This is a patient with a lot of cardiovascular disease. If the doctor is not careful, he will also be taken to the "ditch" by the patient's old problems.
The patient is male, 84 years old.
Previously, there have been hypertension, coronary heart disease, cerebral infarction, and a Holter ecG has a degree of atrioventricular block, atrial premature beats, atrial tachycardia, bordering premature beats, bordertime escape beats, in short, there are rapid and slow arrhythmias. Hypertension took antihypertensive drugs, self-test blood pressure is normal.
First onset
One day, the patient had lunch at home, sat down and suddenly fainted. Foaming at the mouth, but no convulsions, no urinary incontinence, after about 3 or 5 minutes to wake up. Hurry to the nearby hospital emergency department.
When I went to the emergency department, my blood pressure was 104/78mmHg, which was lower than usual; my heart rate was normal, 70 beats per minute. At that time, I checked the electrocardiogram, except for the one-time atrioventricular block, there was no major problem, and the head CT did not find new problems.
2 days later, the patient came to our hospital.
When you hear about the medical history, you will think of several questions.
Cardiac problems, cardiogenic syncope. Patients have coronary heart disease, the key is also arrhythmias. Whether it is a rapid or slow arrhythmia, syncope can occur because of the blood pressure that affects the heart and the blood supply to the brain. Besides, although the arrhythmias we know now are not serious, who knows what arrhythmias the patients have when they are onset?
Problems with blood pressure, hypotension causes ischemic attacks. The 84-year-old elderly hypertensive patient is sick at lunch, and the emergency blood pressure is also low. This is reminiscent of the "postprandial hypotension" that is characteristic of hypertension in old age. It is that the blood pressure is significantly reduced after eating, the systolic blood pressure drops > 20mmHg, or there is a manifestation of insufficient cerebral blood supply. This is because the blood after the meal has to go to the gastrointestinal tract to help digestion, the body will also secrete substances that dilate blood vessels, and the elderly would have a period of time at noon to reduce blood pressure, a few times, blood pressure is low, there may be a possibility of syncope (the elderly faint after a meal, blood pressure as low as 70/40mmHg, myocardial infarction or cerebral infarction?). ）。
Problems with epilepsy. Patients have original cerebral infarction, and the site of cerebral infarction can become a focal point for epilepsy.
No matter what kind of problem you think of, you must first check it and check the body.
Blood pressure measurement, 126/50mmHg, heart rate 64 beats per minute, heart rhythm, systolic murmur can be heard in the apex of the heart, aortic valve area; the point is that in the patient's left carotid artery, a vascular murmur is heard.
In general, it is okay to hear a mild systolic murmur at the apex of the heart, but a physiological murmur; if there is a murmur in the aortic valve area, there is generally a problem; what does the carotid bruit indicate? There is a stenosis in the carotid arteries.
Check it out further! The problem that comes to mind should be ruled out.
Electrocardiogram, cardiac ultrasound, carotid ultrasound, ambulatory blood pressure, Holter electrocardiogram.
After a week, the patient returns
ECG, sinus bradycardia, one-degree AV block.
Ultrasound of the heart, calcification of the aortic valve, decreased left ventricular diastolic function. This calcification of the aortic valve is a change in the aging of the valve in the elderly.
Carotid ultrasound, found the problem, left side severe stenosis. This is consistent with the murmur heard on clinical examination.
How narrow is it? The original pipe diameter is 7mm and the residual pipe diameter is 2.3mm. In this way, the diameter of the blood vessel is reduced by nearly 70%, and the area is reduced even more. Such stenosis can completely cause insufficient blood supply to the brain, and even the original cerebral infarction cannot be excluded from carotid arteriosclerosis stenosis. But ultrasound is only the initial screening, and further examination must also do magnetic resonance or CT angiography (the frequent occurrence of "epilepsy" after cerebral infarction, is it the sequelae of cerebral infarction?). ）。
Holter: Average heart rate 58 beats/min, minimum 47 beats/min, highest 87 beats/min, although the overall slower, but not bad. Atrial premature beats 6887 times.
Ambulatory blood pressure, the overall height, 24-hour average blood pressure is 150/60mmHg, daytime is 142/71mmHg, higher at night, 165/71mmHg; circadian rhythm is not normal, nighttime blood pressure is higher than daytime, is a "reverse spoon" curve. This reminds us to pay attention to sleep apnea at night (blood pressure is higher at night than during the day?). "Anti-spoon type" of high blood pressure, be wary of this disease! ）。
In addition, the patient's blood pressure after breakfast and after lunch has dropped significantly, exceeding 20mmHg, which is obviously "postprandial hypotension".
Do some processing first:
* Improve lifestyle to reduce postprandial hypotension. Improve diet, drink soup or drink water before meals, do not drink porridge, food should not be too hot; after meals, if the symptoms are not obvious, you can move around appropriately under the supervision of your family.
*Control blood pressure not to drop too low. The patient's original dose of levlodipine to lower blood pressure is temporarily maintained. Because after carotid artery stenosis, the human body will regulate the increase in blood pressure in order to ensure blood supply to the brain. At this time, if the antihypertensive standard is emphasized, it will lead to insufficient cerebral blood supply and cerebral ischemia attack.
*Continue lipid-lowering and antiplatelet therapy. Patients due to coronary heart disease, cerebral infarction, has taken cholesterol-lowering pitvastatin, antiplatelet clopidogrel, carotid atherosclerotic stenosis is also used in this way, continue.
Further investigation:
*Carotid MRI vascular imaging.
* Sleep breath monitoring.
* Blood examination, blood routine, blood lipids, liver and kidney function, homocysteine, etc., because it involves subsequent therapeutic drugs.
After another two weeks, the patient returned to the clinic again
I still feel dizzy when walking, there is no more fainting, and there is no blackness.
Blood pressure was measured at 114/40mmHg and heart rate was 62 beats per minute.
Carotid MRI reports bilateral internal carotid artery stenosis, 80% on the left and 60% on the right. The internal carotid artery is responsible for supplying blood to the brain.
Web pictures
Sleep breath monitoring, respiratory disturbance index (AHI) 17 times per hour, reached moderate sleep apnea hypopnea syndrome, 15 or more is moderate.
Blood test results also came out, mild anemia, hemoglobin 103g / L; homocysteine 17 mol / l, high, more than 15 is high. LDL cholesterol 1.74 mmol/L.
Thus, several lines of diagnosis were added: bilateral carotid artery stenosis, sleep apnea hypopnea syndrome (moderate), postprandial hypotension, hyperhomocysteinemia.
Next steps in treatment:
*Continue anti-arteriosclerosis treatment. Carotid artery stenosis also requires LDL cholesterol to drop below 1.8 mmol/L, and patients meet the standard.
*Blood homocysteine is high, take a small dose of folic acid, 2.5 mg once a day.
* Carotid artery stenosis greater than 70%, or 50% of stenosis has symptoms of cerebral insufficiency, and treatment of opening blood vessels should be considered, with carotid artery endometrial detachment or stent implantation. But for the 84-year-old, there are still many considerations, which require neurosurgery, neurology and the patient's family to communicate and determine.
*For hypopnea syndrome with moderate sleep apnea, noninvasive ventilator therapy should be considered.
* Others are lifestyle improvements, monitoring blood pressure heart rate and so on.
What does this case tell us?
The disease is complex and has many causes, especially in the elderly, and doctors need to analyze and identify them specifically.
It is important to take a good look. Like carotid bruits, it is the only sign of carotid artery stenosis, although not necessarily present when stenosis occurs.
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