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Case 408

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An 81-year-old woman who presented with a 15-day history of chest discomfort, onset over two hours with continuous, squeezing, retrosternal pain, not relieved by rest and without radiation. Past medical history: coronary artery disease (CAD), arterial hypertension, dyslipidemia and ischemic stroke in 2010. On examination, HR: 120 bpm, electrocardiography (image 1) and troponin I: 0,057ng/mL (RV: 0,034ng/mL). No other comorbidities related.

According to the clinical history and the electrocardiographic findings presented, what is the probable diagnosis? Abbreviations: STEMI - ST-segment elevation myocardial infarction; NSTEMI - non-ST elevation myocardial infarction

a) Type 2 MI, NSTEMI, caused by atrial fibrillation due to rapid ventricular response.

25%

b) Type 1 MI, STEMI, precipitated by atherosclerotic plaque disruption.

25%

c) Type 2 MI, NSTEMI, caused by sinus tachycardia.

25%

d) Unstable angina, there is not enough evidence to diagnose myocardial infarction.

25%
   

Image analysis

Image 1 - Electrocardiography, I, II and III leads presenting irregular rhythm  (irregular iRR - yellow arrows), P wave absence (blue circles), regular QRS complex length (

Highlights

  • - One third of all deaths worldwide is caused by cardiovascular diseases, only acute coronary syndrome is responsible for 1,8 million deaths per year.

  • - MI diagnosis is made by anginal pain, electrocardiographic findings due to myocardial injury biomarkers.

  • - It is necessary to make the different diagnoses between MI type 1 and 2 for tepheutics purposes. 

  • - Acute atherothrombotic coronary artery disease, precipitated by atherosclerotic plaque disruption is the main cause of type 1 MI. On the other hand, type 2 MI is multifactorial, consequent to a mismatch between oxygen supply and demand.

  • - Fibrinolysis is not indicated in patients with type 2 MI and the primary cause resolution is essential for hemodynamic stabilization.

References

  • 1. Neumann J, Sörensen N, Rübsamen N, Ojeda F, Renné T, Qaderi V et al. Discrimination of patients with type 2 myocardial infarction. European Heart Journal. 2017;38(47):3514-3520. 

  • 2. Sanchis-Gomar F, Perez-Quilis C, Leischik R, Lucia A. Epidemiology of coronary heart disease and acute coronary syndrome. Annals of Translational Medicine. 2016;4(13):256-256. 

  • 3. Thygesen K, Alpert J, Jaffe A, Chaitman B, Bax J, Morrow D et al. Fourth universal definition of myocardial infarction (2018). European Heart Journal. 2018;40(3):237-269. 

Authors

Ana Clara de Paula Caldas, 4th year medical student.

E-mail: anacpcaldas [at] gmail.com 

Supervisor:

Dr. Bruno Ramos Nascimento, cardiologist and professor of Minas Gerais Federal University (UFMG).

E-mail: ppchristo [at] gmail.com

Reviewers:

Marco Fontana; André Luís Drumond; Flávio Augusto Paes; Melina Araújo, Renata Aguiar, prof. Júlio Guerra Domingues.

Translated by:

Ana Clara de Paula Caldas, 3rd year medical student.

E-mail: anacpcaldas [at] gmail.com

Test question

Residência Médica 2015 (ACESSO DIRETO 1) - Sistema único de saúde - SUS - São Paulo SP

In patients with acute coronary syndrome who have increased troponin and CK-MB, presenting NSTEMI, there is no evidence of benefit in the use of:

 

a) EV nitroglycerin

25%

b) Low molecular weight heparin

25%

c) Conventional heparin

25%

d) Antiplatlet agents

25%

e) Thrombolytics

25%
   

Commentics

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