ABC | Volume 111, Nº6, December 2018

Anatomopathological Correlation Nunes et al Chest pain and shock in a patient with ischemic heart disease Arq Bras Cardiol. 2018; 111(6):860-863 Figure 1 – Electrocardiogram - Sinus rhythm, low voltage of the QRS complex in the frontal plane, electrically inactive area in the inferior wall and left bundle branch block. Figure 2 – Electrocardiogram - Sinus rhythm, left bundle branch block and positive T waves on an also positive derivative of the QRS complex. the possibility of acute myocardial infarction should be considered, especially in case of hemodynamic instability. Criteria such as those proposed by Sgarbossa et al., 2 and Smith et al., 3 modified by other authors can contribute to the diagnostic accuracy improvement in this context. 2,3 However, one should consider that the occurrence of left bundle branch block is more commonly a marker of previous structural heart disease. The patient had a cardiorespiratory arrest with pulseless electrical activity (PEA) within a short time after hospital admission. In cases of acute myocardial infarction, PEA can occur in patients with severe ventricular dysfunction and cardiogenic shock and/or mechanical complications such as rupture of the left ventricular free wall with cardiac tamponade, papillary muscle rupture and / or severe dysfunction and acute interventricular septal defect. Other conditions should be considered in patients with acute chest pain who present with rapid clinical deterioration such as aortic dissection and pulmonary thromboembolism. The chest x-ray showed a massive pleural effusion in the right hemithorax, although this finding was not readily apparent at the physical examination. In this patient, pleural effusion may be due to chronic heart failure decompensation but may also be associated with other conditions, such as rheumatologic diseases, tuberculosis or pleural carcinomatosis due to neoplasias. The last two conditions mentioned here are not uncommon in patients with chronic heart diseases. Additionally, massive pleural effusions may coexist, in some conditions, with pericardial involvement and consequent cardiac tamponade. 4 Pleural effusion may also be present in patients with acute aortopathies, such as dissection of the aorta and aortic ulcer with associated rupture, but usually the most frequent effusion is located in the left pleural space as a consequence of the aortic anatomy. (Dr. Hilda Sara Montero Ramirez) Main hypothesis: Acute myocardial infarction complicated by cardiogenic shock. (Dr. Hilda Sara Montero Ramirez) Differential diagnoses: Cardiac tamponade, Pulmonary thromboembolism and Dissection of the aorta. (Dr. Hilda Sara Montero Ramirez) Necropsy The heart weighed 422 g and showed increased volume, with cross-sections (short axis of the ventricles) disclosing a 861