Caso 3/2009: homem de 75 anos de idade com insuficiência cardíaca devida a infarto anterior extenso com formação de aneurisma ventricular

Abstract

A 75-year-old man sought medical assistance due to hemoptysis and general malaise. The patient presented dyspnea triggered by moderate exertion at the end of April. A week after the symptom onset, the dyspnea increased and started to be triggered by mild exertion. He also suffered a syncopal episode, which prompted him to seek emergency medical attention.Two weeks later he sought medical assistance at Instituto do Coracao (InCor -The Heart Institute) due to worsening of the dyspnea and a sensation of suffocation in the chest.The physical examination (May 10, 2008) showed a heart rate (HR) of 88 bpm and blood pressure (BP) of 90/60 mm Hg. The lung examination disclosed pulmonary rales. The remainder of the examination did not reveal any other alterations.The electrocardiogram (May 10, 2008) showed sinus rhythm; HR at 88 bpm; PR interval of 203 ms; QRS duration of 68 ms; low-voltage QRS complex in the frontal plane; extensive anterior and inferior-wall areas that were electrically inactive; and ST-segment elevation from V 1 to V 6 and in I aVL, with positive T waves from V 1 to V 6 (Figure 1).The laboratory assessment (May 10, 2008) showed glycemia of 94 mg/dl; urea of 43 mg/dl; creatinine of 1.07 mg/dl; sodium of 137 mEq/l; potassium of 4.5 mEq/l; hemoglobin of 12.6 g/dl; leukocytes at 6,500/mm³; platelets at 286,000/m³; INR of 1.1; APTT (patient/control ratio) of 1.12; CKMB of 6.46 ng/ml and troponin of 6.27 ng/ml.The chest X-ray (05. 10. 2008) showed cardiomegaly at the expense of the left ventricle (LV).The echocardiogram (05. 14. 2008) showed an enlarged left atrium (45 mm). The left ventricular ejection fraction (LVEF) was 20%. Akinesis of the LV septal and anterior segments and signs suggestive of intracavitary thrombi in the apical region, one measuring 2.4 x 5 mm, fixed, and a mobile one in middle septal segment measuring 1.0 x 0.7 mm, were diagnosed. There was slight pericardial effusion. The pulmonary artery pressure was estimated at 30 mmHg.The coronary angiography (May 14, 2008) identified occlusion of the anterior interventricular branch of the left coronary artery, a 90% lesion at the emergence of the first diagonal branch and a 70% in the left marginal branch; there were also irregularities in the right coronary artery. An angioplasty of the anterior interventricular branch was attempted; however, the guidewire did not surpass the lesion and an angioplasty in the first diagonal branch was performed with a balloon-catheter.The patient was discharged from the hospital (May 20, 2008) with a daily prescription of 100 mg ASA, 12.5 mg carvedilol, 10 mg enalapril, 25 mg spironolactone, 20 mg simvastatin and 5 mg warfarin .The patient developed dyspnea triggered by moderate exertion and three days later, stated to present dyspnea even at rest. On the morning of the following day, he presented an episode of precordial discomfort, followed by intense sudoresis and nausea that lasted for 30 minutes. He sought medical attention at InCor seven hours after the pain onset.At physical examination (May 24, 200...