应激性心肌病

1、应激性心肌病应激性心肌病Stress Cardiomyopathy，SCDiagnosis, Pathophysiology,Management, and Prognosis武汉亚洲心脏病医院武汉亚洲心脏病医院徐徐承承义义History1991年日本学者Dote等报道心理或躯体应激状态可以诱发一过性左心室功能不全，由于在收缩末期左心室造影呈底部圆隆、颈部狭小的图像，类似日本古代捉捕章鱼的篓子，而被命名为“Tako-tsudo”(章鱼章鱼瘘瘘)心肌病心肌病1997年法国的心脏病学家Dominique Pavin报道了2例类似的病例，指出应激状态时儿茶酚胺水平升高和该病明显相关，并且提出了应激性

2、心肌病应激性心肌病的概念2006年AHA关于心肌病的科学声明中，将其分类为一种独立的心肌病，正式命名为应激性心肌病Definition SC is a reversible cardiomyopathy,with a clinical presentation mimicking Acute coronary syndrome in the absence of significant coronary artery disease Tako-tsubo cardiomyopathy, Apical Ballooning syndrome,and ampulla cardiomyopathy

3、Broken Heart syndrome，Transient Cardiac Ballooning syndrome 应激性心肌病是应激因素诱发的类似急性冠脉综合征临床表现，伴有可逆性左室收缩功能障碍的一种临床综合征Mayo Criteria Transient hypokinesis, akinesis, or dyskinesis in the left ventricle midsegments with or without apical involvement, regional wall motion abnormality extending beyond a single e

4、picardial vascular distribution, the presence of a stress trigger 左心室心尖和中部区域室壁运动短暂、超出单一血管供血范围的可逆性收缩功能丧失或异常，并存在应激因素Criteria proposed by the Mayo Clinic in 2004 and modified in 2008 Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture 冠脉造影示冠状动脉管狭窄程度50%，或无急性斑块破裂证据 Ne

5、w electrographic abnormalities and/or modest elevation in serum cardiac enzymes 新出现心电图异常或心肌酶学轻度升高 Absence of pheochromocytoma or myocarditis 排除嗜铬细胞瘤、心肌炎All 4 criteria must be presentINCIDENCE The incidence of SC is likely underrecognized Approximately 1% to 2% of patients presenting with an initial

6、diagnosis ACS actually have SC 发病率不明确，1%-2%的ACS患者实为SC Underestimated for a variety of reasons： nonavailability of cardiac catheterization facilities in many regions the possibility for noncardiac presentation lack of a consensus of diagnostic criteria may contribute to misdiagnosisPRESENTATION It oc

7、curs most commonly in postmenopausal Women（90%）, mean age between 58 and 75 yrs SC seems to have an association with hypertension, COPD, and bronchial asthma SC mimics ACS in most patients，acute substernal chest pain and dyspnea .shock, syncope, and cardiac arrest have been reported rarely 2/3 of pa

8、tients with emotional or physical stressECG FINDINGS ST elevation in the precordial and diffuse T wave are the most common findings 胸前导联ST段抬高及多导联T波倒置最为常见Differentiate SC from anterior STEMIPresence of ST segment depression in lead avR and absence of ST segment elevation in lead V1 identified SC with

9、 91% sensitivity, 96% specificity,and 95% predictive accuracyLABORATORY FINDINGS Elevations in troponin and creatine kinase MB are typically mild Severe hemodynamic compromise is out of proportion and in contrast to the degree of cardiac enzyme elevation Troponin T levels ranged from 0.01 to 5.2 ng/

10、mLCARDIAC CATHETERIZATION Coronary angiography Left ventriculographyA RAO end systolic leftventriculogram in typical variant (apical ballooning) of SC.B RAO end-diastolic ventriculogram in typical variant of SC.C RAO end-systolic left ventriculogram in atypical variant (basal ballooning) of SC. D RA

11、O end-diastolic ventriculogram in atypical variant of SC.IMAGING Echocardiography ventricular ballooning，wall motion abnormalities，decrease in EF Nuclear Imaging using Tc-99m，impairment of myocardial perfusion Magnetic Resonance Imaging patients with SC do not show hyper-enhancement on delayed contr

12、ast enhancement MRIPATHOPHYSIOLOGY The causal mechanisms remain uncertain 机制不明确 Stunned myocardium resulting from brief periods of ischemia owing to vasospasm is one possibility 心肌顿抑（冠脉痉挛引起短暂心肌缺血所致）是一种可能的机制 Coronary microvascular dysfunction 冠状动脉微血管功能障碍 Increasing plasma levels of catecholamines 交感神

13、经过度兴奋和血浆儿茶酚胺水平增高 Reduction in estrogen levels following menopause 雌激素水平降低MANAGEMENT The treatment of patients with SC is mainly supportive 目前尚无标准化的治疗方案,去除诱发因素很关键,加强对症支持治疗 Patients with shock, cautious use of inotropic agents such as dobutamine and dopamine 谨慎使用受体兴奋剂以及多巴胺或多巴酚丁胺，必要时可考虑IABP支持 It is rea

14、sonable to treat SC with -blocker, ACE inhibitor and if pulmonary edema evelops,diuretics 受体阻滞剂、ACEI或ARB被推荐使用，受体阻滞剂可预防2.7%-8%的病人复发PROGNOSISSC has a favorable prognosis with in-hospital mortality 1%, with death more common in the setting of outflow obstructionThe 4-year recurrence rate of SC has been

15、 reported to be 11.4% ,but without any significant difference in survival in an age and gender-matched population over the same duration SC长期预后相对较好, 避免情绪激动,在预防复发中非常重要Case Review 王得清王得清，男，男/66岁岁， 住院号：住院号：654098主诉：主诉：胸痛胸痛2天，晕厥一次天，晕厥一次现病史：现病史：2013.11.2日日突发突发胸痛，胸痛，位于下段胸骨后，压迫位于下段胸骨后，压迫感，感，持续持续约约半小时好转，于当地

16、诊所半小时好转，于当地诊所诊治诊治过程中突发黑朦、过程中突发黑朦、晕厥，数秒后意识恢复晕厥，数秒后意识恢复。11.3日日14:00再发胸痛，性质同再发胸痛，性质同前，程度较前剧烈伴出汗，持续不能缓解，前，程度较前剧烈伴出汗，持续不能缓解，当地医院当地医院诊断诊断 “AMI”，给予药物治疗（，给予药物治疗（ASA300mg ,波立维波立维300mg,立普妥立普妥20mg）及杜冷丁肌注后好转。）及杜冷丁肌注后好转。既往史、个人史及家族史既往史、个人史及家族史无特殊。无特殊。入院查体：入院查体：T 36.6，P 98bpm，R 20bpm，BP 140/80mmHg，肺部以及查体无阳性体征；肺部以及

17、查体无阳性体征；HR 104次次/分，律分，律绝对不齐，绝对不齐，S1强弱不等，强弱不等，各瓣膜听诊区未闻及杂音各瓣膜听诊区未闻及杂音；双下肢无双下肢无水肿水肿院前院前辅助检查：辅助检查：2013年年11月月4日我院日我院ECG:1.心房颤动心房颤动2.前壁导前壁导联联ST-T改变改变。UCG:1.双房扩大双房扩大 室间隔室间隔,左室前壁室壁运动幅度左室前壁室壁运动幅度减低减低,三尖瓣轻度反流三尖瓣轻度反流, 左室收缩功能稍减低左室收缩功能稍减低,心包腔少量积液心包腔少量积液 心心律不齐律不齐;2.先天性心脏病：房间隔小缺损（筛孔型，左向右分先天性心脏病：房间隔小缺损（筛孔型，左向右分流）流）。cTnI 0.096ng/ml急诊室急诊室UCG入院诊断入院诊断 冠状动脉粥样硬化性心脏病冠状动脉粥样硬化性心脏病 急性前壁心肌梗死急性前壁心肌梗死 心房颤动心房颤动 心功能心功能I I级（级（KillipKillip分级）分级）监测监测ECG 12013.11.04监测监测ECG 211.0511.06监测监测cTnI冠脉冠脉CTALADLCXRCA应激因素应激因素-SMA栓塞栓塞入院后治疗方案：入院后治疗方案：抗血小板聚集（阿司匹抗血小板聚集（阿司匹林林+波立维波立维+替罗非班）、抗凝替罗非班）