2009;93(4) – ABC CARDIOL

Página do Presidente

64th Brazilian Congress of Cardiology is the largest in SBC's history

Antonio Carlos Palandri Chagas

THE PRESIDENT’S PAGE

64^th Brazilian congress of cardiology is the largest in SBC’s history

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Artigo Original

Dante Pazzanese risk score for non-st-segment elevation acute coronary syndrome

Elizabete Silva dos Santos et al. Ari Timerman Valéria Troncoso Baltar Maria Tereza Cabrera Castillo … Marcos Paulo Pereira Luiz Minuzzo Leopoldo Soares Piegas

BACKGROUND: The probability of adverse events estimate is crucial in acute coronary syndrome condition. OBJECTIVES: To develop a risk score for the brazilian population presenting non-ST-segment elevation acute coronary syndrome. METHODS: One thousand and twenty seven (1,027) patients were investigated prospectively at a cardiology center in Brazil. A multiple logistic regression model was developed to estimate death or (re)infarction risk within 30 days. Model predictive accuracy was determined by C statistic. RESULTS: Combined event occurred in 54 patients (5.3%). The score was created by the arithmetic sum of independent predictors points. Points were determined by corresponding probabilities of event occurrence. The following variables have been identified: age increase (0 to 9 points); diabetes mellitus history (2 points) or prior stroke (4 points); no previous use of angiotensin converting enzyme inhibitor (1 point); creatinine level increase (0 to 10 points); the combination of troponin I level increase and ST-segment depression (0 to 4 points). Four risk groups were defined: very low (up to 5 points); low (6 to 10 points ); intermediate (11 to 15 points ); high risk (16 to 30 points ). The C statistic was 0.78 for event probability, and 0.74 for risk score. CONCLUSION: A risk score of easy application in the emergency service was developed to predict death or (re)infarction within 30 days in a brazilian population with non-ST-segment elevation acute coronary syndrome.

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Artigo Original

Frequency of left ventricular diastolic dysfunction by mitral doppler in healthy elderly individuals

Luiz Sérgio Alves-Silva et al. Edmundo José Nassri Câmara Carlos Alfredo Marcílio de Souza

BACKGROUND: Healthy elderly individuals present alterations in mitral Doppler velocities, which are characteristic of left ventricular (LV) diastolic dysfunction with impaired relaxation. OBJECTIVE: To determine the frequency of LV diastolic dysfunction by mitral Doppler in healthy elderly individuals and identify clinical and echocardiographic characteristics associated to this finding. METHODS: Seventy-three apparently healthy individuals (64% women, aged 60 to 80) were carefully selected and submitted to clinical, laboratory and Doppler-echocardiographic assessment, with particular regard to the characteristics of the mitral flow. RESULTS: A total of 33 patients (45%) presented an impaired LV relaxation pattern (group I), characterized by the association between the maximum velocities of the mitral wave flow (E/A ratio) 240 ms, and 40 (55%) with a normal pattern (group II). Group I presented a larger aortic root diameter (32.1±4.2 vs 30.3±3.3 mm; p=0.044) and a longer PR interval (156±22 vs 139±23 ms; p=0.002). CONCLUSION: A large proportion of individuals aged 60 to 80 years present normal diastolic function at the Doppler-echocardiographic assessment of the mitral flow. Healthy elderly individuals with impaired LV relaxation filling have a larger aortic root diameter and longer PR interval.

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Artigo Original

Study of vascular reactivity in HIV patients whether or not receiving protease inhibitor

Hamilton Nenrod Pereira Teixeira et al. Evandro Tinoco Mesquita Mário Luiz Ribeiro Anna Ricordi Bazin … Cláudio Tinoco Mesquita Manuel Pereira Teixeira Rafael da Cunha Pellegrini Antonio Claudio Lucas da Nóbrega

BACKGROUND: A great number of HIV-infected patients using antiretroviral drugs develop endothelial dysfunction and atherothrombosis, which lead to a high medical and social burden. Thus, it is important to identify pathophysiological mechanisms involved with the endothelial function in these patients, so that early intervention can be made to avoid disease progression. OBJECTIVE: To evaluate endothelial function using endothelium-dependent and independent vasodilation in HIV-positive patients and in a control group. METHODS: A total of 27 HIV-positive patients and 16 controls were evaluated. Endothelium-dependent (reactive hyperemia) and independent (SL nitroglycerine) vasodilation of the brachial artery was used to evaluate the endothelial function. RESULTS: HIV-positive patients receiving protease inhibitors (PI) showed significantly lower endothelium-independent vasodilation than the HIV-negative (p=0.020) and HIV-positive without PI (p=0.034) subgroups. The change in brachial artery diameter during active hyperemia was not statistically significant in any subgroup. Multiple linear regression analysis showed that only PI was associated with the relative delta of brachial reactivity to vasodilator in HIV-positive patients at 60s and 90s. CONCLUSION: HIV-positive patients receiving PI presented endothelium-independent dysfunction when compared to HIV-positive patients not receiving PI and to the control group.

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Artigo Original

Late enhancement and myocardial perfusion in hypertrophic cardiomyopathy (comparison betw een groups)

Clarissa Almeida Sarmento Barbosa et al. Cláudio Campi de Castro Luiz Francisco Rodrigues de Ávila José Rodrigues Parga Filho … Domingos Mohanad Hattem Edmundo Arteaga Fernandez

BACKGROUND: The magnetic resonance imaging (MRI) is an effective method to study hypertrophic cardiomyopathy (HCM). OBJECTIVE: To evaluate, using MRI, the parameters of systolic function, perfusion and myocardial viability in patients with HCM, comparing the groups with and without obstruction of the left ventricular outflow tract. METHODS: Twenty-one patients with a diagnosis of HCM underwent the assessment of myocardial function, viability and perfusion under stress and at rest through MRI. RESULTS: The ventricular segments most severely impaired by hypertrophy were those of the septal region. The obstructive group presented segmental myocardial thickening distribution similar to the non-obstructive group, but with higher means than the first group. The mean ejection fraction of the patients in the obstructive group was higher than in the non-obstructive group, whereas the means of the end systolic and diastolic volumes were lower in the obstructive group. There was a positive correlation between the ventricular segmental thickening and the late enhancement segmental mass. The stress induction resulted in an increase in the number of segments with perfusion alterations and this alteration was more evident in the obstructive group. CONCLUSION: The thickest ventricular segments are the septal ones. The hypertrophic regions are associated to a greater extension of late enhancement. There was a positive correlation between the areas of ventricular hypertrophy and altered myocardial perfusion and these findings were more evident in the obstructive group.

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Artigo Original

Cardiorespiratory and perceptual responses to walking and running at the same speed

Walace David Monteiro et al. Claudio Gil Soares de Araújo

BACKGROUND: It is possible that different forms of locomotion, when carried out at the same speed, may have a distinct influence on the physiological and perceptual responses to exercise. OBJECTIVE: To compare the cardiorespiratory responses and the subjective perception of the effort to walk and run at the same speed, as determined from the walk-run transition speed (WRTS). METHODS: From an initial sample of 453 subjects enrolled in the compulsory military service, 12 young adult men were selected and carefully homogenized as to age, sex, anthropometric characteristics, aerobic condition and experience in a treadmill. In preliminary sessions, the individual WRTS was determined. Thereafter, on three different days, the subjects walked and ran in balanced order, in each of the following speeds: WRTS; WRTS – 0.5 km/h; WRTS + 0.5 km/h, so as to obtain exhaled gases, heart rate (HR) and perception of effort measurements. RESULTS: The protocol for WRTS detection was highly reproducible (r = 0.92, p <0.05). In an intensity of exercise above the WRTS, the perceived effort, the HR, and the ventilatory variables-VE, VO2, VCO2 and R-showed higher values during walking than during running (p 0.05). CONCLUSION: Walking at a speed above the WRTS tends to be more stressful to the subject, from a physiological and perceptual point of view. It seems appropriate to individualize the WRTS and standardize the form of locomotion for determining a more accurate and physiological intensity of the aerobe exercises.

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Brief Communication

22q11.2 duplication and congenital heart defects

Rafael Fabiano Machado Rosa et al. Paulo Ricardo Gazzola Zen Cláudia Pires Ricachinevsky Carlo Benatti Pilla … Vera Lúcia Berenstein Pereira Tatiana Roman Marilela Varella-Garcia Giorgio Adriano Paskulin

BRIEF COMMUNICATION

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Case Report

Postpartum torsades de pointes and long QT syndrome

Alexandre Maulaz Barcelos et al. Marco Antônio Teixeira Marcelo da Costa Maia Luiz Eduardo Montenegro Camanho Otávio Queiroz Assumpção

This article reports the case of a puerperal patient admitted with diagnosis of urinary tract infection and heart failure. This condition evolved with torsades de pointes ventricular arrhythmias, then, hypokalemia, and use of Ciprofloxacin. Ventricular arrhythmias did not present any improvement after potassium and magnesium replacement, but after implantation of temporary pacemaker, this condition showed signs of improvement. The patient was discharged with QTc at 490 ms, taking Propranolol.

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Artigo Original

Systolic function of patients with myocardial infarction undergoing autologous bone marrow transplantation

Fernanda Belloni dos Santos Nogueira et al. Suzana Alves Silva Andrea Ferreira Haddad Cintia M. Peixoto … Rodrigo Moreira de Carvalho Fabio Antonio A. Tuche Vinício Elia Soares André Luiz Silveira Sousa Arnaldo Rabischoffsky Claudio Tinoco Mesquita Radovan Borojevic Hans Fernando Rocha Dohmann

BACKGROUND: Several studies have been published on the effect of bone-marrow stem cells on the left ventricle when acting on post- acute myocardial infarction remodeling. However, the results have been controversial. OBJECTIVE: To carry out an echocardiographic analysis of the systolic function of patients with acute myocardial infarction after autologous mononuclear bone marrow cell transplantation (AMBMCT) as performed via the intracoronary and intravenous routes. METHODS: This is an open-label, prospective, randomized study. Inclusion criteria: patients admitted for ST-elevation acute myocardial infarction (MI) who had undergone mechanical or chemical reperfusion within 24 hours of the onset of symptoms and whose echocardiogram showed decreased segmental wall motion and fixed perfusion defect related to the culprit artery. Autologous bone marrow was aspirated from the posterior iliac crest under sedation and analgesia of the patients randomly assigned for the treatment group. After laboratory manipulation, intracoronary or intravenous injection of 100 x 106 mononuclear cells was performed. Echocardiography (Vivid 7) was used to assess ventricular function before and three and six months after cell infusion. RESULTS: A total of 30 patients were included, 14 in the arterial group (AG), 10 in the venous group (VG), and six in the control group (CG). No statistical difference was found between the groups for the echocardiographic parameters studied. CONCLUSION: Autologous mononuclear bone marrow cell transplantation did not improve the echocardiographic parameters of systolic function.

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Artigo Original

Coronary artery disease and experiences of losses

Rachel Jurkiewicz et al. Bellkiss Wilma Romano

BACKGROUND: In literature, depression is associated with cardiovascular diseases. From clinical experience, we observed that the psychological category “experience of loss” was associated with the onset and development of coronary heart disease. The experience of loss caused by self-reported significant event(s) leads to grief and the psychosocial factors which predispose the patient to diseases. OBJECTIVE: To study the impact of the experience of loss by investigating the relationship between mourning and depression, in hospitalized patients with coronary heart disease. METHODS: 44 inpatients (50% men and 50% women, aged 33 to 65 years), with a diagnosis of acute myocardial infarction or angina, were evaluated. Two instruments were used: a semi-structured interview, for investigating the experience of loss and evaluating the state of grief; and the Beck Depression Inventory, for measuring the severity of depression. The results were expressed using the computer program Statistical Package for Social Sciences version 11.0. RESULTS: 66% of the patients were in mourning, the relationship between mourning and depression was significant (p<0,05), and we verified that 100% of the patients who had serious depression were in mourning. The most frequent self-reported significant event was death of a family member (47%) and death of a close person (13%), totaling 60% of the events, reported by 84% of the participants. According to the results of Beck Depression Inventory, 48% of them had depression. CONCLUSION: This study suggests that the psychological category "experience of loss" should be used as an indicator of the existence of psychological factors that could predispose the patient to CAD, and also confirms the relationship between a state of mourning and depression.

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Artigo Original

Vaccination against the influenza virus and mortality due to cardiovascular diseases in the city of Sao Paulo

Antonio de Padua Mansur et al. Desidério Favarato José Antonio F. Ramires

BACKGROUND: The effect of vaccination against the influenza virus on the mortality due to cardiovascular diseases (CVD) remains controversial. OBJECTIVE: To analyze the mortality by CVD before and after the start of the vaccination against the Influenza virus in the city of Sao Paulo, Brazil. METHODS: We analyzed the mortality due to ischemic heart diseases (IHD), cerebrovascular diseases (CbVD) and external causes (EC) in the population of the metropolitan region of the city of Sao Paulo, Brazil, aged > 60 years, before and after the start of the vaccination program against Influenza. The population estimates and mortality data were obtained, respectively, from the Brazilian Institute of Geography and Statistics (IBGE; www.ibge.gov.br) and from the Brazilian Ministry of Health (www.datasus.gov.br) for the period between 1980 and 2006. The risk of death was adjusted by the direct method, using the 1960 world standard population. RESULTS: The comparisons between the inclinations of the regression lines were similar for CbVD (p = 0.931) and EC (p = 0.941); however, for IHD (p = 0.022), a significant decrease was observed in the regression line of the post-vaccination period, when compared to the pre-vaccination period. A change in the tendency towards mortality after 1996 was significant only for the IHD (p=0.022), remaining unaltered for the CbVD (p=0.931) and EC (p=0.941). CONCLUSION: The vaccination against the Influenza virus was associated with a significant decrease in the mortality due to IHD.

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Case Report

Late spontaneous regression of obstructive tumor in the mitral valve

Edmar Atik

Cardiac rhabdomyoma is uncommonly found in the mitral valve. However, in the case reported, although the tumor was large (15×14 mm) and even caused obstruction at this level in the first months of life, its complete and spontaneous regression was observed as from 68 months of age, with progressive reduction until the patient was 14 years old.

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Correlação Clínico-Radiográfica

Case 6/2009: 13 years old youngsters with major atrial and ventricular septal defects

Edmar Atik

CLINICORADIOLOGICAL SESSION

Case 6/2009 – 13 years old youngsters with major atrial and ventricular septal defects

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Review Article

Experimental myocardium infarction in rats: analysis of the model

Leonardo A. M. Zornoff et al. Sergio A. R. Paiva Marcos F. Minicucci Joel Spadaro

One of the most often used strategies to study the physiopathological alterations caused by coronary occlusion is the use of the experimental infarction model in rats. Among other factors, this is due to the similarities in the physiopathological alterations that occur after the infarction in humans. One must consider, however, that this model has characteristics that can hinder the use as well as the interpretation of eventual outcomes. Thus, this review aims at analyzing the main characteristics of the experimental infarction model in rats, discussing the coronary occlusion technique, the consequences and the methods of morphological and functional assessment of the infarction and its clinical implications.

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Artigo Original

Peri-operative evaluation by holter in elderly patients submitted to prostatectomy

Thais Orrico de Brito Cançado et al. Fernando Bueno Pereira Leitão Marcelo Luis Abramides Torres Fábio Sândoli de Brito

BACKGROUND: Male patients, aged over 65 years and with no history of heart disease, need the following tests as a preoperative evaluation: blood count, electrocardiogram and X-ray of the chest. OBJECTIVE: To verify the presence of ischemic and heart rate changes and the impact of the anesthetic procedure on these patients. Also to verify, in this population, the value of continuous ambulatory monitoring as a preoperative evaluation, a procedure that is not recommended by current guidelines. METHODS: In this protocol, we used continuous ambulatory monitoring (Holter System), in the perioperative period of 30 patients, aged over 65 years, who underwent transurethral resection of the prostate under spinal anesthesia. RESULTS: In the preoperative and transoperative evaluations, frequent complex ventricular and supraventricular arrhythmias were observed, and also ischemic changes. In the transoperative recording, the patients who had ischemic episodes were the same ones who showed total ischemic burden of more than 60 minutes in the preoperative recording. CONCLUSION: Ambulatory monitoring is not regarded as an appropriate procedure for the screening of myocardial ischemia, due to the characteristics and technical limitations of the method, especially in populations with a low prevalence of coronary disease. In this cross-sectional and observational study, we concluded that the Holter recordings provided additional information which could not be obtained by conventional electrocardiogram.

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Editorial

Considerations on perioperative silent ischemia in patients undergoing transurethral resection of the prostat

Claudio Pinho et al. Bruno Caramelli

EDITORIAL

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Letter to the Editor

Arterial hypertension and physical activity

Karine Zortéa et al. Rafaela Festugatto Tartari

LETTER TO THE EDITOR

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Artigo Original

Electrocardiography in the diagnosis of ventricular hypertrophy in patients with chronic renal disease

Francisco de Assis Costa et al. Ivan Romero Rivera Mirian Lira Castro de Vasconcelos André Falcão Pedrosa Costa … Rui Manoel dos Santos Póvoa Maria Tereza Nogueira Bombig Bráulio Luna Filho Valter Correia de Lima

BACKGROUND: Left ventricular hypertrophy (LVH) is an independent predictor of cardiovascular risk, and its characterization and prevalence in chronic renal disease (CRD) should be further studied. OBJECTIVE: To establish the diagnosis of LVH in patients with stage-5 CRD using six different electrocardiographic criteria, and to correlate them with left ventricular mass index (LVMI) as obtained by echocardiography. METHODS: Cross-sectional study including 100 patients (58 men and 42 women, mean age 46.2 ± 14.0 years) with CRD of all causes undergoing hemodialysis (HD) for at least six months. Electrocardiography (ECG) and echocardiography were performed in all patients, always up to one hour after the end of the HD sessions. RESULTS: LVH was detected in 83 patients (83%), of whom 56 (67.4%) had the concentric pattern and 27 (32.6%) the eccentric pattern of LVH. Diagnostic sensitivity, specificity and accuracy of all the electrocardiographic methods studied were higher than 50%. Using Pearson’s linear correlation for LVMI, only the Sokolow-Lyon voltage criterion did not show a > 0.50 coefficient. Calculation of the likelihood ratio, in turn, showed that ECG has a discriminatory power for the diagnosis of LVH in the population studied, with emphasis on the Cornell-product and Romhilt-Estes criteria. No correlation was observed between LVMI and QTc and QTc dispersion. CONCLUSION: ECG is a useful, efficient, and highly reproducible method for the diagnosis of LVH in HD patients. In this population, the Cornell-product proved to be the most reliable criterion for the detection of LVH.

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Editorial

Body Mass Index has a Good Correlation with a Proatherosclerotic Profile in Children and Adolescents

Marcelo Chiara Bertolami

EDITORIAL

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Artigo Original

Evaluation of the degree of vascular inflammation in patients with metabolic syndrome

Adriana Silva Monteiro Junqueira et al. Luiz José Martins Romêo Filho Camillo de Léllis Carneiro Junqueira

BACKGROUND: Metabolic Syndrome (MS) is defined as a set of cardiovascular risk factors related to visceral obesity and insulin resistance that lead to an increase in general mortality, especially cardiovascular. The inflammatory markers are considered emergent risk factors and can be potentially used in the clinical stratification of cardiovascular diseases, establishing prognostic values. OBJECTIVE: This study aims at evaluating which components of the MS present an increase of IL-6 and hs-CRP, identifying the marker that better expresses the degree of inflammation and which isolate component presents a higher degree of interference on the studied inflammatory markers, in order to identify other important risk factors when determining arterial inflammation. METHODS: A total of 87 hypertensive, diabetic and dyslipidemic patients were selected, aged 26 to 85 years, who met the necessary criteria for the positive diagnosis of MS. The patients were assessed through 24-hour ambulatory blood pressure monitoring (ABPM) and underwent hs-CRP and IL-6 measurements, among other metabolic variables. RESULTS: The patients that presented CRP > 0.3mg/dl showed a significant correlation (p102/88 cm in 83.7%, glycemia > 110mg/dl in 88% and BMI > 30kg/m²in60.5% of the studied individuals. CONCLUSION: We concluded that the CRP was the inflammatory marker with the highest expression regarding the studied variables, with smoking, albuminuria, previous personal history of cardiopathy, BMI, abdominal perimeter and hyperglycemia being the ones with the highest statistical significance. Interleukin-6 did not present a correlation with any of the studied variables.

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Artigo Original

Videothoracoscopy for isolated atrial fibrillation ablation through bipolar radiofrequency

Alexandre Siciliano Colafranceschi et al. Andrey José de Oliveira Monteiro Eduardo Souza Leal Botelho Leonardo Secchin Canale … Arnaldo Rabischoffsky Ieda Prata Costa Fernando Eugênio dos Santos Cruz Filho Roberto Luiz Menssing da Silva Sá Ana Luiza Boechat Luis Alberto Oliveira Dallan

BACKGROUND: The prevalence of atrial fibrillation, expenses with the healthcare system and the associated high morbidity and mortality have justified the search for new therapeutic approaches. OBJECTIVE: To evaluate the reproducibility of the surgical technique, its safety and the initial outcome of the video-assisted surgery for the isolated atrial fibrillation ablation with bipolar radiofrequency. METHODS: Ten patients (90% men) with symptomatic atrial fibrillation (50% paroxystic type) that was refractory to drug therapy, with no heart disease that required concomitant surgical treatment, were submitted to arrhythmia ablation guided by thoracoscopy from May 2007 to May 2008. Clinical, laboratory and image variables were prospectively collected before, during surgery and at the postoperative follow-up. RESULTS: The surgery was carried out as planned in all patients. There was no intra-thoracic structure iatrogenic lesion or deaths. At the mean 6-month follow-up, 80% of the patients were free of atrial fibrillation. There was a significant improvement in the symptoms of New York Heart Association Functional Class heart failure (2.4 ± 0.5 to 1.6 ± 0.7; p=0.011). There was no evidence of pulmonary vein stenosis at the angiotomography in this series. CONCLUSION: The video-assisted surgery for the treatment of atrial fibrillation is reproducible and safe. There is a heart failure symptom evolution improvement after the surgery.

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Review Article

Echocardiography in cardiac resynchronization therapy

Viviane Cordeiro Veiga et al. Henry Abensur Salomón Soriano Ordinola Rojas

Cardiac resynchronization therapy has been an effective option in patients with advanced heart failure. However, 20 to 30% of the patients do not benefit from this therapy. Clinical, electrocardiographic and echocardiographic criteria have been studied in an attempt to select patients who will benefit from a cardiac resynchronization therapy, and the echocardiogram is important both in the selection and in the evaluation and optimization of the therapy. The objective of this review is to describe the main echocardiographic parameters used in the evaluation of the cardiac resynchronization therapy.

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Artigo Original

Prevalence of high blood pressure levels and associated factors among adults in Southern Brazil

Giana Zarbato Longo et al. Janaina das Neves Valmir Martins Luciano Marco Aurélio Peres

BACKGROUND: Few population-based studies have been carried out in Brazilian medium-sized cities in order to estimate high levels of blood pressure and associated factors. OBJECTIVE: To estimate the prevalence of high blood pressure and associated factors among adults in Lages,Southern Brazil. METHODS: Population-based cross sectional study carried out in adults aged 20 to 59 years living in the urban area (n=2,022). The dependent variable was high levels of blood pressure (> 140/90 mmHg). Exploratory variables: sex, age, schooling, per capita family income, self-reported ethnicity, body mass index, tobacco and alcohol addiction, physical activity and self-reported diabetes. The Chi-square test and linear trends were used to test associations between the dependent variable and the exploratory variables. Unadjusted and adjusted multivariate Poisson regression analyses were performed. RESULTS: Response rate was 98.6%. The prevalence of high blood pressure levels was 33.7% (95CI%: 31.7-36.1) for the population as a whole, ranging from 31.1% in men to 38.1% in women. After statistical adjustment for possible confounders, the following were associated with high blood pressure levels: male gender (PR =1.22 95%CI 1.1-1.4), older age, overweight (PR= 1.40 95%CI 1.18-1.67), obesity (PR = 1.95 95% CI 1.61-2.36), Asian ethnicity (PR 1.29 95%CI 1.12-1.48) and self-reported diabetes mellitus (PR 1.29 95%CI 1.12-1.48). CONCLUSIONS: One third of the assessed adults presented high blood pressure levels, similar to most of the Brazilian findings. Factors that can be prevented, such as overweight, obesity and self-reported diabetes were associated with high blood pressure levels.

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Case Report

Radionuclide imaging of myocardium with mental stress in the investigation of thoracic pain

Lívia Maria Lima da Silva et al. Gustavo Borges Barbirato Cantídio Drumond Neto Antonio Claudio Lucas da Nóbrega … Alexandro Coimbra Claudio Tinoco Mesquita

Thoracic pain is a common symptom in emergency services, and stress radionuclide imaging represents one of the phases of risk stratification in these individuals. However, a group of patients with negative functional exams after physical or pharmacological stress develops myocardial ischemia during this psychological stress. Alterations in vascular tonus as a response to endogenous mechanisms are the physiopathologic basis for such alterations. We report a case that illustrates how mental stress radionuclide imaging has the potential to be used in the assessment of myocardial ischemia non-detected by conventional methods in patients with suspicion of ischemic thoracic pain.

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