Neuroprotective Effect of a Pharmaceutical Extract of Cannabis with High Content on CBD Against Rotenone in Primary Cerebellar Granule Cell Cultures and the Relevance of Formulations.

Introduction: Preclinical research supports the benefits of pharmaceutical cannabis-based extracts for treating different medical conditions (e.g., epilepsy); however, their neuroprotective potential has not been widely investigated. Materials and Methods: Using primary cultures of cerebellar granule cells, we evaluated the neuroprotective activity of Epifractan (EPI), a cannabis-based medicinal extract containing a high level of cannabidiol (CBD), components like terpenoids and flavonoids, trace levels of Δ9-tetrahydrocannabinol, and the acid form of CBD. We determined the ability of EPI to counteract the rotenone-induced neurotoxicity by analyzing cell viability and morphology of neurons and astrocytes by immunocytochemical assays. The effect of EPI was compared with XALEX, a plant-derived and highly purified CBD formulation (XAL), and pure CBD crystals (CBD). Results: The results revealed that EPI induced a significant reduction in the rotenone-induced neurotoxicity in a wide range of concentrations without causing neurotoxicity per se. EPI showed a similar effect to XAL suggesting that no additive or synergistic interactions between individual substances present in EPI occurred. In contrast, CBD did show a different profile to EPI and XAL because a neurotoxic effect per se was observed at higher concentrations assayed. Medium-chain triglyceride oil used in EPI formulation could explain this difference. Conclusion: Our data support a neuroprotective effect of EPI that may provide neuroprotection in different neurodegenerative processes. The results highlight the role of CBD as the active component of EPI but also support the need for an appropriate formulation to dilute pharmaceutical cannabis-based products that could be critical to avoid neurotoxicity at very high doses.

Bifurcation lesions involved in the recanalization process of coronary chronic total occlusions: Incidence, treatment and clinical implications.

BACKGROUND: The presence of a bifurcation (BL) in the context of a coronary chronic total occlusion (CTO) represents an additional difficulty. This study analyzes the incidence of BLs in CTO recanalization, the treatment, predictors of bifurcation technical success and their clinical impact. METHODS AND RESULTS: BLs with a side branch (SB) ≥2.0mm located proximally, distally or within the occluded segment were observed in 130 (33%) of 391 CTO. Provisional stenting was the strategy more frequently used (94%). Bifurcation success (stenosis <30% in main vessel and TIMI flow III in both branches) was achieved in 105 patients (81%). In the remaining 25 (19%), the TIMI flow at the SB was

Effect of early treatment with ivabradine combined with beta-blockers versus beta-blockers alone in patients hospitalised with heart failure and reduced left ventricular ejection fraction (ETHIC-AHF): A randomised study.

OBJECTIVES: To analyse the effect of the early coadministration of ivabradine and beta-blockers (intervention group) versus beta-blockers alone (control group) in patients hospitalised with heart failure and reduced left ventricular ejection fraction (HFrEF). METHODS: A comparative, randomised study was performed to compare the treatment strategies of beta-blockers alone versus ivabradine and beta-blockers starting 24hours after hospital admission, for acute HF in patients with an left ventricular ejection fraction (EF)<40%, sinus rhythm, and a heart rate (HR)>70bpm. RESULTS: A total of 71 patients were examined, 33 in the intervention group and 38 in the control group. No differences were observed with respect to their baseline characteristics or standard treatment at discharge. HR at 28days (64.3±7.5 vs. 70.3±9.3bpm, p=0.01) and at 4months (60.6±7.5 vs. 67.8±8bpm, p=0.004) after discharge were significantly lower in the intervention group. Significant differences were found with respect to the EF and brain natriuretic peptide levels at 4months. No differences in clinical events (rehospitalisation/death) were reported at 4months. No severe side effects attributable to the early administration of ivabradine were observed. CONCLUSIONS: The early coadministration of ivabradine and beta-blockers during hospital admission for acute HFrEF is feasible and safe, and it produces a significant decrease in HR at 28days and at 4months after hospital discharge. It also seemed to improve systolic function and functional and clinical parameters of HF patients at short-term.

Disfunção endotelial nas cardiopatias congênitas / Endothelial dysfunction in congenital heart disease

O termo disfunção endotelial tem sido usado para descrevervárias alterações fisiopatológicas que ocorrem no endotéliovascular, alterações estas que estão associadas a muitas doenças.Muito enfoque foi dado a essas alterações e sua associação asdoenças cardiovasculares, em especial as coronariopatias. Naúltima década, várias pesquisas correlacionaram a disfunçãoendotelial às cardiopatias congênitas. No Brasil, as cardiopatiascongênitas apresentam elevada prevalência, sendo responsáveispor morbimortalidade importante, principalmente em menoresde 5 anos de idade. Estas cardiopatias congênitas relacionam-sea um perfil de alterações endoteliais próprias, causadas tantopela hipóxia como por situações de hiperfluxo pulmonar. Essasalterações endoteliais predispõem esses pacientes a fenômenostrombóticos, hemorrágicos, inflamatórios, entre outros, cujoreconhecimento é fundamental para a estratificação de riscoe para a terapêutica clínica e/ou cirúrgica. O objetivo dopresente artigo é descrever as alterações na função endotelialque ocorrem nos pacientes com cardiopatias congênitas,submetidos ou não a intervenções cirúrgicas, à luz daliteratura vigente, e também relatar os alvos terapêuticosque se tornaram relevantes na última década devido aoreconhecimento de processos endotélio-dependentes, como éo caso, principalmente, do tratamento da hipertensão pulmonarnos pacientes com cardiopatias congênitas...

The term endothelial dysfunction has been used to referto several pathological conditions, including alteredanticoagulant and anti-inflammatory properties of theendothelium, impaired modulations of vascular growthand dysregulation of vascular remodeling. Most attentionhas been gi ven to the relationship between endothelialdysfunction and coronary disease, but in the past decadethere was an increase interest in investigations relating theassociation between congenitaJ heart diseases and endothelialdysfunction. There is a high prevalence of congenital heartdisease in Brazil, which is responsible for high morbidityand mortality, mainly in under 5-year-old children. Theyare related to a complex profile of endothelial dysfunctionthat lead to thrombotic, hemorrhagic and infiammatoryevents and other alterations related to congenital cyanoticand non-cyanotic heart diseases, in children undergoing tosurgical procedures or not. The purpose of this chapter isto discuss the role played by the endothelial dysfunction inchildren with congenital heart disease and its impact on thesignaling pathways that regulate vasodilation and vascularremodeling, looking for new therapeutic targets, withspecial attention to the advances reached in the treatmentof pulmonary hypertensionDescriptors: congenital heart...

Percutaneous versus surgical closure of atrial septal defects in children and adolescents.

BACKGROUND: There is a scarcity of data comparing percutaneous and surgical closure of the secundum atrial septal defect (ASD). OBJECTIVES: Assessment of safety and efficacy of both methods of treatment in a referral center affiliated with the Ministry of Health. METHODS: Observational, prospective, non-randomized study of two cohorts of children and adolescents younger than 14 years, treated by catheterization or surgery. Data was collected prospectively in the percutaneous group (A) and retrospectively in the surgical group (B). RESULTS: A total of 75 patients (pts) were enrolled in group A from April 2009 to October 2011 and 105 pts were treated in group B from January 2006 to January 2011. Age was older and weight was higher in group B and the ASD diameter was similar in both groups. Technical success was achieved in all procedures and there were no deaths. Complications (most minor) occurred in 68% of group B and 4% of A (p < 0.001). Rates of total occlusion or non-significant residual shunts were similar in both groups. Median hospitalization time was 1.2 days in group A and 8.4 days in group B (p < 0.001). CONCLUSION: Both treatment modalities are safe and effective, showing excellent outcomes. However, the percutaneous treatment has lower morbidity and shorter in-hospital stay length. These observations support the concept that percutaneous treatment of atrial septal defects should be regarded as the method of choice to manage selected patients with this condition.

Fechamento percutâneo versus cirúrgico da comunicação interatrial em crianças e adolescente / Percutaneous versus surgical closure of atrial septal defects in children and adolescents

FUNDAMENTO: Há uma paucidade de dados comparando o método percutâneo e o cirúrgico para tratamento da comunicação interatrial tipo ostium secundum. OBJETIVOS: Análise de segurança e eficácia comparando ambos os métodos tratamento em um hospital excelência com vínculo o Ministério de Saúde. MÉTODOS: Estudo observacional, prospectivo, não randomizado de duas coortes de crianças e adolescentes < 14 anos tratadas por meio do cateterismo intervencionista (grupo A) ou da cirurgia cardíaca convencional (grupo B). A coleta dos dados foi prospectiva no grupo A e retrospectiva no B. RESULTADOS: De abr/2009 a out/2011 foram alocados 75 pts no grupo A e entre jan/2006 e jan/2011foram tratados 105 pts no grupo B. A idade e o peso dos pacientes foram maiores no grupo B e o diâmetro da comunicação interatrial do tipo ostium secundum foi semelhante entre os grupos. Sucesso técnico foi observado em todos os procedimentos e não houve óbitos. Complicações (a maioria menores) foram encontradas em 68% no grupo B e em 4% do grupo A (p < 0,001). As taxas de fluxo residual não significativo ou de oclusão total do defeito foram semelhantes nos dois grupos. A mediana de internação foi de 1,2 dias após o procedimento percutâneo e 8,4 dias após a correção cirúrgica (p < 0,001). CONCLUSÃO: Ambos os tratamentos são seguros e eficazes com ótimos desfechos, porém o tratamento percutâneo apresenta menor morbidade e tempo de internação. Tais observações embasam a visão que essa forma de tratamento deve ser, hoje em dia, o método de escolha para pacientes selecionados com CIA do tipo ostium secundum.

BACKGROUND: There is a scarcity of data comparing percutaneous and surgical closure of the secundum atrial septal defect (ASD). OBJECTIVES: Assessment of safety and efficacy of both methods of treatment in a referral center affiliated with the Ministry of Health. METHODS: Observational, prospective, non-randomized study of two cohorts of children and adolescents younger than 14 years, treated by catheterization or surgery. Data was collected prospectively in the percutaneous group (A) and retrospectively in the surgical group (B). RESULTS: A total of 75 patients (pts) were enrolled in group A from April 2009 to October 2011 and 105 pts were treated in group B from January 2006 to January 2011. Age was older and weight was higher in group B and the ASD diameter was similar in both groups. Technical success was achieved in all procedures and there were no deaths. Complications (most minor) occurred in 68% of group B and 4% of A (p < 0.001). Rates of total occlusion or non-significant residual shunts were similar in both groups. Median hospitalization time was 1.2 days in group A and 8.4 days in group B (p < 0.001). CONCLUSION: Both treatment modalities are safe and effective, showing excellent outcomes. However, the percutaneous treatment has lower morbidity and shorter in-hospital stay length. These observations support the concept that percutaneous treatment of atrial septal defects should be regarded as the method of choice to manage selected patients with this condition.

Double shunt technique for hybrid palliation of hypoplastic left heart syndrome: a case report.

We report a technique to palliate hypoplastic left heart syndrome, with no PDA stenting, but with double polytetrafluoroethylene shunt from pulmonary artery to ascending and descending aorta by combined thoracotomies. A 30-day-old female was operated with this technique. Five months after first operation, the child was submitted to Norwood/Glenn operation. Good hemodinamic recovery and initial clinical evolution was observed. The child was extubated in 8th post operatory day and reentubated in the next day due to pulmonary infection. Despite antibiotic treatment, the child died after systemic infectious complications.

Divertículo epifrénico / Epinephrine diverticulum

El divertículo epifrénico provocado por el aumento de la presión intraesofágica a causa de alteraciones motoras subyacentes es raro; representa cerca del 10 por ciento de todos los divertículos esofágicos. Se presenta el caso de una paciente de 65 años de edad, que ingresó en el Servicio de Cirugía General con ictericia obstructiva por pancreatitis crónica. Se le realizó una triple derivación de Catell y durante la evolución posoperatoria comenzó a presentar vómitos que contenían alimentos sin digerir, fétidos, ingeridos con horas o días de antelación. Se le realizó una radiografía baritada de esófago, estómago y duodeno, con buen pase de contraste al duodeno, y se observó la presencia de un divertículo epifrénico de gran tamaño, responsable de los síntomas. Fue intervenida quirúrgicamente utilizando como vía de acceso una incisión media previa y vía transhiatal. Se practicó una vagotomía, diverticulectomía, miotomía esofágica extendida, procedimiento antirreflujo y yeyunostomía temporal para la alimentación precoz. La evolución fue favorable y la paciente está hoy asintomática(AU)

The epinephrine diverticulum due to the increase of intraesophageal pressure by underlying motor alterations is a rare entity; it accounts for around the 10% of all esophageal diverticula. This is the case of a female patient aged 65 admitted in the General Surgery Service presenting with obstructive jaundice by chronic pancreatitis. A triple Catell's bypass was carried out and during the postoperative course had vomiting containing non-digested fetid foods, ingested many hours or days ago. Barium radiography of esophagus, stomach and duodenum was obtained with a good contrast passage, verifying the presence of a very large epinephrine diverticulum causing the symptoms. She was operated on using as approach route a previous middle incision and trans-hiatal route. A vagotomy, diverticulectomy, extended esophageal myotomy, anti-reflux procedure and temporary jejunostomy for the early feeding. Course was favorable and patient remains asymptomatic(AU)

Divertículo epifrénico / Epinephrine diverticulum

El divertículo epifrénico provocado por el aumento de la presión intraesofágica a causa de alteraciones motoras subyacentes es raro; representa cerca del 10 por ciento de todos los divertículos esofágicos. Se presenta el caso de una paciente de 65 años de edad, que ingresó en el Servicio de Cirugía General con ictericia obstructiva por pancreatitis crónica. Se le realizó una triple derivación de Catell y durante la evolución posoperatoria comenzó a presentar vómitos que contenían alimentos sin digerir, fétidos, ingeridos con horas o días de antelación. Se le realizó una radiografía baritada de esófago, estómago y duodeno, con buen pase de contraste al duodeno, y se observó la presencia de un divertículo epifrénico de gran tamaño, responsable de los síntomas. Fue intervenida quirúrgicamente utilizando como vía de acceso una incisión media previa y vía transhiatal. Se practicó una vagotomía, diverticulectomía, miotomía esofágica extendida, procedimiento antirreflujo y yeyunostomía temporal para la alimentación precoz. La evolución fue favorable y la paciente está hoy asintomática(AU)

The epinephrine diverticulum due to the increase of intraesophageal pressure by underlying motor alterations is a rare entity; it accounts for around the 10% of all esophageal diverticula. This is the case of a female patient aged 65 admitted in the General Surgery Service presenting with obstructive jaundice by chronic pancreatitis. A triple Catell's bypass was carried out and during the postoperative course had vomiting containing non-digested fetid foods, ingested many hours or days ago. Barium radiography of esophagus, stomach and duodenum was obtained with a good contrast passage, verifying the presence of a very large epinephrine diverticulum causing the symptoms. She was operated on using as approach route a previous middle incision and trans-hiatal route. A vagotomy, diverticulectomy, extended esophageal myotomy, anti-reflux procedure and temporary jejunostomy for the early feeding. Course was favorable and patient remains asymptomatic(AU)

Interrupted aortic arch with cardiac heart failure in young adult.

The interrupted aortic arch (IAA) is a rare cardiopathy, with high morbimortality when treatment is delayed. This study is a case of IAA with atypical clinical behavior in a 19-year-old patient. The history and the clinical assessment were compatible with recent heart failure, associated to syncope episodes and reduction of pulses in the lower limbs. The electrocardiogram showed biventricular and biatrial overload. The echocardiogram showed severe ventricular dysfunction and altered blood flow in the descending aorta. The angiotomography disclosed occlusion of the thoracic aorta after the left subclavian artery. The attained diagnosis was interrupted aortic arch and surgical treatment was indicated.

Interrupção do arco aórtico como causa de insuficiência cardíaca em adulto jovem / Interrupted aortic arch with cardiac heart failure in young adult

A interrupção do arco aórtico é uma cardiopatia rara, com alta morbidade e mortalidade quando o manejo é retardado. Este artigo apresenta um caso com evolução atípica, em paciente de 19 anos. A história e o exame clínico eram compatíveis com insuficiência cardíaca recente, associados a episódios de síncope e diminuição de pulsos em membros inferiores. O eletrocardiograma mostrava sobrecarga biventricular e biatrial. O ecocardiograma mostrou disfunção severa dos ventrículos e alteração de fluxo em aorta descendente. Na angiotomografia, visualizou-se oclusão da aorta torácica após a artéria subclávia esquerda. O diagnóstico instituído foi de interrupção de aorta, sendo indicado tratamento cirúrgico.

The interrupted aortic arch (IAA) is a rare cardiopathy, with high morbimortality when treatment is delayed. This study is a case of IAA with atypical clinical behavior in a 19-year-old patient. The history and the clinical assessment were compatible with recent heart failure, associated to syncope episodes and reduction of pulses in the lower limbs. The electrocardiogram showed biventricular and biatrial overload. The echocardiogram showed severe ventricular dysfunction and altered blood flow in the descending aorta. The angiotomography disclosed occlusion of the thoracic aorta after the left subclavian artery. The attained diagnosis was interrupted aortic arch and surgical treatment was indicated.

Hybrid management for hypoplastic left heart syndrome : an experience from Brazil.

Initial surgical reconstruction for hypoplastic left heart syndrome (HLHS) is associated with satisfactory outcomes only in a few referral centers. Moreover, there is a persistent high-risk period for sudden death while the patient waits for the next surgical procedure. The development of a less invasive approach, so-called "hybrid," postponing a major surgery outside the neonatal period, might reduce the immediate and late surgical burden on these patients. This is a retrospective study of a contemporary series of patients with HLHS seen in two separate institutions. Patients with HLHS or its variants who underwent a "hybrid" management were included in the study. Data are described as the mean and standard deviation or absolute numbers and percentage, as appropriate. From January 2004 to June 2006, 15 patients (10 male; 5 +/- 3.8 days old and 2.9 +/- 0.5 kg) were included in the study. Ten had both mitral and aortic atresia; the ascending aorta and atrial septal defect measured 2.5 +/- 1.4 and 4.9 +/- 1.2 mm, respectively. There were six hospital survivors after stage I (mortality rate 60%). During the interstage period, all but one patient needed additional procedures. One patient died of bacterial meningitis 4 months after stage I. Four patients were submitted to stage II operation at 6.6 +/- 0.5 months of age and one is waiting for the operation. All four required early reinterventions for pulmonary artery stenosis. Only one was discharged home and was not yet submitted to the third stage. The hybrid approach for HLHS was associated with poor results in this early experience from two independent institutions in a developing country. This might have been related to infrastructure and technical problems, as well as our own learning curve. Institutions working under the same conditions might face similar problems during their initial experience.

Use of beta-blockers in the post-operative period of Sano modification of the Norwood procedure with persistent cyanosis.

Persistent cyanosis is a frequent complication in the post-operative period of Sano modification of the Norwood procedure. It may be explained by a dynamic proximal shunt stenosis of the synthetic conduit that links the right ventricle to the pulmonary artery, as detected by echo cardiographic study. The use of beta-blockers in the post-operative period has been recently described in order to improve the arterial oxygen saturation. In this report, we describe the use of propranolol in two patients undergoing Sano modification of the Norwood procedure, in whom a gradient reduction in the synthetic conduit, increase in the levels of arterial oxygen saturation, decrease in heart rate, and increase in blood pressure were observed, thus resulting in clinical improvement. We conclude that the use of beta-blockers in these cases was beneficial.

New transcatheter techniques for creation or enlargement of atrial septal defects in infants with complex congenital heart disease.

OBJECTIVES: To describe a series of 8 consecutive infants (5 with transposition of the great arteries [TGA] and 3 with hypoplastic left heart syndrome [HLHS]) who underwent nonconventional septostomy techniques. BACKGROUND: For some complex congenital heart defects, an unrestrictive atrial septal defect (ASD) is essential to achieve an adequate cardiac output and/or systemic saturation. In some scenarios, the use of conventional septostomy techniques may be technically difficult, hazardous, and/or ineffective. METHODS: Use of transhepatic approach, cutting balloons, and radiofrequency perforation with stenting of the atrial septum. RESULTS: The size of the ASD and the oxygen saturation increased in all patients with no major complications. In those with TGA, the ASDs were considered to be of good size at the arterial switch operation. Two of the 3 patients with hybrid palliation for HLHS have developed some degree of obstruction within the interatrial stent over 2-3 months. At surgery, the stents were found to be secured within the septum with one showing significant fibrous ingrowth after uneventful removal. The other had some nonobstructive ingrowth. CONCLUSIONS: Creation or enlargement of ASDs in infants using new nonconventional transcatheter techniques is feasible, safe, and effective, at least in the short-to-mid-term follow-up. Infants with TGA seem to benefit the most because the procedure results in satisfactory clinical stability for subsequent early surgical intervention. In infants with HLHS palliated by a hybrid approach, stent implantation to the atrial septum seems to buy enough time to bring them to the phase II safely despite progressive in-stent obstruction.

Uso de betabloqueador no pós-operatório de cirurgia de Norwood modificada por Sano com cianose persistente / Use of beta-blockers in the post-operative period of Sano modification of the Norwood procedure with persistent cyanosis

A cianose persistente constitui complicação freqüente no pós-operatório da cirurgia de Norwood modificada por Sano. Sua ocorrência pode ser explicada pela obstrução dinâmica da anastomose proximal do conduto sintético, que liga o ventrículo direito ao tronco pulmonar, evidenciada à ecocardiografia. A fim de melhorar a saturação arterial de oxigênio, foi recentemente descrita a utilização de betabloqueador, no período pós-operatório. Neste relato, descrevemos a utilização de propranolol em dois casos de cirurgia de Norwood modificada por Sano, demonstrando diminuição do gradiente no tubo sintético, aumento dos níveis de saturação arterial de oxigênio, diminuição da freqüência cardíaca e aumento da pressão arterial, traduzido em melhora clínica. Concluímos que autilização de betabloqueador nesses casos mostrou-se benéfica.

Persistent cyanosis is a frequent complication in the post-operative period of Sano modification of the Norwood procedure. It may be explained by a dynamic proximal shunt stenosis of the synthetic conduit that links the right ventricle to the pulmonary artery, as detected by echo cardiographic study. The use of beta-blockers in the post-operative period has been recently described in order to improve the arterial oxygen saturation. In this report, we describe the use of propranolol in two patients undergoing Sano modification of the Norwood procedure, in whom a gradient reduction in the synthetic conduit, increase in the levels of arterial oxygen saturation, decrease in heart rate, and increase in blood pressure were observed, thus resulting in clinical improvement. We conclude that the use of beta-blockers in these cases was beneficial.

Transhepatic access for atrioseptostomy in a neonate.

We report a case in which a neonate with complete transposition of the great arteries was submitted to an atrial septostomy through transhepatic access due to congenital interruption of the inferior vena cava. The technical aspects of the procedure are discussed.

Acesso trans-hepático para atriosseptostomia em neonato / Transhepatic access for atrioseptostomy in a neonate

Relatamos um caso de um neonato portador de transposição completa das grandes artérias que foi submetido a atrioseptostomia de Rashkind por acesso trans-hepático por interrupção congênita da veia cava inferior. Os aspectos técnicos do procedimento são discutidos.

We report a case in which a neonate with complete transposition of the great arteries was submitted to an atrial septostomy through transhepatic access due to congenital interruption of the inferior vena cava. The technical aspects of the procedure are discussed.

Pós-operatório nas cardiopatias congênitas / Postoperative management of the congenital heart diseases

O pós-operatório das cardiopatias congênitas envolve uma grande gama de procedimentos realizados à beira do leito na unidade de terapia intensiva pediátrica, procedimentos estes que envolvem monitorização de dados vitais, dados hemodinâmicos, análises laboratoriais, ajustes ventilatórios, suporte nutricional, infusão de drogas e, algumas vezes, procedimentos mais específicos, como diálise peritoneal ou hemodiálise. Esse "ritual" envolve uma equipe multidisciplinar de profissionais, que deve ter treinamento específico para tal tarefa. A adoção de estratégias específicas para os cuidados pósoperatórios facilita o trabalho dessa equipe. De maneira acadêmica, podemos dividir o atendimento no pós-operatório em dois grandes grupos: o grupo das correções cirúrgicas das cardiopatias simples e o grupo das cardiopatias complexas, que requerem procedimentos diferenciados e maior manuseio por parte da equipe de intensivistas. Procuramos dividir este artigo em duas partes distintas: nas estratégias comuns a todas as correções e nas estratégias específicas utilizadas nas correções das cardiopatias complexas...

Atendimento sistematizado do paciente com dor torácica e placa arterial instável / Management of patients with chest pain and unstable arterial plaque

A avaliação de pacientes com dor torácica ou outros sintomas consistentes com isquemia miocárdica continua sendo um grande desafio nas unidades de emergência. Grande número de pacientes procura essas unidades, gerando dificuldades na triagem, no diagnóstico e na identificação de pacientes com risco cardiovascular. Assim, muitas vezes, a avaliação inicial do médico emergencista não consegue confirmar e identificar com segurança os pacientes de risco. Torna-se necessária cuidadosa avaliação clínica, associada à utilização de recursos laboratoriais (principalmente os marcadores séri- cos miocárdicos -CK massa e troponina), exames de imagem e aplicação de algoritmos de abordagem da dor torácica, permitindo fazer o diagnóstico preventivo de um evitável infarto agudo do miocárdio. Por meio do diagnóstico precoce dos casos suspeitos, pode-se proceder à identificação segura e eficiente de pacientes de alto risco para serem admitidos, e dos casos de baixo risco passíveis de terem alta precoce com tempo de internação e custos menores, além da identificação dos diagnósticos diferenciais, principalmente em aorta (dissecção e aneurisma). Com o objetivo de auxiliar a solução dessa questão, vem evoluindo o conceito dos chamados centros de dor torácica, estruturados na unidade de emergência, que, por meio de um protocolo de atendimento e contando com recursos humanos e técnicos, têm a finalidade de assistir o paciente com dor no tórax de forma global, promovendo qualidade e presteza no diagnóstico e no tratamento da doença coronária, influenciando sua evolução por meio de procedimentos médicos...