Prezentare de caz - UMF
Prezentare de caz - UMF
Prezentare de caz - UMF
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Universitatea <strong>de</strong> Medicina si Farmacie “Iuliu Hatieganu”<br />
Cluj-Napoca<br />
<strong>Prezentare</strong> <strong>de</strong> <strong>caz</strong><br />
G. Gusetu<br />
Clinica <strong>de</strong> Cardiologie – Recuperare
G.I., B, 54 ani, Cluj<br />
Motivele internării (16 mai 2012 – Cardiologie-Recuperare)<br />
- durere retrosternala constrictiva<br />
- febra (38-39 0 C)<br />
AHC - nesemnificative<br />
APP - obezitate (2002)<br />
CVM - fumator, 1 pachet/zi, 20 ani<br />
IBA<br />
- <strong>de</strong>but <strong>de</strong> ~ 3 zile<br />
- febra continua<br />
- fatigabilitate<br />
- durere retrosternala cvasicontinua<br />
accentuata <strong>de</strong> miscarile respiratorii si <strong>de</strong> tuse<br />
- <strong>de</strong> o zi: tuse seaca
Ex. obiectiv:<br />
- obezitate (I=1.73, G=103 Kg, IMC= 34.4)<br />
- tegumente cal<strong>de</strong> (t=38.6 0 C)<br />
- zg. cardiace ritmice, AV=95/min<br />
- zg. aspru, “superficial”, sistolo-diastolic, intensitate medie,<br />
periapexian, (frecatura pericardica)<br />
- TA 115/75 mmHg<br />
Diagnostic <strong>de</strong> etapa:<br />
SINDROM PERICARDIC.<br />
SINDROM FEBRIL.<br />
OBEZITATE.
Investigatiiile <strong>de</strong> prima linie<br />
Tr 245 000 /mm 3 Uree 58.6 mg/dL<br />
Glc 368 mg/dL<br />
Probe biologice:<br />
Col 246 mg/dl<br />
TGL 189 mg/dl<br />
Hb 14.7 g/dl<br />
HDLc 34 mg/dl<br />
Ht 45.9%<br />
LDLc 172 mg/dl<br />
L 11 700 /mm 3<br />
PMN 56 %<br />
Lf 40 %<br />
Eo 3%<br />
Ba 1%<br />
VSH 52 mm/h<br />
CRP 4.8 mg/dl<br />
Ex <strong>de</strong> urina:<br />
d=1030, pH=5,<br />
AP-neg, Z++, sed.- c.cet.-<br />
Creat 0.99 mg/dL<br />
K 4.64 mEq/L<br />
Na 135 mEq/L<br />
CK 138 UI/L<br />
CK-MB 11 UI/L<br />
TnI 0.01 ng/ml<br />
ASAT 30 UI/L<br />
ALAT 24 UI/L
EKG :<br />
RS, AV=95 /min, ax QRS +30 grd, microvoltaj <strong>de</strong>riv standard, T negativ V1-V6
Rx toracica:
Ecocardiografie:
Investigatii <strong>de</strong> a doua linie<br />
Markeri virali serologici ??<br />
Markeri imunologici ai unei<br />
colagenoze ??
Alte investigatii<br />
Profil glicemic Ora 7.00 – 287 mg/dl<br />
Ora 12.00 – 321 mg/dl<br />
Ora 18.00 – 275 mg/dl<br />
Ora 21.00 – 337 mg/dl<br />
Ora 24.00 – 246 mg/dl<br />
Ora 03.00 – 291 mg/dl<br />
HbA1c<br />
Screening complicatii cronice DZ
Diagnostic final:<br />
Pericardita acuta idiopatica.<br />
Obezitate grd I.<br />
Dislipi<strong>de</strong>mie mixta.<br />
Diabet zaharat tip II nou <strong>de</strong>pistat <strong>de</strong>zechilibrat.
Pericardita acuta<br />
– date teoretice -
Pericardita acuta<br />
Inci<strong>de</strong>nta ? ~ 1%<br />
5 % din durerile toracice non – coronariene<br />
(UPU - SUA)<br />
1 % din cauzele <strong>de</strong> supra<strong>de</strong>niv. <strong>de</strong> segment ST<br />
(UPU - SUA)
Etiologia:<br />
1. Idiopatica (80-90%)<br />
2. Infectioasa<br />
1. Virala (Echo, Coxackie, CMV)<br />
2. Bacteriana (Str, Sf, Mycoplasma,Borellia)<br />
3. TBC<br />
3. IMA<br />
4. LES, PAR, SD<br />
5. Medicamente (izoniazida, hidralazina, procainamida)<br />
6. Radiatii<br />
7. Neoplazica<br />
8. Post-cardiotoracotomie<br />
Dupa Braunwald’s Heart Disease, 9 th Ed., 2012
FH Netter, Atlas of Human<br />
Anatomy, 5 th Ed., 2010
Dupa RA Lange et al. Acute Pericarditis N Engl J Med 2004; 351:2195-2012<br />
T. clinic - simptomele<br />
1. Durerea<br />
- Brusca, severa, <strong>de</strong> durata, caracter ascutit<br />
- Variabila cu respiratia, pozitia toracelui<br />
- Localizare, Iradiere<br />
2. Febra<br />
3. Dispneea<br />
4. Tusea<br />
5. Simptome generale - inf. virala<br />
6. Miocardita <strong>de</strong> acompaniament
Ex. obiectiv<br />
1. Frecatura pericardica<br />
- caracter aspru (“zapada inghetata”,”matase”)<br />
- “sperficiala”<br />
- 3 componente<br />
- variabila in dinamica<br />
2. Anxietate<br />
3. Pozitie antialgica<br />
4. Respiratie superficiala
Diagnostic diferential:<br />
1. Ischemia miocardica (IMA, API)<br />
2. Disectia <strong>de</strong> Ao<br />
3. Embolia si infarctul pulmonar<br />
4. Pneumonia cu pleurezie<br />
5. Pneumotoracele<br />
6. Costocondrita<br />
7. Herpes-zoster<br />
8. Reflux GE<br />
Dupa Braunwald’s Heart Disease, 9 th Ed., 2012
Diagnostic diferential:<br />
Al durerii toracice:<br />
Sdr. coronarin acut (factorii <strong>de</strong> risc, localizarea durerii)<br />
Pneumonie (febra, tuse)<br />
Esofagita, spasm esofagian<br />
Al formelor etiologice:
Tratament<br />
Obiective:<br />
1. Combaterea durerii si a febrei<br />
2. Retrocedarea colectiei pericardice<br />
3. Prevenirea complicatiilor<br />
4. Tratamentul conditiilor asociate
Tratament:<br />
Repaus la pat ?<br />
Dieta: hiposodat, hipocaloric (1900 kcal), hipolipidic<br />
Medicatia: Ibuprofen 400 mg, 1-1-1-1<br />
Bisoprolol 5 mg, 1-0-1<br />
Colchicina 0.5 mg, 1-0-1<br />
Paracetamol 500 mg, 1-0-1<br />
Atorvastatina 20 mg/zi<br />
Insulatard 16 UI seara<br />
Siofor 2 x 1000 mg
Complicatiile pericarditei acute – date din literatura:<br />
• Colectia pericardica mare<br />
• Tamponada cardiaca (3,1 %)<br />
• Pericardita constrictiva (1.5%)<br />
- multe din <strong>caz</strong>urile complicate – etiologie specifica<br />
(i<strong>de</strong>ntificabila)<br />
B Maisch et al. Diagnosis and management of pericardial diseases Eur Heart J 2004; 25:587
Evolutia<br />
Recidiva – 15-30 % din p. ac. idiopatice<br />
Femei, cei cu raspuns incomplet la AINS<br />
Episoa<strong>de</strong> recurente <strong>de</strong> durere pericardica<br />
Uneori persistenta, <strong>de</strong>bilitanta<br />
Reevaluare pentru o caua specifica (autoimuna)<br />
Prognosticul pe termen lung e bun:<br />
cele mai multe remit (chiar daca 8 ani)<br />
pericardita constrictiva e rara<br />
Recurentele dureroase pot crea confuzie <strong>de</strong> diagnostic cu SCA
Tratamentul durerii recurente post - p. acuta<br />
AINS: 2 saptamani<br />
Colchicina: 2-3 mg incarcare, apoi 1 mg/zi, 6 sapt – 3 (6) luni<br />
(<strong>de</strong> la inceput sau dupa AINS initial)<br />
10-15 % intoleranta digestiva la colchicina<br />
Prednison: cure scurte (1 saptamana) la fiecare recidiva<br />
Daca recidivele sunt frecvente – cure lungi cu doza minima<br />
eficienta (0.2-0.5 mg/Kgc)
Afebrilitate din ziua a 3 a<br />
Ecografie control 18 iun 2012
Prognostic:<br />
Remisiunea completa: regula, pt etiologia virala<br />
Recurenta: posibila pana la 20-30 %<br />
Al bolilor asociate: riscul cardiovascular f. inalt<br />
poate fi redus – sa<strong>de</strong>rea in G<br />
- control dislipid<br />
- control diabet
Concluzie:<br />
Pericardita acuta - realitate in practica clinica<br />
Recunoasterea – clinic si EKG<br />
Diferentierea <strong>de</strong> alte conditii acute, in special cardiovasculare<br />
Importanta pentru tratamentul <strong>de</strong> urgenta al acestor pacienti
Particularitatea <strong>caz</strong>ului<br />
Durere toracica anterioara care survine la<br />
un pacient cu factori <strong>de</strong> risc CV si care<br />
poate crea confuzii <strong>de</strong> diagnostic.
Va multumesc