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Coronaire spasmen

CORONAIRE SPASMEN = PRINZMETAL ANGINA

 

1. Andere namen

- Prinzmetal angina
- variant angina

 

2. Oorzaken

- focale coronaire spasmen
- meestal bij stenosen
- verder sympatische stimulatie zonder parasympatische stimulatie door endogene hormonen.
- thv de coronairen zelf abnormale vasodilatatiefunctie, hypersensitiviteit voor vasoconstrictoren.

 

3. Diagnostische workup

- kliniek:
- thoracale pijn retrosternaal, in rust (soms bij koude, stress, hyperventilatie. Soms is een cicardiaans patroon merkbaar, meer specifiek: vooral pijn 's morgens.  Vaak uitstraling naar hals, kaak en arm.  Verbetert soms met oefeningen.
- palpitaties
- (pre-) syncopaal
- zelden associatie met migraine of ziekte van Raynaud
- ook bij personen zonder risicofactoren
- risicofactoren: ouderdom (mannen tussen 51 en 57), roken, hyperinsulinaemie, insulineresistentie
- anamnese
- aanleiding?
- duur?
- aard?
- Electrocardiogram
- ST segment: transiente elevatie gevolgd door ST depressie en T-inversie
- Labo
- CK-MB
- troponine
- toxico screening (risico: cocaine)
- Beeldvorming
- RX-thorax:
- andere oorzaken: pneumonie? pneumothorax? aortadissectie?
- fietstest: controversieel.  Alleen zichtbaar indien ook een stenose
- Thallium scintigrafie

- coronarografie met provocatietesten (hyperventilatie, acetylcholine, ergovine) toont vaak milde atherosclerose

 

4. DD

- cardiovasculair
- angina pectoris
- AMI
- pericarditis
- mitralisklep prolaps
- aortadissectie
- longen
- pneumothorax
- longembolen
- gastro-intestinaal
- oesofagaal (spasme, ruptuur, oesofagitis, reflux)
- maagulcera
- angststoornis

 

 

Eerste opvang

- ABC
- monitoring
- IV lijn
- zuurstof
- pulse oximetrie
- aspirine altijd toedienen!

 

Spoeddienst

- anti-angiosa
- indicaties: angina pectoris, linker hartfalen (vb longoedeem), hypertensieve crisis
- contra-indicaties: hypotensie, shock, rechter ventrikelinfarct
- welke producten?
- Nitraten SL: Nitrolingual (1 dosis spray = 0,4 mg), Cedocard (meerdere dosages! meestal 5 mg)
- Nitraten IV: Cedocard: 1 amp = 10mg/10ml
- molsidomine (Corvaton) 1 amp = 20mg/10ml
- calcium antagonisten (indien de anamnes specifiek is)
- Verapamil (Isoptine, Lodixal):
- Per os: bij angor 320 à 360 mg/d in 3 giften, Bij aritmie 120 à 480 mg/d, bij AHT 240 à 480 mg/d
- IV: bij supraventriculaire tachycardie 1 amp (5 mg) traag IV, evtl te herhalen na 10 min
- Diltiazem (Tildiem)
- Per os: bij angor 1x daags 200 à 300 mg of 3x daags 60 à 120 mg.  Bij hypertensie 1x daags 200 à 300 mg
- Heparine of beta-blokkers hebben GEEN nut!
 

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