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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introdu&#231;&#227;o</span><p id="par0005" class="elsevierStylePara elsevierViewall">O l&#250;pus eritematoso sist&#234;mico &#40;LES&#41; &#233; uma doen&#231;a autoimune de ocorr&#234;ncia incomum e ainda de causa desconhecida&#46; Sua preval&#234;ncia &#233; estimada em um caso para cada 2000 pessoas&#44; sendo 1&#58;10 a rela&#231;&#227;o entre os sexos masculino e feminino&#44; respectivamente&#46; Entre as manifesta&#231;&#245;es da doen&#231;a&#44; o acometimento cardiovascular &#233; um dos mais frequentes e mais graves&#44; seja sob a forma de miocardite&#44; pericardite&#44; endocardite&#44; vasculites ou doen&#231;a arterial coron&#225;ria<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Devido ao car&#225;ter inflamat&#243;rio cr&#244;nico do LES&#44; os pacientes apresentam reconhecidamente o desenvolvimento de aterosclerose precoce&#44; sendo a pr&#243;pria doen&#231;a um fator de risco independente para a ocorr&#234;ncia de infarto agudo do mioc&#225;rdio &#40;IAM&#41;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a>&#46; Nesse cen&#225;rio&#44; o melhor esquema terap&#234;utico ainda &#233; um desafio&#46; Em casos de s&#237;ndromes coron&#225;rias agudas &#40;SCA&#41; a melhor forma de tratamento intervencionista mant&#233;m&#8208;se indefinida&#46; Algumas s&#233;ries de casos apresentam a sua experi&#234;ncia com angioplastia coron&#225;ria &#40;ATC&#41; e&#47;ou cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica &#40;CRM&#41;&#44; por&#233;m com pouca consist&#234;ncia<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Dessa forma&#44; descrevemos as caracter&#237;sticas basais&#44; manifesta&#231;&#245;es cl&#237;nicas&#44; tratamento definitivo adotado e a evolu&#231;&#227;o intra&#8208;hospitalar de pacientes com LES que apresentaram SCA&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><p id="par0020" class="elsevierStylePara elsevierViewall">Entre os anos de 2004&#8208;2011 foram analisados retrospectivamente 11 pacientes com LES que apresentaram SCA &#40;angina inst&#225;vel e&#47;ou IAM&#41;&#46; O diagn&#243;stico de LES foi realizado com base nos crit&#233;rios do <span class="elsevierStyleItalic">American College of Rheumatology</span> revisados em 1997<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Todos os pacientes com dor tor&#225;cica t&#237;pica foram imediatamente categorizados como SCA e estratificados de acordo com o risco de sua apresenta&#231;&#227;o cl&#237;nica&#46; Aqueles com dor at&#237;pica e&#47;ou sintomas de equivalente isqu&#234;mico &#40;como dispneia&#41; foram submetidos a um protocolo de dor tor&#225;cica permanecendo em observa&#231;&#227;o por 12 horas e realizando eletrocardiograma e marcadores de necrose mioc&#225;rdica &#40;troponina e CKMB&#41; de 3 em 3 horas&#46; Caso apresentassem altera&#231;&#227;o de eletrocardiograma como infradesn&#237;vel de ST ou invers&#227;o de onda T e&#47;ou positivassem os marcadores de necrose&#44; seria dado o diagn&#243;stico de SCA e&#44; portanto&#44; seriam inclu&#237;dos no estudo&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Foram obtidas as seguintes informa&#231;&#245;es&#58; idade&#44; sexo&#44; manifesta&#231;&#245;es cl&#237;nicas e eletrocardiogr&#225;ficas&#44; estado hemodin&#226;mico &#40;Killip&#41;&#44; fatores de risco para SCA&#44; marcadores de necrose mioc&#225;rdica &#40;CKMB e troponina&#41;&#44; <span class="elsevierStyleItalic">clearance</span> de creatinina&#44; fra&#231;&#227;o de eje&#231;&#227;o de ventr&#237;culo esquerdo&#44; marcadores inflamat&#243;rios &#40;prote&#237;na&#8208;C reativa e velocidade de hemossedimenta&#231;&#227;o&#41;&#44; autoanticorpos&#44; medica&#231;&#245;es utilizadas no internamento&#44; achados angiogr&#225;ficos&#44; tratamento definitivo adotado &#40;cl&#237;nico&#44; ATC e&#47;ou CRM&#41; e evolu&#231;&#227;o intra&#8208;hospitalar&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">As les&#245;es coronarianas foram consideradas significativas quando correspondiam a no m&#237;nimo 70&#37; do di&#226;metro luminal do vaso&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Quando realizado o tratamento por ATC foram descritos os tipos de <span class="elsevierStyleItalic">stent</span> empregados &#40;convencional ou farmacol&#243;gico&#41;&#46; Em rela&#231;&#227;o &#224;s CRM realizadas&#44; foram relatados todos os enxertos arteriais e&#47;ou venosos utilizados&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A an&#225;lise estat&#237;stica foi apresentada sob a forma descritiva com percentagens e valores absolutos&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0050" class="elsevierStylePara elsevierViewall">Dez pacientes eram mulheres &#40;91&#37;&#41;&#46; A mediana de idade foi de 47 anos&#46; As caracter&#237;sticas basais dos pacientes est&#227;o descritas na <a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#46; A apresenta&#231;&#227;o cl&#237;nica predominante foi o IAM em 64&#37; dos casos&#44; com eletrocardiograma apresentando supradesn&#237;vel de ST em 45&#37; das vezes&#44; conforme descrito na <a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Os seguimentos arteriais mais acometidos foram a art&#233;ria descendente anterior em 73&#37; das vezes e art&#233;ria coron&#225;ria direita em 45&#37; dos casos&#44; seguidos por art&#233;ria diagnonal em 36&#37; dos pacientes&#46; Somente em um &#40;9&#37;&#41; caso de SCA n&#227;o foi encontrada les&#227;o obstrutiva coron&#225;ria&#46; A les&#227;o ostial foi observada em 9&#37; dos pacientes&#46; Do total&#44; tr&#234;s &#40;27&#37;&#41; casos eram triarteriais e tr&#234;s &#40;27&#37;&#41; biarteriais &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Em um caso optou&#8208;se pela CRM&#44; em sete pacientes realizou&#8208;se uma ATC com <span class="elsevierStyleItalic">stent</span> convencional e em tr&#234;s doentes manteve&#8208;se o tratamento cl&#237;nico&#46; Registrou&#8208;se mortalidade intra&#8208;hospitalar de 18&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Tabela 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discuss&#227;o</span><p id="par0065" class="elsevierStylePara elsevierViewall">O acometimento cardiovascular relacionado ao LES tem sido uma das principais causas de morbimortalidade nesses pacientes&#46; As primeiras descri&#231;&#245;es dessa associa&#231;&#227;o foram relatadas na d&#233;cada de 1960<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6</span></a>&#46; A incid&#234;ncia de IAM relacionado &#224; aterosclerose precoce em jovens com LES chega a ser nove a 50 vezes maior do que em pacientes sem a doen&#231;a e de mesma idade&#44; tornando o LES um fator de risco independente para a ocorr&#234;ncia de doen&#231;a arterial coron&#225;ria<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3&#44;7</span></a>&#46; Especificamente em mulheres jovens&#44; o risco &#233; ainda maior devido ao desconhecimento m&#233;dico do assunto e &#224; pouca relev&#226;ncia dada a esses pacientes&#44; considerados de baixo risco cardiovascular&#44; frente aos sintomas apresentados<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;7</span></a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Estudo publicado por Hak et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> avaliou a incid&#234;ncia de eventos cardiovasculares atrav&#233;s de uma coorte retrospectiva de 148 mulheres com LES por um per&#237;odo de 28 anos&#46; Desse grupo&#44; 13&#44;5&#37; apresentaram algum evento durante o seguimento&#44; com idade m&#233;dia de 53 anos&#46; A incid&#234;ncia de IAM foi cerca de tr&#234;s vezes o relatado para o restante da popula&#231;&#227;o sem LES&#44; atribuindo&#8208;se um risco relativo de 2&#44;25 &#40;1&#44;37&#8208;3&#44;69&#44; IC 95&#37;&#41; para a ocorr&#234;ncia do mesmo<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Na casu&#237;stica apresentada em nosso estudo&#44; h&#225; predomin&#226;ncia de mulheres &#40;91&#37;&#41; com idade mediana de 47 anos conforme relatado na literatura&#44; sendo que a paciente mais jovem apresentava apenas 27 anos e foi uma das que evoluiu a &#243;bito na interna&#231;&#227;o&#44; salientando a necessidade de diagn&#243;stico e tratamento precoce&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Entre pacientes jovens com LES e com menos de 35 anos&#44; o IAM tem sido relatado como a principal forma de manifesta&#231;&#227;o de doen&#231;a cardiovascular&#44; seguido de insufici&#234;ncia card&#237;aca&#44; morte s&#250;bita e angina<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;7</span></a>&#46; Estudos de aut&#243;psias de pacientes em LES mostraram que 54&#37; dos pacientes possu&#237;am aterosclerose significativa&#46; O diagn&#243;stico de doen&#231;a coron&#225;ria atrav&#233;s de testes de isquemia em pacientes com LES &#233; limitado devido &#224; idade e predomin&#226;ncia de sexo feminino<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; No entanto&#44; quando pacientes assintom&#225;ticos com LES s&#227;o submetidos &#224; cintilografia de perfus&#227;o mioc&#225;rdica&#44; cerca de 35&#8208;40&#37; possuem <span class="elsevierStyleItalic">d&#233;ficits</span> de perfus&#227;o mioc&#225;rdica<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a>&#46; Estudos realizados com angiotomografia coron&#225;ria t&#234;m mostrado maior incid&#234;ncia de placas n&#227;o calcificadas em rela&#231;&#227;o ao grupo controle<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; Al&#233;m disso&#44; a reserva de fluxo coron&#225;rio tamb&#233;m vem mostrando&#8208;se reduzida em pacientes com LES mesmo quando n&#227;o existe les&#227;o coron&#225;ria significativa&#44; ressaltando a presen&#231;a de inflama&#231;&#227;o permanente nesses pacientes<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Referente &#224; manifesta&#231;&#227;o cl&#237;nica da doen&#231;a coron&#225;ria&#44; encontramos dados semelhantes ao mostrado na literatura&#46; IAM foi a manifesta&#231;&#227;o de SCA em 64&#37; dos pacientes&#44; sendo que 45&#37; do total apresentaram supradesn&#237;vel de ST e 91&#37; dos pacientes tiveram dor tor&#225;cica t&#237;pica relatada&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">A fisiopatologia do acometimento coron&#225;rio no LES ainda &#233; incerta&#46; Al&#233;m de fatores de risco tradicionais&#44; atribui&#8208;se que a principal causa seja realmente a aterosclerose precoce proveniente da inflama&#231;&#227;o cr&#244;nica com les&#227;o endotelial relacionada &#224; pr&#243;pria doen&#231;a e do uso cr&#244;nico de medicamentos como corticosteroides<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;10</span></a>&#46; No entanto&#44; o paciente com LES tamb&#233;m pode apresentar SCA devido seu maior risco de trombose vascular&#44; principalmente quando o LES estiver associado &#224; s&#237;ndrome do anticorpo antifosfol&#237;pide &#40;a presen&#231;a de anticorpo antifosfol&#237;pide positivo est&#225; associado a um risco quatro vezes de IAM e morte s&#250;bita&#41;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;10&#8211;12</span></a>&#46; Em pacientes com LES&#44; a presen&#231;a de fatores de risco tradicionais para aterosclerose deve ser ativamente pesquisada e tratada agressivamente&#46; Hipertens&#227;o arterial sist&#234;mica est&#225; presente em at&#233; 75&#37; dos pacientes com LES e aumenta consideravelmente o risco de eventos cardiovasculares&#46; Al&#233;m disso&#44; tabagismo pode aumentar o risco de IAM em tr&#234;s vezes em pacientes com LES&#44; al&#233;m de supostamente reduzir a a&#231;&#227;o de medicamentos antimal&#225;ricos&#46; Por &#250;ltimo&#44; no paciente com LES&#44; o perfil lip&#237;dico tende a ser modificado em 40&#37; das vezes&#44; com &#237;ndices elevados de colesterol total e triglic&#233;rides&#46; De forma controversa&#44; n&#227;o existe correla&#231;&#227;o entre LES e diabetes <span class="elsevierStyleItalic">mellitus</span>&#44; com associa&#231;&#227;o presente em apenas 1&#44;9&#37; dos pacientes<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;10</span></a>&#46; Na nossa popula&#231;&#227;o&#44; encontramos dados coincidentes com a literatura em rela&#231;&#227;o &#224; preval&#234;ncia de hipertens&#227;o arterial e dislipidemias&#44; presentes em 55 e 36&#37;&#44; respectivamente&#46; No entanto&#44; diferente do exposto anteriormente&#44; 18&#37; dos pacientes apresentados possu&#237;am diagn&#243;stico de diabetes <span class="elsevierStyleItalic">mellitus</span>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">No contexto inflamat&#243;rio&#44; n&#237;veis s&#233;ricos de citocinas pr&#243;&#8208;aterog&#234;nicas como TNF&#8208;&#945;&#44; IL&#8208;6 e IL&#8208;17 t&#234;m sido encontrados elevados em pacientes com LES e SCA&#46; Hiperhomocisteinemia&#44; LDL&#8208;oxidado e resist&#234;ncia &#224; insulina tamb&#233;m t&#234;m sido relatados nesse grupo&#46; Al&#233;m disso&#44; a presen&#231;a de atividade do LES parece estar diretamente relacionado ao risco do paciente apresentar IAM&#44; principalmente em pacientes com atividade renal&#44; redu&#231;&#227;o do <span class="elsevierStyleItalic">clearance</span> de creatinina e anti&#8208;DNA positivo<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;10&#44;13&#44;14</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Alguns estudos t&#234;m mostrado que o uso cr&#244;nico de corticosteroides pode contribuir de maneira independente para o desenvolvimento de aterosclerose precoce&#44; al&#233;m de aumentar &#237;ndices de peso corp&#243;reo e press&#227;o arterial&#44; e modificar o padr&#227;o plasm&#225;tico de colesterol circulante<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;10&#44;15</span></a>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Na casu&#237;stica apresentada incluindo somente pacientes com SCA observamos que o padr&#227;o angiogr&#225;fico em todos os casos mostrava aterosclerose difusa&#44; independente da presen&#231;a de anticorpo antifosfol&#237;pide positivo&#44; sendo que em 54&#37; dos casos havia mais de uma art&#233;ria coron&#225;ria acometida de maneira significativa&#44; e n&#227;o foram documentados casos de trombose coron&#225;ria&#46; Isso refor&#231;a os achados pr&#233;vios de que a aterosclerose precoce &#233; causa principal de IAM em pacientes com LES&#46; Estudo publicado por Lee et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> mostrou em uma casu&#237;stica de 25 casos de LES com doen&#231;a coron&#225;ria que 20&#37; dos pacientes possu&#237;am mais de uma les&#227;o coron&#225;ria significativa e tamb&#233;m n&#227;o relatou casos de trombose<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; No entanto&#44; algumas caracter&#237;sticas peculiares mostradas em outros estudos n&#227;o foram observadas nessa amostra de pacientes&#46; Em nosso estudo&#44; apenas 27&#37; dos casos possu&#237;am anti&#8208;DNA positivo e o <span class="elsevierStyleItalic">clearance</span> de creatinina m&#233;dio apresentava&#8208;se preservado&#46; Cabe ressaltar que&#44; como marcador de atividade inflamat&#243;ria&#44; a prote&#237;na&#8208;C reativa esteve elevada em apenas 45&#37; dos pacientes e a velocidade de hemossedimenta&#231;&#227;o em 73&#37;&#46; Al&#233;m disso&#44; C4 somente encontrou&#8208;se reduzido em 27&#37; dos pacientes&#44; ao passo que C3 encontrou&#8208;se diminu&#237;do em 73&#37; dos casos&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Encontramos uma taxa de mortalidade intra&#8208;hospitalar de 18&#37; nesse estudo&#44; &#237;ndice cerca de tr&#234;s vezes superior &#224; mortalidade relacionada &#224; SCA na popula&#231;&#227;o em geral&#46; Al&#233;m disso&#44; a preval&#234;ncia de IAM com supradesn&#237;vel de ST tamb&#233;m se encontrou elevada&#44; sendo praticamente o dobro da taxa encontrada em pacientes sem LES&#46; Concordante com este achado&#44; Roldan<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> relatou em pacientes com SCA e LES um &#237;ndice de mortalidade a curto e longo prazo pelo menos duas vezes maior do que a popula&#231;&#227;o em geral&#46; No entanto&#44; outro estudo em pacientes com LES p&#243;s&#8208;angioplastia coron&#225;ria&#44; mostrou &#237;ndice de mortalidade nulo&#44; ressaltando a necessidade de estudos que avaliem caracter&#237;sticas espec&#237;ficas do tratamento coron&#225;rio nesses pacientes<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; A melhor forma de abordagem intervencionista ainda &#233; incerta&#46; Taxas de eventos adversos &#40;trombose&#47;reestenose&#41; relacionados a implante de <span class="elsevierStyleItalic">stent</span> coron&#225;rio convencional e farmacol&#243;gico foram relatadas em&#44; respectivamente&#44; 35 e 14&#37; de pacientes com LES<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7</span></a>&#46; De maneira semelhante&#44; s&#233;ries de casos de pacientes com LES submetidos &#224; CRM mostraram bons resultados e seguran&#231;a apesar do n&#250;mero limitado de pacientes inclu&#237;dos<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4&#44;16&#44;17</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclus&#227;o</span><p id="par0105" class="elsevierStylePara elsevierViewall">Pacientes com LES t&#234;m risco maior risco de IAM comparativamente ao restante da popula&#231;&#227;o&#46; Apesar da casu&#237;stica limitada&#44; os dados encontrados s&#227;o semelhantes ao restante da literatura&#44; ressaltando a precocidade da doen&#231;a coron&#225;ria&#44; a presen&#231;a de aterosclerose como desencadeante principal e a amplitude de sua gravidade com elevada taxa de mortalidade intra&#8208;hospitalar&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Responsabilidades &#233;ticas</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Prote&#231;&#227;o dos seres humanos e animais</span><p id="par0110" class="elsevierStylePara elsevierViewall">Os autores declaram que os procedimentos seguidos estavam de acordo com os regulamentos estabelecidos pelos respons&#225;veis da Comiss&#227;o de Investiga&#231;&#227;o Cl&#237;nica e &#201;tica e de acordo com os da Associa&#231;&#227;o M&#233;dica Mundial e da Declara&#231;&#227;o de Helsinki&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidencialidade dos dados</span><p id="par0115" class="elsevierStylePara elsevierViewall">Os autores declaram ter seguido os protocolos de seu centro de trabalho acerca da publica&#231;&#227;o dos dados de pacientes e que todos os pacientes inclu&#237;dos no estudo receberam informa&#231;&#245;es suficientes e deram o seu consentimento informado por escrito para participar nesse estudo&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Direito &#224; privacidade e consentimento escrito</span><p id="par0120" class="elsevierStylePara elsevierViewall">Os autores declaram ter recebido consentimento escrito dos pacientes e&#47;ou sujeitos mencionados no artigo&#46; O autor para correspond&#234;ncia deve estar na posse deste documento&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflito de interesses</span><p id="par0125" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Devido ao car&#225;ter inflamat&#243;rio cr&#244;nico do lupus eritematoso sist&#234;mico &#40;LES&#41;&#44; os pacientes apresentam reconhecidamente o desenvolvimento de aterosclerose precoce&#44; sendo a pr&#243;pria doen&#231;a um fator de risco independente para a ocorr&#234;ncia de infarto agudo do mioc&#225;rdio&#46; Em s&#237;ndromes coron&#225;rias agudas &#40;SCA&#41; a melhor forma de tratamento intervencionista mant&#233;m&#8208;se indefinido&#46; Dessa forma&#44; descrevemos as caracter&#237;sticas basais&#44; manifesta&#231;&#245;es cl&#237;nicas&#44; achados angiogr&#225;ficos&#44; tratamento definitivo adotado e a evolu&#231;&#227;o intra&#8208;hospitalar de pacientes com LES que apresentaram SCA&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Entre 2004&#8208;2011 foram analisados retrospectivamente 11 pacientes com LES que apresentaram SCA&#46; As seguintes informa&#231;&#245;es foram obtidas&#58; idade&#44; sexo&#44; manifesta&#231;&#245;es cl&#237;nicas e eletrocardiogr&#225;ficas&#44; estado hemodin&#226;mico&#44; fatores de risco para SCA&#44; marcadores de necrose mioc&#225;rdica&#44; <span class="elsevierStyleItalic">clearance</span> de creatinina&#44; fra&#231;&#227;o de eje&#231;&#227;o de ventr&#237;culo esquerdo&#44; marcadores inflamat&#243;rios&#44; autoanticorpos&#44; medica&#231;&#245;es utilizadas&#44; achados angiogr&#225;ficos&#44; tratamento definitivo adotado e evolu&#231;&#227;o intra&#8208;hospitalar&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Dez &#40;91&#37;&#41; pacientes eram mulheres&#46; A mediana de idade foi 47 anos&#46; Dor precordial t&#237;pica esteve presente em 91&#37;&#46; Cerca de 73&#37; apresentaram aumento de velocidade de hemossedimenta&#231;&#227;o&#46; O seguimento mais acometido foi a art&#233;ria descendente anterior em 73&#37;&#46; Em um caso optou&#8208;se por revasculariza&#231;&#227;o cir&#250;rgica&#44; em sete pacientes realizou&#8208;se angioplastia com <span class="elsevierStyleItalic">stent</span> convencional e em tr&#234;s doentes manteve&#8208;se tratamento cl&#237;nico&#46; Obteve&#8208;se mortalidade intra&#8208;hospitalar de 18&#37;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclus&#227;o</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Apesar da casu&#237;stica limitada&#44; os dados encontrados s&#227;o semelhantes ao restante da literatura&#44; ressaltando a precocidade da doen&#231;a coron&#225;ria&#44; a presen&#231;a de aterosclerose como desencadeante principal e a amplitude de sua gravidade com elevada taxa de mortalidade intra&#8208;hospitalar&#46;</p>"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Due to the chronic inflammation associated with systemic lupus erythematosus &#40;SLE&#41;&#44; patients develop premature atherosclerosis and the disease is a risk factor for acute myocardial infarction&#46; The best interventional treatment for acute coronary syndrome &#40;ACS&#41; in these patients is unclear&#46; The objective of this study is to describe the baseline characteristics&#44; clinical manifestations&#44; treatment and in&#8208;hospital outcome of patients with SLE and ACS&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Eleven SLE patients with ACS were analyzed retrospectively between 2004 and 2011&#46; The following data were obtained&#58; age&#44; gender&#44; clinical and electrocardiographic characteristics&#44; Killip class&#44; risk factors for ACS&#44; myocardial necrosis markers &#40;CK&#8208;MB and troponin&#41;&#44; creatinine clearance&#44; left ventricular ejection fraction&#44; inflammatory markers &#40;C&#8208;reactive protein and erythrocyte sedimentation rate&#41;&#44; drugs used during hospital stay&#44; treatment &#40;medical&#44; percutaneous or surgical&#41; and in&#8208;hospital outcome&#46; The statistical analysis is presented in percentages and absolute values&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Ten of the patients &#40;91&#37;&#41; were women&#46; The median age was 47 years&#46; Typical precordial pain was present in 91&#37;&#46; Around 73&#37; had positive erythrocyte sedimentation rate&#46; The vessel most often affected was the anterior descending artery&#44; in 73&#37;&#46; One patient underwent coronary artery bypass grafting&#44; seven underwent percutaneous coronary intervention with bare&#8208;metal stents and three were treated medically&#46; In&#8208;hospital mortality was 18&#37;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Despite the small number of patients&#44; our findings were similar to those in the literature&#44; showing coronary artery disease in young people with SLE due to premature atherosclerosis and a high mortality rate&#46;</p>"
      ]
    ]
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        "etiqueta" => "Tabela 1"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">CF&#58; classe funcional&#59; CCS&#58; Canadian Cardiovascular Society&#59; CRM&#58; cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica&#59; DAC&#58; doen&#231;a arterial coron&#225;ria&#59; FAN&#58; fator antin&#250;cleo&#59; FEVE&#58; fra&#231;&#227;o de eje&#231;&#227;o do ventr&#237;culo esquerdo&#59; IAM&#58; infarto agudo do mioc&#225;rdio&#59; NYHA&#58; New York Heart Association&#59; VHS&#58; velocidade de hemossedimenta&#231;&#227;o&#46;</p>"
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            0 => array:2 [
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tabagismo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;36&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FEVE &#40;m&#233;dia&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">51&#44;1 &#40;16&#8208;80&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>IAM&#47;DAC pr&#233;vios&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CCS <span class="elsevierStyleSmallCaps">I</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CCS <span class="elsevierStyleSmallCaps">II</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">3 &#40;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CCS <span class="elsevierStyleSmallCaps">III</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CF <span class="elsevierStyleSmallCaps">II</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CF <span class="elsevierStyleSmallCaps">III</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CF <span class="elsevierStyleSmallCaps">IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Exames laboratoriais &#40;m&#233;dia&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Clearance</span> de creatinina &#40;ml&#47;m&#237;n&#47;1&#44;73m<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53&#44;75 &#40;14&#8208;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hemoglobina &#40;g&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#44;7 &#40;9&#44;0&#8208;17&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Leuc&#243;citos &#40;&#47;mm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;986 &#40;4&#46;300&#8208;10&#46;500&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Plaquetas &#40;&#47;mm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">241&#46;636 &#40;21&#46;000&#8208;412&#46;000&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LDL&#8208;colesterol &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
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