<Brief
History>
A 71
year old woman was admitted to hospital for recurrent chest
pain and increasing shortness of breath for 3 hours. She had
been hospitalized about 3 months ago for unstable angina, when
ECG revealed biphasic T waves in leads V1 – V4 (Figure1
). She
had a past history of type 2 diabetes controlled on
drugs and hypertension. She described daily symptoms of chest
pain and dyspnea with mild to moderate exertion, and had woken
on two occasions at night with similar symptoms. She had
no other problems, her blood
sugars were
satisfactory (averaging 110 to 150 mg/dl), and she reported no
other features of heart failure. She
had never smoked, lived by herself and was normally fully
independent. Her usual medications consisted of:
aspirin 100mg once
per day,
glipizide
5mg three times per day, and diltiazem CD
180mg once per day.
Physical
examination revealed an elderly lady in no distress at rest,
with regular pulse 80 bpm, BP 140/80 with no postural drop,
JVP elevated 3cm, mild ankle edema, third heart sounds with
2/6 pan-systolic murmur at the apex, and widespread crackles
in the lung bases on chest auscultation. ECG (Figure2
) at ER revealed tall ST
segment elevation in leads V1 – V5, while CXR showed mild
cardiomegaly with pulmonary venous congestion and small
bilateral pleural effusions. Blood tests revealed mild
normochromic anaemia (Hb 10.2 g/dl), elevated serum creatinine
1.6mg/dl, urea 28 mg/dl, potassium 4.9 mmol/l, and raised
troponin-I to 10 U/I. Urinalysis shows 2+ proteinuria.
Under the impression of acute
anteroseptal AMI, emergent cardiac catheterization was
performed and coronary angiogram showed LM short & patent,
RCA patent, proximal LAD total occlusion, proximal LCX 60%
stenosis; ballooning dilatation with stenting for LAD was
performed with flow restoration and 0% residual stenosis . The
post-procedural course was rather smooth. However, dyspnea
followed by collapse was noted 5th days after infarction.
BP70/40mmHg, HR124/min, grade 3/6 pan-systolic murmur at the
apex, and diffuse wheezing were noted. F/U 12-lead ECG showed
sinus tachycardia and Q wave in V1-4. Meanwhile, biochemistry
and ABG was shown as following: BUN/Cr 36/1.8 mg/dl, AST 43
U/I, Na/K/Cl 141.6/4.53/111mM, Ca 2.06 mM, P 5.9 mg/dl, Mg
1.13 mM, CK/CK-MB/Troponin-I 70/16/14.1U/I;
ABGs pH/pCO2/pO2/HCO3/BE 7.31/19.7/181.3/9.7/-15.0.
Echocardiography revealed a jet from LV apical septum
to RV. Intra-arterial counter-pulsation and repair
for ventricular septal rupture were done soon. She was
discharged 4 weeks later with improved condition.
Disscusion
這位婦人前次住院的病情符合 Wellen's
syndrome 的臨床診斷,Wellen's
syndrome的定義是有典型心絞痛的病史再加上心電圖胸前導程V1-4
(尤其是V2-3)出現雙相或倒置的T
波,則可高度預期有嚴重的近端左前降枝冠狀動脈狹窄。患者因而有發生大片前壁心肌梗塞或猝死的高危險性;所以不建議做運動心電圖等壓力性檢查,而是應該及早做心導管檢查並且處理血管狹窄的問題。本病例提醒我們不應該忽略掉這些心電圖變化或是僅以保守性藥物治療的方式處理這類病人,以免延誤病情,造成更大的傷害。
參考文獻: Wellens' Syndrome, Annals of Emergency Medicine,
March 1999, Vol.33, No. 3, pp347-351.
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