Akut miyokard infarktüsü ile başvuran bir COVID-19 hastasına yaklaşım

Abstract

Koroner arter hastalığı sıklıkla, şiddetli koroner arter daralmasına neden olan ve miyokardiyuma yetersiz kan akışına yol açan koroner aterosklerotik hastalığı ifade eder. COVID-19 pnömonisinin şiddetli endotelyal inflamasyon, mikrovasküler tromboz ve multiorgan yetmezliği ile birlikte sitokin fırtınası ile karakterizedir. COVID-19'un hem tromboz hem de miyokard hasarı üzerindeki etkileri sonucunda bu hastalarda miyokard infarktüsü sıklıkla görülmektedir. 68 yaşında erkek hasta 3-4 gün önce başlayan göğüste baskı hissi, nefes darlığı, el ve kollarda uyuşma şikayetleri ile acil servise başvurdu. Kardiyak troponin değerleri sırasıyla 560 ve 680 ng/L (üst sınır: 14 ng/L) idi. Toraks bilgisayarlı tomografi görüntüleri viral pnömoni ile uyumlu olduğu için hasta akut koroner sendrom ve COVID-19 pnömonisi ön tanılarıyla yoğun bakım ünitesine yatırıldı. Medikal tedavi sonrası aynı gün kardiyojenik şok gelişince hasta koroner anjiyografi laboratuvarına alındı. Kardiyojenik şoklu hastada ilişkili tüm arterlere girişim düşüncesiyle lezyonlarına stent implante edildi. Şu anda, miyokardiyal hasarın sadece hastalık şiddetinin bir belirteci olup olmadığı veya COVID-19 morbidite ve mortalitesine doğrudan katkıda bulunup bulunmadığı belirsizliğini korumaktadır. Olgumuzda olduğu gibi troponin birçok COVID-19 hastasında limit değerleri aşmaktadır. Bu artış; miyokardit, akut koroner sendrom ve enfeksiyon gibi nedenlere sekonder olabilir ve bu nedenle ihmal edilebilir. Troponin yükselmesi olan ve akut klinik instabilite belirtileri olmayan hastalar (EKG değişiklikleri, ağrının tekrarlaması) öncelikle konservatif bir yaklaşımla tedavi edilebilir. COVID19 ve akut koroner sendrom tanısıyla kardiyojenik şok birlikteliğinde primer perkütan girişim yaptığımız hastamızda ekokardiyografi, EKG, klinik ve kardiyak enzim kombinasyonu ile merkezimizin multidisipliner yaklaşımından bahsederek bu sunumla başvuran hastaların tedavi uygulamalarına katkı sağlamaya çalıştık.

Keywords

• Akut koroner sendrom
• COVID19
• perkütan koroner girişim

Approach to COVID-19 Patient Presenting with Acute Myocardial Infarction

Abstract

Coronary artery disease (CAD) often refers to coronary atherosclerotic disease that results in severe coronary artery narrowing and leads to insufficient blood flow to the myocardium. It is clear that COVID-19 pneumonia is characterized by cytokine storm with severe endothelial inflammation, microvascular thrombosis and multiorgan failure.As a result of the effects of COVID-19 on both thrombosis and myocardial damage, myocardial infarction is frequently seen in these patients. A 68-year-old male patient was admitted to the emergency room with complaints of pressure in the chest, shortness of breath, and numbness in the arms and hands that started 3-4 days ago. Cardiac troponin values were 560, 680 ng / L (upper limit: 14 ng / L), respectively, and when sections compatible with thorax computed tomography images were seen, he was taken to the intensive care unit with the pre-diagnoses of ACS and COVID-19. The patient was taken to the coronary angiography laboratory when the shock picture developed on the same day after medical treatment.Stent was implanted in LAD and RCA lesions with the idea of intervention in all associated arteries in the patient with cardiogenic shock. Currently, it remains unclear whether myocardial damage is only a marker of disease severity or directly contributes to COVID-19 morbidity and mortality. As in our case, troponin exceeds the limit values in many COVID-19 patients. This increase; It may be secondary to causes such as myocarditis, acute coronary syndrome and infection, and can therefore be neglected. Patients with troponin elevation and without signs of acute clinical instability (ECG changes, recurrence of pain) can be treated primarily with a conservative approach.In the case where we performed primary percutaneous intervention under the picture of ACS with COVID-19 and as a result of cardiogenic shock, we tried to contribute to the treatment practice of patients who presented with this picture by mentioning the multidisciplinary approach of our center with the combination of TTE, ECG, clinical and cardiac enzyme.

Keywords

• acute coronary syndrome
• COVID-19
• percutaneous coronary intervention

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