Eficácia de uma estratégia diagnóstica para pacientes com dor torácica e sem supradesnível do segmento ST na sala de emergência / Efficacy of a diagnostic strategy for patients with chest pain and no ST-segment elevation in the emergency room

PURPOSE: To evaluate the efficacy of a systematic model of care for patients with chest pain and no ST segment elevation in the emergency room. METHODS: From 1003 patients submitted to an algorithm diagnostic investigation by probability of acute ischemic syndrome. We analyzed 600 ones with no elevation of ST segment, then enrolled to diagnostic routes of median (route 2) and low probability (route 3) to ischemic syndrome. RESULTS: In route 2 we found 17 per cent acute myocardial infarction and 43 per cent unstable angina, whereas in route 3 the rates were 2 per cent and 7 per cent, respectively. Patients with normal/non--specific ECG had 6 per cent probability of AMI whereas in those with negative first CKMB it was 7 per cent; the association of the 2 data only reduced it to 4 per cent. In patients in route 2 the diagnosis of AMI could only be ruled out with serial CKMB measurement up to 9 hours, while in route 3 it could be done in up to 3 hours. Thus, sensitivity and negative predictive value of admission CKMB for AMI were 52 per cent and 93 per cent, respectively. About one-half of patients with unstable angina did not disclose objective ischemic changes on admission. CONCLUSION: The use of a systematic model of care in patients with chest pain offers the opportunity of hindering inappropriate release of patients with ACI and reduces unnecessary admissions. However some patients even with normal ECG should not be released based on a negative first CKMB. Serial measurement of CKMB up to 9 hours is necessary in patients with medium probability of AMI.

Dor torácica na sala de emergência: a importância de uma abordagem sistematizada / Chest pain in the emergency room: importance of a systematic approach

OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a pre-established process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74 per cent of these had a final diagnosis of acute myocardial infarction [AMI]). Of the 660 patients that remained in the emergency room under observation, 77 (12 per cent) had AMI without ST segment elevation and 202 (31 per cent) had unstable angina (UA). In route 2 (high probability of ACS) 17 per cent of patients had AMI and 43 per cent had UA, whereas in route 3 (low probability) 2 per cent had AMI and 7 per cent had UA. The admission ECG has been confirmed as a poor sensitivity test for the diagnosis of AMI ( 49 per cent), with a positive predictive value considered only satisfactory (79 per cent). CONCLUSION : A systematic diagnostic strategy, as used in this study, is essential in managing patients with chest pain in the emergency room in order to obtain high diagnostic accuracy, lower cost, and optimization of the use of coronary care unit beds.

Importância do diagnóstico precoce da dissecção aguda da aorta / Importance of an early diagnosis of acute acortic dissection

A dissecção aguda da aorta (DAA) é uma patologia potencialmente fatal, não muito comum, que necessita de um diagnóstico precoce e de conduta terapêutica imediata eficaz. A DAA é uma doença de instalação súbita e evolução catastrófica, que tem uma mortalidade diretamente relacionada ao tempo de evolução da doença, sendo que pacientes não tratados, ou que tem seu diagnóstico retardado, apresentam uma mortalidade em torno de 25por cento nas primeiras 24 horas, ou 1por cento por hora, nas primeiras 48 horas. Nas últimas décadas houve avanços promissores no tratamento clínico e cirúrgico, mudando o prognóstico desses pacientes. A alta suspeita diagnóstica é feita através da realização de uma boa história e exame clínico, pricipalmente em pacientes que se apresentem com dor torácica associada a alguns fatores de risco específicos, como hipertensão e doenças do tecido conectivo. Esta suspeita clínica pode ser confirmada rapidamente através de métodos de imagem não invasivos ou semi-invasivos com boa acurácia diagnóstica ou, se necessário, através de aortografia. A terapêutica inicial deve ser introduzida juntamente com a suspeita clínica, através do uso de inotrópicos negativos e anti-hipertensivos. A partir da confirmação diagnóstica, então o tratamento cirúrgico imediato deverá ser procedido em caso de envolvimento de aorta ascendente ou conduta clínica conservadora, se houver acometimento de aorta descendente sem complicações