caso clínico ii diabético insulino-dependente multivascular sca cirilo pereira da fonseca neto...
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Caso Clínico II
• Diabético Insulino-Dependente
• Multivascular
• SCA
Cirilo Pereira da Fonseca NetoHospital Socor – IHB – HC/UFMG
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Admissão CTI Hospital Socor
• 08/06/2005 as 00:20 hs
• Transferência do Hospital de Felixlândia
• Diagnóstico de SCA (IAM-SSST)
• À admissão:– Assintomática (última precordialgia à 24 hs)– PA: 220/140 mmHg
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T.N.P., Fem, Melanoderma
TIMI• 74 anos 1• HAS grave (Clonidina, Captopril, Diltiazem) DMID (NPH 20+30)
Dislipidêmica (Sinvastatina) 1• STENT Cx há 12 anos 1• Uso contínuo de AAS 1• 1 episódio de Angina de Repouso (15 min - 24 hs) 0• Troponina I aumentada (0,56) 1• ECG com infra de ST anterior/inferior (?) 1
Total 6 (alto risco)
* IVP: úlcera isquêmica crônica em MID
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Admissão: 08/06/2005
DI DII DIII AVR
AVL AVF V1 V2
V3 V4 V6V5
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• Sem novos episódios de angina• Medicação:
– AAS– Clopidogrel– Enoxparina (60 mg SC - BID)– Nitroglicerina EV → Mononitrato VO– Propranolol (40 mg TID)– Captopril (50 mg TID)– Clonidina (0,2 mg BID)– Sinvastatina– Diazepam– Insulina Regular (EV-SC)
• CATHE: 09/06
No CTI: 08/06 a 11/06
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No CTI: 08/06 a 11/06
• Creatinina: 0,6 → 1,0• Uréia: 23• K: 4,0• Glicose: 180• CK-MB: 16/12/8 (n: 10)• Hb: 10,7• Leuco: 6.800 (s/d.e.)• ECO: FE 62%, HVE importante e RDA
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CATHE:09/06
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DA
Cxp
STENT
ME
Cxm
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CATHE:09/06
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DA
ME
Cxp
CATHE:09/06
Cxm
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CATHE:09/06
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CATHE:09/06
MECxp
DA
STENT
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CATHE:09/06
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CATHE:09/06
ME
DA
CxpSTENT
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CATHE:09/06
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CATHE:09/06
DP
CDVP
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CATHE:09/06
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CATHE:09/06
VP
DP
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CATHE:09/06
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CATHE: conclusão
• DA– Obstr. grave (80%) e segmentar proximal– Obstr. moderada (60%) e segmentar médio-distal
• Cx– Obstr. grave (80%) proximal– STENT: OK– Obstr. grave (80%) médio– Obstr. grave (80%) no ramo ME
• CD– Obstr. grave (70%) médio-distal– Obstr. grave (80%) no DP– Obstrs. graves (80%) no VP VE: HVE com função sist. OK
O que fazer?
CATHE:09/06
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ICP: estratégia
• Lesões a tratar?– CE e CD
• Escalonado?
• Qual STENT?– Farmacológicos em todas as lesões(8 STENTS!!)– “Tratamento Hibrido”
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• Lesões tratadas no mesmo tempo:– DA: STENT FARMACOLOGICO – Cxp: STENT CONVENCIONAL – Cxm: STENT CONVENCIONAL – ME: STENT CONVENCIONAL
• Lesões da CD com tratamento guiado por sintomas em outro momento
ICP: estratégia
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ICP:16/06
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ICP:16/06
ME
Cxp
DA
Cxm
STENT
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ICP:16/06
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ICP:16/06
Cxp
STENT
ME
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ICP:16/06
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(FlexMaster 2,75 x 12 mm - Abbot)
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ICP:16/06
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ICP:16/06
STENT Cxm
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ICP:16/06
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(FlexMaster 2,75 x 12 mm - Abbot)
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ICP:16/06
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ICP:16/06
STENT ME
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ICP:16/06
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ICP:16/06
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(FlexMaster 3,0 x16 mm - Abbot)
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ICP:16/06
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ICP:16/06
STENT Cxp
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ICP:16/06
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ICP:16/06
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(Taxus 3,0 x 32 mm - Boston)
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ICP:16/06
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ICP:16/06
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ICP:16/06
STENT DA
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ICP:16/06
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ICP:16/06
STENT DA
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Evolução: alta hospitalar20/06/2005
• Assintomática• Em uso de:
– AAS– Clopidogrel– Captopril (50 mg TID)– Propranolol (40 mg BID)– Clonidina (0,2 mg BID)– Anlodipina (10 mg MID)– Ciprofibrato (100 mg MID)– Insulina NPH (30 + 10)
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• Laboratório:• Creatinina; 0,9• Uréia: 38• K: 4,5• Glicose: 140• Hb: 11,0
• ECG: RS, SVE, ADRVE importantes
Evolução: alta hospitalar20/06/2005
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DI DII DIII
AVL
AVR
AVF V1 V2
V3 V4 V5 V6
Alta: 20/06/2005
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AdmissãoAdmissão: 08/06/2005
DI DII DIII AVR
AVL AVF V1 V2
V3 V4 V6V5
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• Evolução cardiológica favorável
• Dez/2006: piora da isquemia do MID
(leito distal ruim)
• Necrose e infecção → CTI
Evolução: tardia