Download Problémový okruh 5 (Dušnost a bolest na hrudi)

Course 5
Case 25
Kas 5-26E: A man with palpitation and syncope
Patient: male, 54 years
History of presenting complaint: A 54 years old disabled pensioner, former barber, is brought
in from home by emergency. He says he had a sudden feeling of palpitation at rest
accompanied with dyspnoea and dull pressure behind the sternum. His wife called an
emergency. A few minutes before the emergency arrived, he went unconscious and was
resuscitated first by his wife and then, by attending physician. Patient was intubated, ECG
monitor showed broad QRS complex tachycardia. Electrical cardioversion proceeded without
delay with a short-term restoration of sinus rhythm. In a few seconds, tachycardia returned
with fast deterioration to ventricular fibrillation. Defibrillation (300 J) and administration of
Amiodarone 1 amp i.v. led to successful recovery of sinus rhythm which remained maintain
till admission. At admission, patient is sedated and ventilated.
Past history: Since 1995 hypertension, 1998 inferior myocardial infarction
10/2002 anterior myocardial infarction treated with primary PCI+stent in LAD (left anterior
descending artery), 3 vessel disease, chronic RCA (right coronary artery) occlusion, diffuse
disease of coronary arteries including periphery not amendable to CABG, hence, a
conservative treatment was recommended. At the same time, severe left ventricular
dysfunction (EF 35%) was diagnosed. In the following months, patient developed symptoms
of heart failure (NYHA III)
Operation: 0
Chronic
medication:
Gopten
(trandolapril)
1x2mg,
furosemid
forte
1x1
acidum
acetylosalicylicum (Aspirin) 1x200mg, Concor (bisoprolol) 1x2,5mg 1x1/2 tbl. Zocor
(simvastatin) 1x20mg, Verospiron (spritolacton) 2x1
Social habits: non-smoker since infarction, till infarction 10 cigarettes a day since his 20.
Family history: father died of pulmonary embolization at 78, mother died of breast cancer. He
did not have brothers and sisters, 2 healthy children.
Physical examination: 180 cm, 100 kg, ventilated, lungs: symmetrical breath sounds, basal
crackles. Regular heart rate around 100/min. BP 115/70 mmHg. Holosystolic murmur over
the apex radiating towards axillae, (3/6). Otherwise normal.
ECG taken after defibrillation (Figure 1)
Course 5
Case 25
ECG recorded by an emergency ambulance (Figure 2)
Course 5
Case 25
Blood tests: potassium 3,8 mmol/l,. Urea 16,8, mmol/l, otherwise normal including Mg,
creatinine, troponin
Echocardiography (normal valueus in parentheses): Dilation and dysfunction of the left
ventricle, EF 30% (above 55%), akinesis in the a. right coronary artery supplied segments, the
rest hypokinetic, Moderate mitral insufficiency due to papillary muscle displacement. Right
ventricle 30mm (within 30mm), left ventricle 62mm (within 60mm), left atrium 47 mm
(within 43mm).
Coronary angiography: No change as compared to 10/2002
Therapy: Amiodarone i.v., betablockers, diuretics
Questions:
1. Make a list of admission diagnoses arranged in order by priority.
2. Describe both ECGs
3. Explain pathophysiological and anatomical basis of the case.
4. What is the prognosis of the patient? What is the patient life in danger of? In this
regard, what other therapeutic measures do you recommend?
5. This patient has high blood levels of urea with normal level of creatinine. What is
possible explanation ?
6. Causes and consequences of heart failure
7. Causes and consequences of atherosclerosis
8. Atherosclerosis – morphology
9. Morphologic changes of organs in consequence of heart failure