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Sindromul coronarian acut fara supradenivelare ST – prezentare de caz

Sindromul coronarian acut fara supradenivelare ST – prezentare de caz. Dr. Radu Cojan. Date personale. B.M., barbat, 64 ani Fumator (30 tig/zi) de 40 ani Hipertensiv de 15 ani Diabetic (tip 2) de 8 ani Supraponderal (ICM- 38)

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Sindromul coronarian acut fara supradenivelare ST – prezentare de caz

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  1. Sindromul coronarian acut fara supradenivelare ST – prezentare de caz Dr. Radu Cojan

  2. Date personale • B.M., barbat, 64 ani • Fumator (30 tig/zi) de 40 ani • Hipertensiv de 15 ani • Diabetic (tip 2) de 8 ani • Supraponderal (ICM- 38) • Agregare familiala pe linie CV (ambii parinti hipertensivi, coronarieni) • AP de efort in ultimii 2 ani

  3. Motivele internarii • Durere retrosternala intensa, continua, cu iradiere interscapulara, cu debut de 3 ore • Dispnee-polipnee, anxietate • Fen. vegetative (transpiratii, greturi, varsaturi)

  4. Examen clinic • Anxietate • Polipnee • Tahicardic (95/min.) • Galop protodiastolic • S.s. gr. III apexian • Reactie hipertensiva (190/105 mm Hg) • S.s. carotidian bilateral, s.s. femural bilat. • Puls redus la ambele a. poplitee si absent distal

  5. Electrocardiograma • Tahicardie sinusala • Ax QRS intermediar • subdenivelari importante ST (2-3 mm) cu T neg./difazic V3-V6, D2, D3, aVF

  6. Ecografia cardiaca si vasculara • Hipochinezie importanta apex VS, per. anterior, SIV distal (segm.10, 12, 13) • IM gr. III • Disfunctie diast. VS • Placi aterosclerotice cu stenoze 70% pe ambele carotide comune; stenoze 30-50% la niv. a. carotide interne • Stenoze ATS seriate 50-70% pe ambele a. iliace comune si a. femurale comune si superficiale

  7. Dg. enzimatic • Tn T - 0,1 ng/ml - la internare - 0,3 ng/ml - la 12 ore • CPK - 1048 ui • LDH - 982 ui

  8. Laborator • Glicemie – 204 mg% • Colesterol total – 284 mg% • LDL-col. – 209 mg% • HDL-col. – 31 mg% • Trigliceride – 222 mg% • Ac. Uric – 11,7 mg% • Ht – 52% • SO2 – 90%

  9. Radiografia CP – la pat • Cord global dilatat • Hiluri incarcate • Excluderea altor cauze de durere toracica

  10. Diagnostic pozitiv • Anamneza: durere prelungita cu caracter coronarian, factorii de risc CV • Clinic: stigmate ale ATS cu div. localizari • ECG: subdeniv. persistente segm. ST • Laborator: enzime de citoliza miocardica, sindr. metabolic • Ecografic: hipochinezie segmentara

  11. Diagnostic diferential • Pericardita (stetacustica, ecografie) • Disectia de aorta (rgf. CP, ecografie) • Pleurita, pleurezia (stetacustica, rgf. CP) • Pneumotorax (rgf. CP) • Pneumonia (rgf. CP) • Embolia pulm. (rgf. CP, SO2, conditii emboligene) • Ulcerul gd., refluxul gastroesofagian (caract. durerii, endoscopie dig.) • Durerea musculo-scheletala (caract. durerii)

  12. Conduita terapeutica • Imobilizare la pat • Monitorizare continua ECG, TA ,SO2 • Oxigenoterapie • Aspirina 250 mg / zi • Clopidogrel (Plavix) incarcare 300 mg→75 mg/zi • Enoxaparina (Clexane) 80 mg / 12 ore • NTG in perfuzie continua (10 μg/min) • Metoprolol 2 mg/6 ore i.v. apoi 100 mg / 12 ore • Lisinopril 10 mg / zi

  13. Evolutie …Nefavorabila: • ischemie miocardica recurenta (angor persistent, modif. dinamice ECG, tulb. de ritm ventriculare – TV nonsustinute, ESV Lown III)

  14. Procedee invazive • Stratificarea riscului – integrarea cazului in clasa “high risk” • Transfer de urgenta dupa 48 ore la Clinica de Cardiologie InterventionalaTg. Mures: - coronarografie - angioplastie coronariana +/- implantare stent

  15. Stenoza critica ADA

  16. Strategia pe termen lung – profilaxia secundara (1) • Modificarea factorilor de risc: - abandonarea fumatului - dieta hipolipemianta, hipocalorica - reeducare fizica - hipolipemiante-statine (LDL tinta ≤130mg%) - controlul eficient al TA si al glicemiei

  17. Strategia pe termen lung – profilaxia secundara (2) • Aspirina 150 mg/zi • Clopidogrel – cel putin 9 luni dupa PTCA • Betablocante • Inhibitori ai enzimei de conversie • Statine

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