ABC | Volume 113, Nº5, November 2019

Viewpoint Souza & Herdy Exercise-related SCAD in young people Arq Bras Cardiol. 2019; 113(5):988-998 which cannot be considered true SCAD. The risk factors of each patient were analyzed: 30.7% were smokers, 30% had high cholesterol and 15.3% had a family history of ischemic heart disease. Obesity was identified as a risk factor in only 1 of these patients. 18 Only one 25-year-old male, out of 13 patients,had SCAD without identifiable risk factors or atherosclerosis on the angiography. 20,27 Apparently, when related exclusively to physical exercise, SCAD presents variable, recurrent and sometimes prolonged or subacute symptoms. As reviewed by Ellis et al. 20 and also in two of the cases described in this article, five of these patients presented themselves later after the dissection event, the longest was a patient with symptoms after a cycling tour andwho suffered from angina for four months before seeking medical attention. 20,27,28 In a literature review, Sherrid et al. 19 also described 3 cases of exercise-related SCAD between 1965 and 1994, with varying clinical presentations. 19 Two patients were female, 38 and 39 years old, respectively, and both had no risk factors. The first one died after manifesting pain in the arms followed by seizure, and an autopsy, an intermedial dissecting hematoma of the proximal portion of the ADA was found. At the time, the patient was shoveling snow (moderate exercise). The second patient presented anteroseptal and lateral AMI also when performing moderate physical activity (running > 40 km per week). During the CATE, a left lumen compressed by a false lumen secondary to dissection was evidenced. The other arteries were normal. Finally, the male patient presented cardiopulmonary arrest during high-intensity exercise (marathon training) at a ventricular fibrillation rate. During the CATE, a dissection on of TBI trifurcation was observed obstructing flow in the ADA. Both surviving patients were treated with myocardial revascularization surgery, showing no symptoms after the procedure. 19 The case of DEAC in a 41-year-old woman on the ninth day of IVF therapy and without other risk factors was described by Balakrishnan et al. 18 The patient who presented chest pain during high-intensity exercise (body pump) was diagnosed with STEMI by emergency resting ECG and underwent emergency coronary angiography.During CATE, a double-lumen signal, secondary to dissection, was observed in SCAD. Due to the instability of the condition during intra-artery contrast injection (by dissection propagation), a pharmacological stent and angioplasty was chosen. The patient had a good clinical course. 18 The case of DEAC in a younger male patient was published by Kalaga et al., in 2007. 17 This is a 17-year-old boy, captain of the school's football team, who felt a heavy burden in the chest during a friendly match of basketball. He had no modifiable risk factors, but his father had died at 38 due to a massive heart attack. The ECG showed anterior STEMI and CATE showed proximal ADA dissection with a large amount of thrombus and normal distal flow. Other arteries had no changes. He was treated conservatively with glycoprotein IIb/IIIa inhibitor and was discharged eight days after hospital admission. He performed a posterior physical stress test that did not demonstrate myocardial ischemia. He was advised not to participate in physical activities with intense competition, but released for moderate physical activity, since there was not, and currently is not, clear recommendation regarding the practice of competitive activities in patients with a history of physical activity-related DEAC. 17 In the 3 cases described, no patient presented modifiable or non-modifiable risk factors for CAD. Figure 12 – Cardiac catheterization: recanalized artery with distal thrombus migration. 996