Infarto miocardico acuto (IMA)
Definizione
Generalmente l’infarto miocardico acuto è dovuto alla rottura di una placca instabile, con formazione secondaria di un trombo che occlude parzialmente o totalmente il lume della coronaria, provocando un deficit della perfusione a livello distale. Questa è la forma più frequente ed è secondaria a un processo di aterosclerosi. Tra le cause più rare si includono: l’embolia coronarica, il vasospasmo coronarico ( cocaina, ergotamina ecc..),cause iatrogene (chirurgia,interventi percutanei), extracardiache che riducono il flusso coronarico e favoriscono la trombosi (stati di ipercoagulabilità, anemia falciforme, inalazione di CO, ecc..).
Classificazione
Quasi tutti gli infarti colpiscono il ventricolo sinistro.
Possono essere distinti in due differenti tipi:
- Infarto miocardico trasmurale: la parete ventricolare è totalmente interessata.
- Infarto subendocardico: la necrosi ischemica interessa gli strati più interni della parete ventricolare.
Manifestazioni cliniche
La manifestazione clinica più frequente è il dolore toracico di tipo anginoso, ma di maggior durata e più intenso, che appare al riposo e non recede con nitroglicerina sublinguale. Frequentemente si associa a un importante quadro vagale. E’ tipico il suo verificarsi al mattino, dopo che il paziente si è alzato. Il dolore è spesso accompagnato da ansia , agitazione, sudorazione fredda, vomito. Le estremità sono fredde, la pressione arteriosa è normale o bassa, talvolta aumentata durante la fase dolorosa.
Non è infrequente osservare presentazioni cliniche atipiche, come per esempio un dolore epigastrico nell’infarto inferiore, dispnea, sincope non accompagnata da dolore toracico. Le presentazioni tipiche sono più frequenti nei pazienti anziani, nei diabetici e nei pazienti in stato critico o postperati. Le donne hanno una più alta probabilità di presentarsi con un fastidio toracico atipico.
La localizzazione dell’IMA ne determina la prognosi; per esempio un IMA anteriore esteso ha una prognosi peggiore che un IMA Inferiore.
Classificazione di Killip
Grazie all’esame obiettivo si può inoltre classificare l’infarto in base alla classificazione di killip, che
permette una valutazione prognostica.
- Classe I: nessun segno di insufficienza cardiaca ed assenza di 3° tono cardiaco (toni cardiaci)
- Classe II: rumori umidi < 50 % dei campi polmonari con o senza 3° tono cardiaco
- Classe III: rumori umidi > 50 % dei campi polmonari (edema polmonare franco)
- Classe IV: shock cardiogeno (pressione sistolica <90 mmHg, ipoperfusione periferica, oliguria / anuria).
Esami complementari
Un esame fondamentale e in qualunque caso di sospetta sindrome coronarica acuta deve essere effettuato entro 10 minuti dal primo contatto medico.
L’infarto miocardico acuto si può manifestare in due modi:
Infarto miocardico acuto senza sopraslivellamento del tratto ST (NSTEM).
Elettocardigraficamente può presentarsi con:
- ECG normale (almeno in primissima valutazione)
- Sottoslivellamento orizzontale o discendente del tratto ST
- Comparsa di onde T negative -simmetriche
Tale riscontro fa riferimento alla presenza di una lesione subendocardica, non trasmurale, conseguenza di una subocclusione coronarica.
Infarto miocardico acuto con sopraslivellamento del tratto ST (STEMI)
Come indica il suo stesso nome, si manifesta con la presenza di un sopraslivellamento convesso del tratto ST, che traduce la presenza di una lesione transmurale, dovuta all’occlusione completa della coronaria. L’evoluzione ECG prevede la negativizzazione dell’onda T, con la comparsa successiva dell’onda Q di necrosi e progressiva normalizzazione del tratto ST. Se a mesi dall’infarto persistere sopraslivellamento dell’ST bisogna sospettare la presenza di un aneurisma o di una regione discinetica. Il tempo di evoluzione delle alterazioni elettrocardiografiche dipende dalla terapia e dal tempismo con la quale questa venga instaurata. In alcuni casi è possibile riscontare la presenza di un’onda Q durante la loro evoluzione, che indica che si è completata la necrosi transmurale.
Esami di laboratorio
Gli enzimi miocardici che si determinano nella diagnosi dell’IMA sono:
- CK e la sua sezione specifica CK-MB massa. Inizia ad aumentare alle 4-6 ore dall’inizio dell’ischemia, e si normalizza dopo 48-72 ore. La CK aumenta anche in caso di danno muscolare (esercizio fisico, iniezioni intramuscolari, ipotiroidismo, ictus, patologia muscolare). La frazione CK-MB, in particolare CK-MB massa ha una specificità maggiore ma si può comunque elevare in situazioni di danno miocardico di origine ischemica: miocardite, cardioversione elettrica, chirurgia cardiaca e alcune neoplasie.
Altri enzimi che si possono misurare in questo contesto
La mioglobina, che si eleva precocemente alla seconda ora (ma è poco specifica; la GOT e l’ LDH, che iniziano ad aumentare nelle 24 ore hanno un picco tardivo (48 ore e 3-5 giorni rispettivamente), per cui possono essere utili nella diagnosi dell’IMA evoluto.
Altri dati analitici aspecifici
Leucocitosi, iperglicemia, variazioni del profilo lipidico.
Tecniche di imaging
Ecocardiogramma
E’ una tecnica molto utile per valutare le alterazioni della contrattilità segmentaria (le aree necrotiche sono acinetiche mentre quelle ischemiche sono generalmente ipocinetiche) e per escludere la presenza di complicanze (trombi interventricolari, comunicazioni interventricolari,versamento pericardico,aneurisma, valvulopatie).
L’ecocardiogramma, grazie alla grande quantità di informazione che apporta, è utile fin dall’inizio del quadro, e deve essere effettuato in tutti i pazienti in fase acuta per valutare la funzione ventricolare. È l’esame più utilizzato insieme all’elettrocardiogramma nella diagnosi differenziale del dolore toracico acuto.
Gestione dell’infarto miocardico acuto senza sopraslivellamento del tratto ST (NSTEMI)
La trombosi di una placca ateromasica complicata, in base al grado di stenosi che provoca a livello del lume vascolare, provocherà rispettivamente un infarto con sopraslivellamento del tratto ST (di solito occlusione completa dell’arteria), un infarto senza sopraslivellamento del tratto ST (occlusione parziale dell’arteria con elevazione dei marcatori di danno miocardico) o una angina instabile (occlusione parziale del vaso senza elevazione di marcatori di danno miocardico). La gestione dell’angina instabile e dell’infarto senza sopraslivellamento dell’ST è identica ed entrambe le entità vengono inglobate nella sindrome coronarica acuta senza sopraslivellamento del tratto ST.
Terapia
Ricovero e sedazione lieve
Antiaggregazione
- Acido Acetilsalicilico indefinitamente più un secondo antiaggregante ( ticagrelor,prasugel o clopidogrel). Nella SCA-NSTE a rischio molto elevato si può aggiungere un terzo antiaggregante (inibitire della glicoproteina IIb-IIIa: tirofiban o eptifibatide).
Anticoagulazione
- Si utilizzano fondaparinux, eparina sodica o eparina di basso peso molecolare.
Terapia antianginosa
Nitrati, beta-bloccanti e calcio-antagonisti.
Gestione dell’infarto miocardico con sopraslivellamento del tratto ST
La SCA con sopraslivellamento del tratto ST include qualunque caso clinico caratterizzato da sintomi compatibili con ischemia miocardica associata a una elevazione persistente del tratto ST all’ ECG (più di 20 minuti) o a un blocco di branca sinistra di nuova insorgenza. Nella pratica la SCA con sopraslivellamento del tratto ST è sinonimo di IMA con sopraslivellamento del tratto ST, giacchè in tutti i casi si associa un aumento degli enzimi di necrosi miocardica. Lo STEMI è dovuto alla fusione completa di un’arteria conoraria.
La differenza fondamentale con NSTEMI è che in caso di sopraslivellamento si deve realizzare una strategia di riperfusione precoce, in cui il tempo ha un’importanza prioritaria (il tempo definisce la quantità di miocardio salvato). Il massimo beneficio della riperfusione infatti si ottiene le prime 3 ore (soprattutto durante la prima ora) ed è significativo durante le prime 6 ore dall’inizio dei sintomi.
CHIRURGIA
Angioplastica e stent coronarici che dilatano le arterie ostruite, lasciando che il flusso di sangue arrivi più liberamente al cuore.
Intervento chirurgico di bypass coronarico che viene effettuato in casi dove l’angioplastica non dà sufficienti garanzie.
VEDI ANCHE
- Aterosclerosi
- Angina instabile: sintomi, prognosi, terapia
- Angina pectoris
- Dolore toracico
- Edema polmonare
- Sincope
- Emergenza cuore: i consigli da non dimenticare in caso di infarto
I calcio-antagonisti sono una classe di farmaci antipertensivi;bloccano i canali del calcio, riducendo la concentrazione intracellulare di Ca++.
Classificazione
I calcio-antagonisti vengono distinti in tre gruppi:
- Benzodiazepinici (diltiazem)
- Fenilalchilaminici (verapamil)
- Diidropiridinici (nifedipina, amlodipina, felodipina, nicardipina, isradipina, nisoldipina, manidipina,lacidipina, lercanidipina)……LEGGI>
Meccanismi d’azione dei beta-bloccanti
I beta-bloccanti sono farmaci che bloccano i recettori adrenergici beta:
Beta-1
Sono recettori presenti a livello cardiaco, la cui inibizione ha un effetto inotropo e cronotropo negativo.
Beta-2
Sono recettori presenti soprattutto a livello vascolare e bronchiale la cui inibizione provoca
broncocostrizione…. Leggi>
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