ABC | Volume 113, Nº4, October 2019

Anatomopathological Correlation Martins et al. Cardiac failure after non-ST-elevation myocardial infarction Arq Bras Cardiol. 2019; 113(4):775-782 Figure 4 – 4-chamber magnetic resonance imaging - circumferential late enhancement. compared outcomes of patients diagnosed with type 1 AMI, type 2 AMI, and myocardial injury and showed that the risk of death was higher among those with a history of type 2 AMI compared to those with a history of type 1 AMI, even after variable adjustment. Most deaths in the first 2 groups were due to noncardiac causes. Regarding major cardiovascular events, there was no difference between the groups. Coronary artery disease was an independent predictor of major cardiovascular events among patients with type 2 AMI or myocardial injury with a 1.71 odds ratio and a confidence index of 1.31-2.24. 5 Management of type 2 AMI remains uncertain and there are no well-defined clinical management strategies. Initial management should be performed by controlling the precipitating factor that leads to an imbalance in the demand and supply. 6 Another study published in 2019 showed that almost 30% of the patients in the sample were diagnosed with type 1 AMI when they actually had a type 2 AMI diagnosis. 6 Regarding myocarditis, it is known that this entity consists of a myocardial inflammatory process with multiple presentation aspects, from asymptomatic presentations to sudden death, including heart failure and fulminant presentations in this spectrum. The etiological agents are diverse, including viral or bacterial, fungal or protozoal infections, hypersensitivity reaction, autoimmune diseases and toxins. 7 Regarding the epidemiological evaluation, it is known that it is an underdiagnosed disease, with a bimodal peak (ranging from 1 year and 20 years) and corresponds to an important cause of cell loss by direct action necrosis of the virus, cytotoxic agents with inflammatory mediators and oxidative stress products. 8 After the initial action process of the immune system, there may be an improvement in conditions, fighting the myocyte aggressive organism and reducing the immune response or persistence of the injury due to persistent aggressivemechanisms or exacerbated immune responses. 9 In regards to complementary exams, there is usually an increase in inflammatory markers and there may be an increase in myocardial necrosis markers. As for ECG, there may not be changes or changes that are not specific, and the echocardiogram findings may also be variable and include diffuse hypokinesia, pericardial effusion, or segment changes. Magnetic resonance imaging is a fundamental exam, as it presents high sensitivity and specificity for myocardial inflammatory processes, and may show segment changes, regional hypertrophy, dilatation of the cardiac chambers. In the endomyocardial biopsy assessment, the exam has high levels of specificity, with moderate sensitivity. Class I indications by the Brazilian Myocarditis Guideline for biopsy include the IC level for cases lasting up to 2 weeks with no established cause with progressive haemodynamic worsening, and IC for cases beginning less than 3 months ago and more than 15 days after, no definite cause and presenting ventricular arrhythmias or second and third degree atrioventricular blocks. 10 Regarding treatment, uncomplicated cases do not require specific approaches, only symptomatic management and rest guidelines. Heart failure cases that present decreased ejection fraction require special attention and must receive medications that are known to reduce mortality. Cases requiring antiviral treatment and immunosuppressive therapy need tobe evaluated. 10 The prognosis of myocarditis is favorable in most cases. A study published in 2019 showed that 13%of the evaluated patients had a poor evolution. 11 Summarizing, despite raising other hypotheses for the recent onset of IC, the hypothesis of coronary disease is still the main one for this patient due to risk factors, epidemiological context and alteration of complementary exams. (Dr. Ana Vitória VitoretiMartins andDr. José RobertodeOliveira da Silva Filho) Diagnosis hypothesis: Type 2 infarction with heart failure; death from cardiogenic shock. (Dr. Ana Vitória Vitoreti Martins and Dr. José Roberto de Oliveira da Silva Filho) Necropsy The necropsy showed the presence of myocardial infarction in the final healing phase in all left ventricular walls (Figures 5 and 6). 779