Akut miyokard infarktüsü ile başvuran bir COVID-19 hastasına yaklaşım

Yıl 2021, Cilt: 2 Sayı: 1, 40 - 43, 30.03.2021

Ali Duygu , Uğur Küçük , Mehmet Arslan

Öz

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.

Anahtar Kelimeler

Akut koroner sendrom, COVID19, perkütan koroner girişim

Approach to COVID-19 Patient Presenting with Acute Myocardial Infarction

Öz

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.

Anahtar Kelimeler

acute coronary syndrome, COVID-19, percutaneous coronary intervention

Kaynakça

• 1- Gilutz H et al. Adherence to NSTEMI Guidelines in the Emergency Department: Regression to Reality. Crit Pathw Cardiol. 2019 Mar;18(1):40-46. doi: 10.1097/HPC.0000000000000165. PMID: 30747764.
• 2- Piątek Ł, et al.. Outcomes of a routine invasive strategy in elderly patients with non-ST-segment elevation myocardial infarction from 2005 to 2014: results from the PL-ACS registry. Coron Artery Dis. 2019 Aug;30(5):326-331. doi: 10.1097/MCA.0000000000000708. PMID: 30724817.
• 3- Basit H, Malik A, Huecker MR. Non ST Segment Elevation Myocardial Infarction. [Updated 2020 Oct 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.
• 4- Fauci AS, Lane HC, Redfield RR. Covid-19 - Navigating the Uncharted. N Engl J Med. 2020 Mar 26;382(13):1268-1269. doi: 10.1056/NEJMe2002387. Epub 2020 Feb 28. PMID: 32109011; PMCID: PMC7121221.
• 5- Wang D, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020 Mar 17;323(11):1061-1069. doi: 10.1001/jama.2020.1585. PMID: 32031570; PMCID: PMC7042881.
• 6- Smeeth L, et al. Risk of myocardial infarction and stroke after acute infection or vaccination. N Engl J Med. 2004 Dec 16;351(25):2611-8. doi: 10.1056/NEJMoa041747. PMID: 15602021.
• 7- Shi S, et al.. Characteristics and clinical significance of myocardial injury in patients with severe coronavirus disease 2019. Eur Heart J. 2020 Jun 7;41(22):2070-2079. doi: 10.1093/eurheartj/ehaa408. PMID: 32391877; PMCID: PMC7239100.
• 8-Giustino G, et al. Coronavirus and Cardiovascular Disease, Myocardial Injury, and Arrhythmia: JACC Focus Seminar. J Am Coll Cardiol. 2020 Oct 27;76(17):2011-2023. doi: 10.1016/j.jacc.2020.08.059. PMID: 33092737; PMCID: PMC7572122.
• 9- Cordeanu EM, et al. Prognostic Value of Troponin Elevation in COVID-19 Hospitalized Patients. J Clin Med. 2020 Dec 17;9(12):4078. doi: 10.3390/jcm9124078. PMID: 33348719; PMCID: PMC7766903
• 10- Gluckman TJ, et al.Case Rates, Treatment Approaches, and Outcomes in Acute Myocardial Infarction During the Coronavirus Disease 2019 Pandemic. JAMA Cardiol. 2020 Aug 7;5(12):1–6. doi: 10.1001/jamacardio.2020.3629. Epub ahead of print. PMID: 32766756; PMCID: PMC7414426.
• 11- Kucharski AJ, et al.Centre for Mathematical Modelling of Infectious Diseases C-wg. Early dynamics of transmission and control of COVID-19: a mathematical modelling study. Lancet Infect Dis 2020;20(5):553-558. https://doi.org/10.1016/S1473-3099(20)30144-4
• 12- Abdelaziz HK,et al. COVID-19 Pandemic and Acute Myocardial Infarction: Management Protocol From a British Cardiac Centre. Crit Pathw Cardiol. 2020 Jun;19(2):55-57. doi: 10.1097/HPC.0000000000000222. PMID: 32229766; PMCID: PMC7188064.
• 13- Ruan Q, et al. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med 2020;46(5):846-848. https://doi.org/10.1007/s00134-020-05991-x
• 14- Boeddinghaus J, et al. Impact of age on the performance of the ESC 0/1h-algorithms for early diagnosis of myocardial infarction. Eur Heart J 2018;39(42):3780-3794. https://doi.org/10.1093/eurheartj/ehy514
• 15-Collet JP, et al. ESC Scientific Document Group. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2020 Aug 29:ehaa575. doi: 10.1093/eurheartj/ehaa575. Epub ahead of print. PMID: 32860058.
• 16- Aktoz M, et al.Consensus Report from Turkish Society of Cardiology: COVID-19 and Cardiovascular Diseases. What cardiologists should know. Turk Kardiyol Dern Ars. 2020 Mar;48(Suppl 1):1-48. Turkish. doi: 10.5543/tkda.2020.97198. PMID: 32250347.
• 17- Romaguera R, Cruz-Gonzales I, Ojeda S, et al. Consensus document of the Interventional Cardiology and Heart Rhythm Associations of the Spanish Society of Cardiology on the management of invasive cardiac proce- dure rooms during the COVID-19 coronavirus outbreak. Revista Espanola de Cardiologia. Mar 3, 2020
• 14- Boeddinghaus J, et al. Investigators T-A. Impact of age on the performance of the ESC 0/1h-algorithms for early diagnosis of myocardial infarction. Eur Heart J 2018;39(42):3780-3794. https://doi.org/10.1093/eurheartj/ehy514