medicina de urgenta
TRANSCRIPT
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Sincopa de la unitate la
diversitate diagnostica si terapeutica -
cazuri clinice
Mariana Radoi, PhD, FESC
Facultatea de Medicina, Universitatea Transilvanis din Brasov
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Incidenta sincopei
1 National Disease and Therapeutic Index on Syncope and Collapse, ICD-9-CM 780.2, IMS America, 19972 Blanc J-J, L’her C, Touiza A, et al. Eur Heart J, 2002; 23: 815-820.
3 Day SC, et al, AM J of Med 19824 Kapoor W. Evaluation and outcome of patients with syncope. Medicine 1990;69:160-175
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Soteriades ES, et al. NEJM . 2002;347:878-885.
Prognostic • Deces
– Mortalitate > 10% la 6 luni la cei cu sincopă– Sincopa cardiacă dublează riscul de deces
• Recurenţe – 32% in 3 ani– 80% din recurenţe
apar în primii 2 ani
N Engl J Med. Sept. 19, 2002
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– Clinica• Ex clinic complet
– TA in clino si ortostatism– masaj sinus carotidian
• Specialist cardiolog / neurolog / psihiatru– Paraclinica pentru diagnosticul etiologic al
sincopei • in centre primare de diagnostic
– ECG de repaus – ecocardiografie
• monitorizare ECG prelungita – teste de stress
Evaluarea diagnostica si prognostica
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• in centre secundare de diagnostic- ECG prelungită (înregistrare externă,
inregistrator implantabil) – studiu electrofiziologic– Tilt test
• in centre tertiare de diagnostic– monitorizare ECG – “implantable loop
recorder”
Evaluarea
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Algoritm de diagnostic in sincopaIstoric , EX fizic, ECG
Holter ELR
evaluare completa - dg cardiologic - dg neurological -dg endocrine - dg psihologic
Ecocardiografie, ECG stess, evaluarea ischemiei
40 - 60% sincopa de cauza neprecizata
Boala structurala cardiaca
Normal
Unic episode sincopa
Rare episoade
ssncope
Frecuente episoade sincope
- SAECG -
electrophysiology study ILR
Sincopa cu ritm sinusal Sincopa cu aritmie
Evaluare completa Tratament
Modified by AHA/ACCF Scientific Statement on the Evaluation of Syncope. JACC Vol. 47, No. 2, 2006
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Diagnostic prin metode conventionale
Test/Procedura Valoare diagnostica
Istoric and ex fizic ( masaj sinus carotidian)
49-85% 1, 2
ECG 2-11% 2
Monitorizare ambulatorie ECG • Holter 2- 5% 3
• External Loop Recorder(2-3 weeks duration)
20% 3
• Insertable Loop Recorder(up to 14 months duration)
88 - 100% 4 5
Wireless (internet) event monitoring In evaluare
1 Kapoor, et al N Eng J Med, 1983;2 Kapoor, Am J Med, 1991;3 Linzer, et al. Ann Int. Med, 1997 ; 5 Krahn, Circulation, 1995; 6 Krahn, Cardiology Clinics, 1997
.
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Criterii de internare în spital– durere toracică sau suspiciune de ischemie– ECG anormal
• ischemie• aritmie semnificativă• QT lung, sindr WPW etc..
– insuficienţă cardiacă acută, embolie pulmonară, tamponadă pericardică, disecţie de aortă
– istoric de aritmie ventriculară, boală cardiovasculară,
– istoric familial de moarte subită – sincopa cu injurii severe
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Când să nu internăm în spital ?? – sicopa izolata– persoana tanara– condiţii de aparitie si aspect clinic de sincopa
vasovagala– fara AHC de moarte subita – ECG normal
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• Barbat 58 ani– 2008 internare pentru sincope repetate– mare fumator (50 tigari/zi, 20 ani)– in urma cu 2 luni – extirpare carcinom
spinocelular epidermoid al bazei limbii• Sincopa
– predominent la trecerea in ortostatism, – precedate de transpiratii, vedere incetosata– urmate de cadere si traumatisme minore
– Ex fizic• cicatrice laterocervicala stanga• TA = 120/80mmHg, AV = 80/min, regulat
Cazul no 1
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– TA in ortostatism
• masurarea TA si AV in pozitie culcat si ortostatism in primele 3 minute
– TAs < 20mmHg si TAd<10mmHg = hipoTA ortostatica cu bradicardie sau AV crescuta
(AV >28 bătăi mai mult în 5 min de ortostatism sau de
“tilt test” fără scăderea TA = sindrom de tahicardie ortostatică)
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Evaluare initiala
• Trecere in ortostatism– sincopa
• Bradicardie sinusala ~ 30 min• TA = 80mmHg
– ECG
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Diagnostic clinic
• Sincopa vaso-vagala• Carcinom spinocelular epidermoid al bazei
limbii - operat
Evaluare paraclinica
• Ecografie Doppler artera carotida – leziuni aterosclerotice minime
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• Implant de pacemaker (BIOTRONIK PHILOS DR)
• Evolutie 2 luni– fara sincopa– ameteli episodice
• La 6 luni– reapare sincopa
ortostatica
Tratament / Evolutie
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Ex fizic- masa tumorala laterocervicala stanga
CT gat si torace
- Masa tumorala infiltreaza vasele gatului si sinusul carotidian
- Adenopatii mediastinale multiple ~ 2-3cm
Reinternare
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In timpul sincopei
-TAs = 70mmHg- AV = 58/min
Evaluare la trecerea in ortostatism
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1. Sincopa vaso-vagala cu recurenta prin componenta vasodilatatoare cu componenta cardioinhibitorie neevidenta datorita implantului pacemaker
2. Carcinom epidermoid spinocelular al bazei limbii, operat. Metastaza laterocervicala staga cu invazia sinusului carotidian. Adenopatii metastatice intratoracice
Diagnostic
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Valoarea terapeutica a implantului de pacemaker – cresterea temporara a calitatii vietii
Discutii
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Femeie, 64 ani cu HTA, dislipidemie si suprapondere
- dispnee la eforturi mari
- episod sincopal la efort (spalat parchet)
- in urmă cu 2 ani în contextul unui accident ischemic tranzitor evaluat clinic ca posibil embolic a fost diagnosticată cu fibrilatie atriala permanenta .
- tratament antihipertensiv (indapamid SR 1,5 mg/zi, metoprolol succinat 50 mgx2/zi, candesartan 8 mg/zi).
- nu a fost indicată terapie cu anticoagulante orale.
Cazul no 2
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Ex obiectiv:
- pacienta supraponderala ( IMC=29 kg/m2) - TA 160/80 mmHg, - FA 80/min, absenţa suflurilor cardiace sau
vasculare, puls prezent bilateral la nivelul arterelor periferice, fara raluri pulmonare
Evolutie in spital – fara sincopa
Cazul no 2
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Ex laborator:
- VSH = 45/90mm- Fibrinogen = 600mg/dL - LDLc = 174mg/dL- HDLc = 39mg/dL
Cazul no 2
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ECG de repaus:
Cazul no 2
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Ecocardiografia 2D
- apical ax lung
Cazul no 2
Formatiune intraatriala - 40/30mm, arie 18 cm2
- omogenă, suprafaţa netda, relativ fixa - pare a fi inserată la nivelul septului interatrial spre originea VP drepte - nu prolabează în diastola in VS - nu interferează cu mişcarea valvei mitrale - nu influenţază hemodinamica fluxului mitral si nici presiunea în AP (PAPs= 30 mmHg).
AS este dilatat ~ arie 24 cm2, tumora ocupa 75% din aria AS. FE%VS = 60%.
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Ecocardiografia 2D- subcostala 4 camere
Coronarografie – coronare subepicardice normale
Cazul no 2
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1. Sincopa de efort. Tumora intratatriala stg (posibil mixom)
2. Fibrilatie atriala. Suprapondere. HTA grad 2. Dislipidemie aterogena.
Diagnostic
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1. Sincopa de efort si tumora AS- reducrea debitului cardiac la efort
– tumora ocupa 75% din volumul AS
- prolabarea in VS- microembolii cerebrale- aritmii asociate
2. Sincopa ischemica
Discutii
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Indicatie opeartorie de urgenta
Ex macroscopic
Cazul no 2
Tumora
- baza larga de implantare la nivelul septului interatrial şi peretelui liber al AS
- dimensiuni de 7,5/ 4,5cm
- consistenţă moale
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Ex microscopic
Cazul no 2
Proliferari de celule alungite cu nuclei ovalari, in cercuru concentrice (sageata) intr-un mediu mixoid, cu fibre elestice.
Hemoragii, numeroase macrofage si siderofage, infiltrat leucocitar nespecific, spatii vasculare, incrustatii cu fier cu tendinta la formare de corpi Gamma Gandi (depozite calciferuginoase).
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Evolutie - 1 luna: VSH = 12/24mm, fibrinogen = 400mg/dL - 3 ani fara sincopa, fara dispnee
Cazul no 2
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Pacient – 58 ani
Internare de urgenta dupa accident de circulatie, fiind soferul unei masini implicate in accident
- dureri precordiale si hemitoracele stg si drept, accentuate de respiratie
- stare depresiva ~ soc psihic posttraumatic
- hipomnezie, dupa accident de circulatie cu autovehicul din sensul opus, conducea autovehicul personal (6 decedati)
Cazul no 3
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Anamneza
- Pacientul relateaza ca a prezentat disconfort precordial si la baza gatului, il jena centura de siguranta .
- A dorit sa comunice aceste date cumnatului asezat pe scaunul din dreapta ....
- A observat un TIR in fata, ce lua curba ...nu isi mai aminteste nimic... la trezire pasagerul din dreapta decedat ...
Cazul no 3
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Ex fizic
- hematom cot drept - fara semne externe de traumatism toracic, durere la palparea
hemitoraclui dr si stg posterior- TA = 130/80mmHg, AV=80/min, regulat- TA ortostatism = 135/80, AV=78/min la 24 ore de la prezentare
Rx grafia toracica – fracturi de arcuri costale
posterioare, coastele 9 - 11 dreapta si coasta 10 stg
Ex biologice – in limite normale
Cazul no 3
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Probleme de diagnostic la prezentare
1.Sincopa la volan ?
- ischemica ?
- mediata reflex ?
- alta etiologie …
2. Comotie cerebrala
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ECG la internare si dupa 24 ore
Cazul no 3
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Ecocardiografia 2D
- Cavitati normale - FE=60%- fara anomalii
de contractie segmentara
Cazul no 3
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Evaluarea clinica initiala
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Compresia de sinus carotidian stang la 24 ore de la
internare
Cazul no 3
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Bradicardia/hTA au fost nereproductibile prin compresie sinus carotidian in clinostatism
Diagnostic Sincopa prin hipersensibilitatea sinusului carotidian ?
Probleme de diagnostic la 24 ore
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….” ‘Carotid sinus’ syncope deserves special mention. In its rare spontaneous form it is triggered by mechanical manipulation of the carotid sinuses. In the more common form no mechanical trigger is found and it is diagnosed by carotid sinus massage (CSM).”
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Sincopa prin hipersensibilitatea sinusului carotidian ?
- efectul mecanic al centurii de siguranta ?
- stress – condus autovehicol ?
- stress posttraumatica ?
- hipovolemia ?
- hipersensibilitate tranzitorie a sinusului carotidian ?
Probleme de diagnostic la 24 ore
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Tratament
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Cazul 4
Pacienta 63 ani- sincopa la biserica, precedata de vedere
incetosata, transpiratii, paloare, vaga jena precordiala
- astm bronsic de la 41 ani, in tratament cu seretide, fara crize astmatice in ultimile 3 luni
- HTA cunoscuta de 10 ani, valori ~190mmHg in afara terapiei cu isoptin 240mg/zi. De 1 sapt dureri precordiale atipice pentru angor, urmate de asocierea 50mgx2ori/zi metoprolol succinat
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Cazul 4
Ex fizic
- paloare cutanata, astenica
- plaman fara raluri
- TAs = 60mmHg in clinostatism, - AV = 40/min regulat
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Cazul 4 – ECG la internare
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Cazul 4 - ECG la 24 ore
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Cazul 4
Diagnostic
1. Sincopa iatrogena prin hipotensiune/ bradicardie (isoptin plus metoprolol)
2. HTA std III controlata
3. Astm bronsic controlat
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Cazul 5
Pacient 78 ani- sincopa la domiciliu, precedata de dispnee si vaga precodialgie
- diabetic echilibrat prin dieta, IM inf in antecedente, ICC clasa III NYHA, in tratament cu enalapril 20mgx2ori/zi, spironolactona 50mg/zi alternand cu 25mg/zi, carvedilol 6,25mgx2ori/zi, digoxin 1tb/zi
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Cazul 5
Ex fizic- raluri subcrepitante fine la baza ambelor
hemitorace, AV=40/min, TA =150/90mmHg,
ECG
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Cazul 5
Ex paraclinice- glicemie = 139mg/dL
- creatinina = 1,30mg/dL, 1,40mg/dL
- ionograma serica K = 7mEq/L, Na =142mEq/L
- ex sumar urina – microalbuminurie (200mg/zi)
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Diagnostic
1. Sincopa iatrogena. Bloc AV grad II 3/1. Hiperkaliemie tranzitorie (enalapril, spironolactona) 2. Diabet zaharat tip2. HTA gr 2 risc f inalt. IM vechi. Boala renala cronica. IRC (nefroangioscleroza, nefroptie diabetica)
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Concluzii – cazurile prezentate
1. Sincopa cu etiologie precizata prin evaluarea initiala clinica si paraclinica2. Etiologia - sincope vaso-vagale - aritmice - boala structurala (mecanism potential multiplu)
3. Sincope cu prognostic grav
4. Implicatii privind conducerea de autovehicol etc… inclusiv in sincopa mediata reflex
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Va multumesc pentru atentie !