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Elevacion Segmento ST con Arterias Coronarias Normales

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Elevacion Segmento ST con Arterias Coronarias Normales

  1. 1. Elevación Segmento ST con A.Coronarias Normales Dr. Daniel Agüero V Becado Medicina Interna Mayo 2014
  2. 2. Introducción  Pacientes con elevación segmento ST que no tienen ninguna oclusión en coronariografía (3 %-5%)  Varía en relación con la población estudiada y criterios de normalidad coronariografía.  El cuadro se ha asociado a múltiples etiologías  Pronóstico a mediano y largo plazo tiende a ser mejor que el de los pacientes con lesiones coronarias.
  3. 3. Epidemiología  PERFIL: Hombre, Edad Media (50 a ), Fumador, Hipertenso.  24% dislipemia  9% diabetes
  4. 4. Diagnóstico Diferencial
  5. 5. Condiciones Benignas:
  6. 6. SDST normal Patrones Masculinos
  7. 7. - 90% Hombres jóvenes - Más común en V2 - SD: Asimétricos, concavos.
  8. 8. Variante Normal Repolarización Precoz
  9. 9. • Elevación 1 – 4 mm • Más Frecuente en V4, II>III • Muesca antes del SDST • ST Cóncavo • PR discretamente infradesnivel • Raro compromiso de derivadas de miembros • Onda T prominente • Atletas y Población de Raza Negra.
  10. 10. Post-CVE
  11. 11. - Aproximadamente 15% - 20% - No específica y sin evidencia de daño miocárdico - No se debe utilizar como diagnóstico de IAM – Complicación CV o de la arritmia - Sin elevación Enzimas Cardíacas.
  12. 12. Condiciones Criticas:
  13. 13. Puente Miocárdico  Haces de fibras musculares que recubren un trayecto variable de una arteria coronaria epicárdica  Su diagnóstico se realiza in vivo por estudio angiográfico, al comprobar una compresión sistólica de una arteria coronaria que desaparece durante la diástole. (“Milking”)  La mayoría incidentales ( 0,5-7,5%)
  14. 14. Anomalías Coronarias Transitorias
  15. 15. 1.- Obstrucción coronaria por un trombo que se lisa rápidamente - Tromboembolia a partir de un trombo mural cardíaco, valvular o aórtico. - Formación del trombo in situ: estado de hipercoagulabilidad secundarios a trombofilia hereditaria, presencia de factor V de Leiden y otros.
  16. 16.  2.- Espasmo Arteria Coronaria o Angina Variante (Prinzmetal) - Aumento temporal en el tono vascular coronario (vasoespasmo) de una arteria epicárdica, causando una marcada pero transitoria reducción en el diámetro luminal. - 20% Coronariografía normal. - Clínica dolor intenso en el pecho, que por lo general viene sin esfuerzo físico, y se asocia con una elevación del ST transitorio en ausencia de biomarcadores cardíacos séricos elevados.
  17. 17. Anormalidades de la Conducción:
  18. 18. Bloqueo de Rama Izquierda - QRS ancho con complejos QS o rS en V1 y puede acompañarse por elevación ST. - SCA Interpretar BRI - Criterios de Sgarbossa  ECG, que colaboran en el dg IAM en contexto de BRI
  19. 19. Pericarditis Aguda  Elevación segmento ST es difusa, concavo y se asocia con depresión PR y ausencia Q
  20. 20. Sindrome Brugada  Pacientes sin cardiopatía estructural, que muestran en el (ECG) una elevación del segmento ST en precordiales V1-V3 con un punto J elevado que simula una R’ dando la apariencia de bloqueo de rama derecha (BRD), y P invertida.
  21. 21. Hemorragia Subaracnoidea  La prevalencia elevación del segmento ST (HSA) se ha descrito  7,5 a 31%.  Alteración Autonómica Afectaría Repolarización Ventricular.  Pueden cursar con Elevación Enzimas Cardiacas y alteraciones de la contractilidad (“Aturdimiento Miocárdico”)
  22. 22. Sd de Discinesia apical transitoria VI Cardiomiopatía Takotsubo  Se caracteriza por : aquinesia o discinesia transitoria principalmente al ápex del ventrículo izquierdo, ausencia de lesiones coronarias y cambios electrocardiográficos con elevación del segmento ST o inversión de la onda T.  Afecta principalmente a mujeres (4:1) (3), de edad (media 62-75 años).  Casi siempre existe un desencadenante que suele ser un episodio de estrés físico, un ejercicio físico inhabitual, un estrés emocional agudo, o una cirugía.
  23. 23.  Las enzimas cardíacas pueden elevarse levemente (CPK en el 56%, troponina casi en el 100%), con caída rápida.  Ventriculografía: imagen típica, que recuerda a una vasija de cuello angosto y base globular y ancha como las que en Japón se utiliza para capturar pulpos, denominadas Tako-Tsubo  Clinicamente mejoran 2º -3º día, cambios ECG y Ecográficos días-semanas
  24. 24. Bibliografía  ST-Segment Elevation in Conditions Other Than Acute Myocardial Infarction Kyuhyun Wang, M.D., Richard W. Asinger, M.D., and Henry J.L. Marriott, M.D. NEJM 2003  ST-segment elevation in non-atherosclerotic coronaries: a brief overview Subhash Chandra • Vikas Singh • Mahendra Nehra • Dipti Agarwal • Nishit Singh, 10 November 2010  Puente Miocárdico Sintomático Rodríguez-B. Aguirre R, Mayoralas Palomo Mª V, Sánchez-Maroto Lozano T, Cardenete Aljama M A. Servicio de Urgencias del Hospital General Universitario de Ciudad Real 19 NOVIEMBRE 2010  Infarto y arterias coronarias normales. La realidad vista desde el otro lado del espejo  Myocardial infarction and normal coronary arteries. From the other side of the mirror  Xavier Bosch a, Pablo Loma-Osorio Ricón Unidad Coronaria. Servicio de Cardiología. Hospital Clínic. Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Departamento de Medicina. Universidad de Barcelona. Barcelona. España, Nov/2007  Diagnosing a Brugada syndrome: the role of primary care M. Retana-Puigmartí a, E. De Frutos-Echaniz a, , I. Castro-Acuña-Baixauli a, A. Val-Jimenez diciembre 2011

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