor torácica não-traumática, porém elevada incidência de infarto e angina instável (AU)

Introduction: Among the cardiovascular emergencies the most frequent cause is nontraumatic acute thoracic pain in the emergency room. Objective: To identify thoracic pain frequency in the emergency and cardiovascular events in 6 months. Methods: A crosssectional and a case series study were carried out to evaluate thoracic pain guideline. Myocardial infarct, angina pectoris, and non-angina pain were identified based on clinical features, ECG abnormality and myocardial necrosis indicators. The ergometric test was carried out according to the Bruce Protocol. The events in 6 months were measured. Results: Between November 2004 through January 2005, 80,184 patients received care in the emergency room of Hospital Conceição. Among them, 1564 (2%) had thoracic pain. We had investigated 52 of these patients, 34 (65%) of whom were males, with an average age of 59 years old (sd 14.74). Regarding to the diagnosis, 69% had been admitted (38% with the diagnosis of infarct, 27% with angina and 4% with non-angina pain), 17% performed the ergometric test. Conclusion: A low frequency (2%) of non-traumatic thoracic pain has been identified, although there was a high incidence of infarct and unstable angina in these patients. There was a high prevalence of cardiovascular events in 6 months in the three studied groups (AU)

The Effects of Increasing Thoracic Mobility on Lumbar Stability

OBJECTIVE: To determine the effects on the lumbar stability caused by various thoracic exercise programs, the extent of spinal posture correction and the increase in thoracic mobility to the extension direction. METHOD: Exercise programs, which can increase the thoracic mobility to the extension direction, were applied to the exercise group. The control subjects were trained for the correct posture according to ergonomic principles by exercise at home and at the clinic. Both groups had three sessions of exercise program per week for 8 weeks. RESULTS: A comparison of the various parameters in the exercise group before and after exercise showed that the VAS, thoracic kyphosis and lumbar mobility decreased significantly (p <0.05), and the thoracic mobility in the extension direction, chest expansion, maximal elevation of the arms and spinal length increased significantly (p <0.05). In addition, the thoracic kyphosis and lumbar mobility increased significantly (p <0.05), and thoracic mobility in the extension direction, chest expansion, maximum elevation of the arms and the spinal length decreased significantly (p <0.05), but the VAS did not show a significant difference. CONCLUSION: A thoracic exercise program, which can correct the posture, improve the functional restrictions of the thoracic spine and reduce the lumbar mobility, is very important.