ABC | Volume 113, Nº5, November 2019

Viewpoint Souza & Herdy Exercise-related SCAD in young people Arq Bras Cardiol. 2019; 113(5):988-998 insidious retrosternal chest fatigue and discomfort evolving for a month, with strong intensity and short duration, related to intense physical efforts (soccer training) and relieved at rest. He denied irradiation or associated symptoms, but presented progressive symptom worsening. The patient, who initially only had indefinite tiredness at the end of the match, ended up developing burning chest pain early in the training. Upon physical examination, the patient was well overall, eupneic at ambient air, normal color, acyanotic, feverless and anicteric. The patient weighed 79 kg; 1.79 m tall; with a heart rate of 60bpm; and blood pressure (BP) at 120/80 mmHg. Chest examination showed an apical thrust and normal heart and lung sounds. Pulses were symmetrical with normal amplitudes and there was no peripheral edema. Laboratory tests within normal limits. Resting ECG evidenced ARV with anterior septum T-wave inversion (Figure 8). Following the investigation, he underwent ergospirometric testing that showed no arrhythmias or electrocardiographic changes for myocardial ischemia, but there were symptoms of mild typical chest pain during the examination and abnormal findings concerning oxygen consumption ( VO2 ) - 48.3mL/kg/min (the reference standard was 48.9); and the oxygen pulse was 21.1 ml 02/bpm (the reference standard was 19.9), with a plateau curve at the peak effort reached. He then underwent transesophageal echocardiography, which showed normal wall thickness and dimensions, no septal defects and normal LV systo diastolic function, despite anteroapical hypokinesia. The patient remained with anginal pain when an anatomical evaluation with CT angiography was necessary and showed proximal obstruction in the ADA which presented normal distal flow due to the receipt of collateral circulation in the right circumflex and coronary arteries. The examination disregarded coronary atherosclerosis (Figures 9 and 10). Thrombophilias, rheumatological, inflammatory and connective tissue diseases were also investigated; with negative results. Due to the obstruction of the ADA, we investigated the repercussion of this lesion on ventricular function by myocardial scintigraphy, which showed transient hypocaptation in the anterior, apical and septal walls with great extent, reaching 28% of the LV. Once the lesion was evidenced and its relevant repercussion was demonstrated, the patient was submitted to CATE, confirming the previous findings, in which the ADA TCA was performed with a pharmacological stent (Promus 4.0×2.8mm), although the patient was aware of the possibility of distal embolization, resulting in a final TIMI 3 flow. After the procedure, the patient remained asymptomatic receivingdailyASA, prasugrel andcontinuedcardiac rehabilitation. A control scintigraphy, after three months of CATE, demonstrated total reversal of myocardial ischemia. Currently, the patient remains asymptomatic, performing outpatient follow-up, and practicing intense physical activity. Case 3 Patient R.O.H, male, 31 years old, amateur soccer athlete (2 times/week), without risk factors for early CAD, without previous use of drugs, anabolic, ergogenic, illicit or anorectic drugs. Negative family history for coronary heart disease, cardiomyopathy or thrombotic disease. Sought medical guidance due to dyspnea and tiredness which started after practicing 1h of football. Symptoms progressively worsened, progressing to moderate-intensity retrosternal chest pain and irradiation to the left upper limb, with a 2h course, with no other associated symptoms. He reported a similar and single episode about a month earlier, in a similar situation, with spontaneous resolution after 2h feeling bad and having dyspnea. On admission to hospital, he was in good general conditions, hypotensive, sweating, tolerating ambient air, normal color, acyanotic, feverless and anicteric. He weighed 74 kg; was 1.69 m tall; and had a heart rate of 48 bpm; and BP 60/30 mmHg. BP maintenance was required, which increased rapidly after an infusion of 500 mL crystalloid (119/90 mmHg). There were no changes in cardiac and pulmonary auscultation; extremities were not infiltrated. On admission, the ECG showed ST-segment junctional rhythm in DII, DIII, aVF, V7, and V8 leads, and the was diagnosed with inferodorsal ST-segment elevation myocardial infarction. Measurements for ACS were performed and referred to CATE, showing right dominance with severe proximal lesion (95%) in SCAD and a large amount of thrombi. Primary ATC performed for thrombus aspiration SCAD. Thrombi migrated to the distal portion of the ventricular and posterior descending arteries, and tirofiban was initiated (Figures 11 and 12). He remained hospitalized for 4 days, with asymptomatic evolution, being discharged with a prescription of daily use of AAS 100 mg; clopidogrel 75 mg; atenolol 50 mg and rosuvastatin 10 mg. Remains asymptomatic and has returned to football practice approximately 4 times/week. Discussion Vigorous exercise is known to cause acute ischemia, but such events often occur in patients with established or underdiagnosed CAD. 19,23,24 Reports of exercise-related SCAD in young patients without risk factors or CADare rare in the literature. 17-20 Most of theoccurrences were described among young women related to the peripartum period, Marfan syndrome, oral contraceptive use, primary vascular diseases (vasculitis), or in patients with already diagnosed atherosclerosis or undiagnosed subclinical disease. 1-3,13,14,25,26 Although some publications estimate the prevalence of ACSD between 23 and 36% in some populations (female), 2,13 the actual prevalence of ACSD as the etiology of ACS in the general population remains uncertain. 1 993