Old woman with acute coronary syndrome and history of repetitive syncope

Dr. Raimundo Barbosa Barros
Brazil

Case presentation

Main complaint: precordial pain and fainting.

Elderly, female patient (83 years old): diabetic, dyslipidemic, and with hypothyroidism. She was admitted in the ER due to symptoms of syncope, which she mentions has been happening to her since she was 38 years old, associated to different troubles. After recovering consciousness, she reported oppressive precordial pain and dyspnea.

The ECG made at the time revealed complete right bundle branch block, left anterior fascicular block, and ventricular repolarization alterations (VRA), left ventricular enlargement (LVE) and positive myocardial necrosis biomarkers (troponin T; 0.3/ml). A diagnostic hypothesis of non-ST segment elevation acute coronary syndrome was made, and diagnostic coronary angiography was requested, which could not be done as her consciousness got depressed again, presented hypertensive peak and renal dysfunction. She mentioned precordial pain associated to nausea and dyspnea 3 months before, with no previous investigation.

She was sent to the ICU to continue with her care. She was admitted alert, cooperative, in Glasgow 15 with no deficit, and good respiratory pattern and asymptomatic hypertension. BP 203/105 mmHg, HR 80 bpm, split regular heart rhythm, rhythmic and normal sounds with no murmurs.

Echo: 16/10, discrete increase of left ventricular volume for the biotype (33 mm/m2), discrete concentric LV hypertrophy and preserved overall and segmentary LV contractility.
Raimundo and Andres.

Questions

What is the electro vectorcardiographic diagnosis?
What is / are the causes of the prominent anterior QRS forces? And Why?

Apresentação do caso

Queixa principal: Dor precordial e desmaio.

Paciente idosa, (83 anos) diabética, dislipidêmica, e hipotiroidea. Admitida na emergência por quadro de síncope o que refere ocorrer periodicamente desde os 38 anos que ela associa a contrariedades. Após a recuperação da conciencia refere dor percordial opressiva e dispnéia.

O ECG realizado nesse momento mostrava probable bloqueio completo do ramo do ramo direito, bloqueio divisional ântero-superior e alterações de repolarização ventricular (ARV), sobrecarga do ventrículo esquerdo (SVE) e aumento dos biomarcadores de necrose miocárdica (troponina T; 0.3/ml). Feita a hipótese diagnóstica de síndrome coronariana aguda sem elevação do segmento ST, se solicita cinecoronariografia diagnóstica a qual não foi realizada em consequência de novo rebaixamento da consciência, pico hipertensivo e disfunção renal.

Refere dor precordial associado a náuseas e dispneia há 3 meses sem investigação prévia.. Referida a UTI para continuidade dos cuidados. Da entrada alerta, cooperativa, Glasgow 15 sem déficit com bom padrão respiratório e hipertensão assintomática. PA 203/105 mmHg, FC 80bpm RCR me 2 tempos , bulhas rítmicas e normofonéticas sem sopros.

EC0: 16/10 discreto aumento do VVE para o biótipo ( 33mm/m2) hipertrofia concêntrica discreta do VE e contratilidade global e segmentar do VE preservada.
Raimundo e Andres