КЛИНИЧЕСКИЙ СЛУЧАЙ ВАЗОСПАСТИЧЕСКОЙ СТЕНОКАРДИИ У ПАЦИЕНТА С ГАСТРОЭЗОФАГЕАЛЬНОЙ РЕФЛЮКСНОЙ БОЛЕЗНЬЮ

Abstract

Introduction. The combination of CAD and GERD is a common clinical situation. In recent years, more and more information has appeared indicating that the coexistence of both diseases is not accidental. Clinical example. A 51-year-old man was admitted to the KGBUZ "AKKD" by transfer from the Central District Hospital with complaints of burning, pressing pains behind the sternum without a clear connection with physical activity, more often in the early morning hours, lasting up to 5 minutes, stopped by sitting, drinking cold water. Upon admission, the state of the average degree. BMI 23.9 kg/m2. Temperature 36.6 0С. NPV 16 per min. SpO2 - 96%. Heart rate 55 beats. in min. AD = 110/60 mm. rt. Art. Vesicular breathing in the lungs, no wheezing. The heart sounds are clear, the rhythm is correct. There are no edema. The abdomen is soft and painless. ECG at admission: sinus rhythm with a heart rate of 55 per minute. Negative T wave II, III, aVF, V7-V9. From the anamnesis: he had not previously controlled blood pressure, he did not take regular medications. Long history of smoking. During the year, he began to notice rare episodes of burning behind the sternum lasting up to 10 minutes without a clear connection with physical activity. He was examined at the place of residence, EGD was performed, where a hernia of the esophageal opening of the diaphragm, chronic atrophic gastritis were diagnosed. During the week before hospitalization, the condition worsened in the form of a decrease in exercise tolerance, an increase in burning sensation, pressing pain behind the sternum. On May 11, 23, due to a long-term pain syndrome behind the sternum, he called an ambulance, was hospitalized at the Central District Hospital, and then transferred to the AKKD. Upon admission to the AKKD, emergency coronary angiography was performed, where subocclusion of the circumflex artery (OA) was diagnosed, stenting of the OA with a drug-eluting stent. Echocardiography revealed hypokinesis along the lateral wall, the ejection fraction of the left ventricle was 59%. Laboratory: troponin I at admission and in dynamics within the reference values; dyslipidemia. After PCI in the department, daily recurrences of burning in the epigastrium and behind the sternum more often at night. Repeated EGD - reflux gastritis with metaplasia, cardiac insufficiency. HMECG recorded episodes of ST segment elevation in II, III, aVF, V5-V6, duration up to 70 minutes; frequent polymorphic ventricular extrasystole. Taking into account recurrent pains, the results of HMECG, a control coronary angiography was performed - the coronary arteries were without pathology, the OA stent was passable. Treatment was corrected, antianginal therapy was increased with beta-blockers, dihydropyridine calcium antagonists and long-acting nitrates, as well as therapy with proton pump inhibitors. During therapy, the condition improved, anginal pain did not recur. According to HMECG in dynamics - no ischemic changes. Discharged from the hospital in a satisfactory condition with recommendations. Conclusion. To date, a number of pathophysiological mechanisms have been established, both causing the pathogenetic relationship between IHD and GERD, and contributing to their mutual aggravation. The basis of the occurrence of associated angina pectoris is the esophagocardial reflex, caused by irritation of the esophagus and the development of coronary spasm as a result. In patients with variant angina pectoris, a time relationship was found between periods of esophageal spasm and episodes of ECG-registered ischemia. At the same time, it was found that with impaired esophageal motility in patients with coronary artery disease, a vicious circle may form: esophagospasm provokes myocardial ischemia, which, in turn, contributes to new episodes of esophageal spasm.