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CASE REPORT
Coronary atherosclerotic plaque rupture following thoracic trauma – an uncommon cause of angina and ventricular tachycardia (“torsade de pointes”)
Luís Henrique Wolff Gowdak, Márcio Sommer Bittencourt
Corresponding author
msbittencourt@bol.com.br

Tel.: 55 11 30623124
, Carlos Eduardo Rochitte, Luís Alberto Oliveira Dallan, Luiz Antonio Machado César
Cardiologia Clínica, Instituto do Coração (InCor), Faculdade de Medicina da Universidade de São Paulo, São Paulo/SP, Brazil.
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">CASE REPORT</span><p id="para10" class="elsevierStylePara elsevierViewall">Blunt thoracic trauma has been previously described as a rare and often missed cause of acute myocardial infarction&#44;<a class="elsevierStyleCrossRef" href="#bib1">1</a> cardiac rupture&#44; ventricular aneurysms&#44;<a class="elsevierStyleCrossRef" href="#bib2">2</a> aortocoronary bypass occlusion&#44;<a class="elsevierStyleCrossRef" href="#bib3">3</a> coronary aneurysms&#44;<a class="elsevierStyleCrossRef" href="#bib4">4</a> angina&#44;<a class="elsevierStyleCrossRef" href="#bib5">5</a> and arrhythmias&#46;<a class="elsevierStyleCrossRef" href="#bib6">6</a></p><p id="para20" class="elsevierStylePara elsevierViewall">Here&#44; we report the case of a 44-year-old man whose complaints of exertional chest pain and lightheadedness began after suffering a motor-tricycle accident with blunt thoracic trauma 1 month earlier&#46; His past history was unremarkable except for mild hypercholesterolemia&#59; he was overweight and had a familial history of early-onset myocardial infarction&#46;</p><p id="para30" class="elsevierStylePara elsevierViewall">Immediately after the accident&#44; the patient began to experience chest pain associated with lightheadedness&#44; sweating&#44; and pale skin while walking briskly&#59; the symptoms were relieved by resting and lasted less than five minutes&#46; He sought medical attention in an emergency department from another facility seven days after the accident&#46; Bruises were observed in the epigastrium close to the 12<span class="elsevierStyleSup">th</span> left costal arch&#44; with tenderness in the left anterior thoracic wall&#59; the physical exam was otherwise normal&#46; No fractures were revealed by a chest X-ray&#46; A 12-lead resting ECG yielded normal results&#44; but CKMB-mass and troponin-I levels were slightly elevated&#46; Coronary angiography was performed and revealed a non-obstructive plaque in the left main coronary artery &#40;LM&#41; and 50&#37; stenosis of the proximal left anterior descending artery &#40;LAD&#41;&#46; No obstructions were seen in the circumflex or right coronary artery&#46; Cardiac scintigraphy &#40;<span class="elsevierStyleSup">99m</span>Tc- Sestamibi with dipyridamole&#41; did not indicate any myocardial perfusion defects&#59; a transthoracic echocardiogram revealed preserved left ventricular function and a very small pericardial effusion with no sign of cardiac restriction&#46; The patient was discharged with diagnoses of uncomplicated thoracic trauma and non-critical coronary atherosclerosis&#44; with a referral for medical treatment&#46;</p><p id="para40" class="elsevierStylePara elsevierViewall">Amlodipine&#44; aspirin&#44; and pravastatin were prescribed&#44; but the patient&#39;s symptoms did not improve&#46; Due to the persistence of symptoms&#44; the patient was later seen by a cardiologist&#44; who ordered a treadmill test&#46; During the first stage of the Bruce protocol&#44; between the 2<span class="elsevierStyleSup">nd</span> and 3<span class="elsevierStyleSup">rd</span> minutes of exercise&#44; the patient developed a non-sustained polymorphic ventricular tachycardia &#40;<span class="elsevierStyleItalic">&#8220;torsade de pointes&#8221;</span>&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1A</a>&#41;&#44; followed by ST-T ischemic changes &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1B</a>&#41;&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><p id="para50" class="elsevierStylePara elsevierViewall">A high-resolution ECG and cardiac magnetic resonance imaging study were normal&#44; excluding right ventricular dysplasia and myocardial fibrosis due to myocarditis or to an old infarction scar&#46; Previously undiagnosed myocardial ischemia secondary to coronary atherosclerosis was presumed to be the cause for his symptoms&#44; along with exercise-induced ventricular arrhythmia&#46; Surgical myocardial revascularization was therefore advised&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">Due to the persistence of symptoms and the high-risk features of the patient&#39;s treadmill activity &#40;not only because of the low level of activity associated with ischemic changes but also because of the high-risk arrhythmia associated with the ischemic changes&#41;&#44; surgical treatment was chosen as the most appropriate therapy&#46;</p><p id="para70" class="elsevierStylePara elsevierViewall">The patient underwent an off-pump coronary artery bypass graft with arterial grafts to the LAD and circumflex arteries four weeks after the initial presentation&#46; It should be noted that&#44; during surgery and before the graft was placed&#44; as the surgeon inspected the heart looking for evidence of cardiac trauma&#44; ST-T elevation was observed on the heart monitor&#46; This observation was confirmed by ECG and persisted for 24 h&#44; evolving with new Q waves in leads II and III and poor progression of R waves in leads V1 through V3&#44; with a striking elevation of CKMB-mass &#40;which peaked at 25 times the normal level 17 h after surgery&#41;&#46; An echocardiogram performed on the second day postoperatively revealed a very small area of hypokinesia in the apex&#46; The patient had an uneventful recovery&#46; An echocardiogram performed at the one-month follow-up was completely normal&#46;</p><p id="para80" class="elsevierStylePara elsevierViewall">Another treadmill test was performed forty days after surgery&#59; the patient was able to tolerate maximal exercise&#44; and no ECG changes suggestive of myocardial ischemia or arrhythmias were observed&#46; A coronary computed tomography angiogram &#40;16&#215;0&#46;5-MDCTA&#44; Aquilion16TM&#44; Toshiba Medical Systems Corporation&#44; Otawara&#44; Japan&#41; with calcium score evaluation revealed a non-calcified atherosclerotic plaque on the proximal segment of the LAD&#46; Inside the plaque&#44; an area of very low density &#40;&#60;40 Hounsfield Units&#41; was observed &#40;<a class="elsevierStyleCrossRef" href="#fig2">Figure 2</a>&#41;&#44; a finding compatible with a coronary thrombus&#46; Both of the grafts were patent&#46;</p><elsevierMultimedia ident="fig2"></elsevierMultimedia><p id="para90" class="elsevierStylePara elsevierViewall">Although acute myocardial infarction &#40;AMI&#41; caused by a trauma with laceration of the coronary arteries has been previously described in many case reports&#44;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;7</a> especially in the vicinity of the LAD&#44; most reported cases involved ST-elevation MI or ventricular aneurysm preceded by a history of trauma&#44; as recently reviewed&#46;8 In the present case&#44; myocardial necrosis was detected by serum markers one week after chest trauma&#44; even though the ECG remained normal&#46; Coronary intravascular ultrasound was not recommended to further investigate the extension of the stenotic lesions due to the risk of disrupting the left main plaque&#46; Thus&#44; the initial CK-MB and elevation of troponin might have been caused by direct trauma&#44; whereas the ruptured plaque and thrombus might be responsible for the delayed clinical symptoms&#46;</p><p id="para100" class="elsevierStylePara elsevierViewall">Notably&#44; there was a striking moment in time relating the thoracic trauma and the onset of anginal symptoms&#46; We believe that a more careful interpretation of the patient&#39;s presenting symptoms would have been helpful to identify the cause&#46; Non-invasive imaging revealed a coronary thrombus inside an atherosclerotic plaque&#44; most likely resulting from the chest trauma and leading to exercise-induced ischemia and malignant ventricular arrhythmia&#46; However&#44; the possibility of post-CABG thrombus formation cannot be excluded&#44; as the CT was only performed after surgery&#46;</p><p id="para110" class="elsevierStylePara elsevierViewall">Another important finding in this case report was the intraoperative myocardial infarction&#46; The most probable etiology of this event was the dislodgement and embolization from the thrombus&#44; which previously rested on the ruptured plaque&#46; Other possible causes of intraoperative myocardial infarction&#44; including hemodynamic instability or surgical technique&#44; are improbable in the present case&#46;</p><p id="para120" class="elsevierStylePara elsevierViewall">At a follow-up visit one year after the procedure&#44; the patient was doing well and had not experienced the recurrence of any of his symptoms&#46;</p></span></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos