How does an aneurysm form?
During a heart attack, a section of the myocardium dies due to cessation of blood flow. If the affected area is extensive and covers the entire thickness of the wall, a connective tissue scar is formed in its place. Such a scar does not contract and cannot withstand blood pressure, so in the first weeks and months it gradually stretches and bulges. Most often, an aneurysm forms in the area of the apex and anterior wall of the left ventricle. Separately, a false aneurysm is distinguished - a rupture of the wall, covered by adhesions and pericardium: this is an emergency condition.
- True aneurysm - stretched scar
- False aneurysm - a covered rupture of the wall
- Acute - in the first weeks after a heart attack
- Chronic - formed later
- Typical locations: apex and anterior wall
- Rare causes: trauma, myocarditis, Chagas disease
Causes and risk factors
The vast majority of aneurysms are associated with a major infarction, especially of anterior localization, when blood flow in the blocked artery was not restored in time. The risk increases in the absence of a network of bypass vessels, with high blood pressure in the acute period and with early physical activity. Less commonly, an aneurysm develops after severe myocarditis, chest trauma, heart surgery, or with congenital features of the ventricular wall.
- Extensive transmural myocardial infarction
- Late restoration of blood flow in the artery
- Arterial hypertension
- Smoking and high cholesterol
- Diabetes mellitus
- Previous severe myocarditis or cardiac injury
Symptoms
A small aneurysm may not appear for a long time and can only be detected on ultrasound. As it increases, signs of heart failure increase: shortness of breath on exertion, and then at rest, nocturnal attacks of suffocation, swelling, heaviness in the right hypochondrium. Interruptions and attacks of heartbeat are often disturbing - the source is the scar zone. A separate group of manifestations is associated with blood clots: a broken fragment can clog a vessel in the brain, kidney or limb, causing a stroke or acute ischemia.
- Dyspnea on exertion and at rest
- Swelling of the legs, enlarged liver
- Interruptions and attacks of heartbeat
- Angina on exertion
- General weakness, decreased exercise tolerance
- Thromboembolic complications
Diagnostics
An ECG allows one to suspect an aneurysm: in a patient who has had a heart attack, ST segment elevation in the scar area persists weeks and months later. Echocardiography confirms the diagnosis - it shows the area of bulging, its size, absence of wall contraction, ejection fraction and the presence of a blood clot in the cavity. MRI of the heart with contrast provides the most accurate picture of the scar and helps to distinguish a true aneurysm from a false one. Coronary angiography is needed to assess the condition of the arteries before surgery. The level of NT-proBNP reflects the severity of heart failure.
- ECG: frozen ST elevation in the scar area
- EchoCG with assessment of ejection fraction and thrombus
- MRI of the heart with contrast
- Coronary angiography or CT coronary angiography
- NT-proBNP
- Holter monitoring for arrhythmias
Treatment and prevention
Treatment always begins with drug therapy: drugs that relieve the heart, slow down the pulse and reduce fluid retention, slow down the stretching of the wall. If a blood clot is detected in the aneurysm cavity, anticoagulants are prescribed. Surgical removal of the aneurysm with restoration of the ventricular shape is discussed in cases of large size, severe heart failure, repeated thromboembolism and persistent ventricular arrhythmias, often simultaneously with bypass surgery. All medications are selected by a doctor; stopping treatment on your own is dangerous.
- Continuous therapy for heart failure
- Anticoagulants for thrombus in the cavity
- Blood pressure, lipid and glucose control
- Quitting smoking
- Surgical resection of aneurysm according to indications
- Implantable defibrillator for dangerous arrhythmias
