特殊STEMI-协和病例讨论-杨明

CaseSharing:

BrokenHeartSyndrome北京协和医院

杨明病例1高某，女，67岁，病案号：C767493入院日期：2011-3-30主诉：

心悸、胸闷3h入院情况心电图既往史

个人史、月经婚育史、家族史无殊

入院查体

T36.8℃、HR117bpm、BP110/80mmHg，

SpO2100%（3L/min）

精神烦躁，时间及空间定向力准确，对答切题，言语欠清，双侧瞳孔等大，对光反射灵敏，鼻胆管引流通畅、可见墨绿色胆汁、无异常臭味，心肺腹未见明显异常，四肢肌力肌张力正常，双侧病理征及脑膜刺激征阴性。

入院诊断STEMI!

急诊冠脉造影病例1冠脉造影病例1冠脉造影病例1冠脉造影病例1冠脉造影病例1冠脉造影心脏超声(入院当天3-30)：心尖部心肌运动明显减弱，EF41%心脏超声(入院当天3-30)：入院后治疗可达龙艾司洛尔2d倍他乐克至今心肌酶变化表心电图变化入院一周后一周后心脏超声：

心尖部及左室余室壁运动未见异常,EF73%

入院当天一周后心脏超声入院当天一周后心脏超声病例2韩某某，女，72岁

病案号1681545

主诉：胸闷10小时

入院日期：2010-11-30

入院情况胸痛时ECG

II，III，AVF，V2,V3,V4导联ST段抬高我院急诊抢救室（发病4h）

I，AVL，V2-4导联ST抬高，V2呈QS型，V3rS型1：15pm（起病5h）：我院急诊查心肌酶：CK97U/l、CKMB9.5ug/l、cTnI2.51ug/l。

床旁UCG：室间隔中下段无运动、心尖部、前壁运动减低，EF单平面50%既往史：否认高血压、糖尿病、高血脂病史。个人史、月经婚育史、家族史无特殊，不嗜烟酒。入院查体：HR100bpm，BP108/63mmHg，双肺呼吸音低，双下肺可及细湿罗音，左肺为著。心律齐，全腹韧，叩诊实音，中下腹可及不规则包块，质韧，压痛（+），无反跳痛、肌紧张，肝脾肋下未及，肝脾区无叩痛，移动性浊音（+），肠鸣音正常。双下肢无水肿，双足背动脉正常。左胸可见穿刺引流管通畅。入院诊断：冠状动脉粥样硬化性心脏病

急性ST段抬高性心肌梗死（前壁）心功能1级（Killip）盆腔占位卵巢癌可能性大双侧胸腔积液腹腔积液

STEMI!

病例2冠脉造影病例2冠脉造影病例2冠脉造影病例2冠脉造影病例2冠脉造影病例2冠脉造影病例2冠脉造影病例2冠脉造影诊治经过心肌酶发病12h达峰：cTnI4.87ug/l，CKMB28.1ug/l，CK239U/l，之后逐渐回落至正常床旁心脏超声：室壁运动及左室收缩功能逐渐恢复正常血脂:TC:3.57mmol/l,TG:1.24mmol/lLDL:1.83mmol/l,HDL:1.18mmol/l发病24h

I，AVLST段抬高，V2-4ST段抬高，V3R波恢复12月6日（发病7天）

V2-4T波双向，R波恢复正常入院ECHO1周后ECHO入院ECHO1周后ECHO2个病例与常见的STEMI不同：STEMI？MyocardialinfarctionwithnormalcoronaryarteriesPathogeneticmechanisms正向重构负向重构IVUS纤维帽破口OCT能敏锐发现斑块破裂OCTOCT能敏锐发现内膜撕裂MisdiagnosesTako-tsubo-likesyndromeTako-tsubo-likesyndromeThisraresyndrome,firstdescribedinJapanesepatientsin1991,consistsoftransientleftventriculardysfunctionwithchestsymptoms,electrocardiographicchangesandminimalmyocardialenzymereleasemimickingAMI,butwithoutsignificantCAD.stresscardiomyopathy“ampulla”cardiomyopathytransientleftventricularapicalballooningsyndrome“brokenheartsyndrome”neurogenicmyocardialstunning

In2006,underthename“stresscardiomyopathy”,itwasclassifiedwithinthegroupofacquiredcardiomyopathiesItwasnamedTako-tsubo-likesyndromebecauseoftheend-systolicshapeoftheleftventricleatventriculography,withapicalballooning,whichresemblesatako-tsubo,i.e.,theJapanesedeviceusedfortrappingoctopuses.EpidemiologyTheprevalenceofthediseaseisunknown.InJapanitisestimatedtobeashighas1-2%ofhospitaladmissionsforchestpainandacutedynamicST-segmentelectrocardiographicchanges.IntheUnitedStates

2-2.2%ofthepatientspresentingwiththeclinicalpictureofanST-segmentelevationacutemyocardialinfarction(STEMI)orunstableanginaareultimatelydiagnosedwithTTC.EpidemiologyStudiesinspecificpopulationshaveshownamuchhigherincidence.1/3ofthepatientstheystudied,whowereadmittedtoamedicalICUwithanon-cardiacdiagnosis(respiratoryfailureorsepsis),sufferedfromtransientleftventricularapicalballooning.AnincreasedincidenceofchronicobstructivepulmonarydiseaseorbronchialasthmawasfoundbyHerttingetalin32patientsdiagnosedretrospectivelywithTTC.Allthesefindingsoffersomeevidencesupportingthehypothesisthatcatecholaminesurgemayplayanimportantroleinthepathogenesisofthesyndrome.Triggeringconditions：psychologicaltrigger：unexpectedlossofacloserelative,confrontationwithanotherperson,devastatingfinancialloss,fearpriortoamedicalprocedure,etc.physicalstress

：pulmonarydisease,sepsis,trauma,cerebrovascularaccidentPathogenesisUnknownSeveraltheoriesCatecholaminesurgeoccultcoronaryatherosclerosiswithplaquerupturecoronaryspasmMicrovasculardysfunctionandspasmClinicalcharacteristicsChestpain（100%）ECG：56%ST-segmentelevation17%T-waveinversions10%Q-wavesorabnormalR-waveprogression.17%non-specificchangesornochangesatall.ECGdifferencearetoosubtletobehelpfulinthedifferentialdiagnosisbetweenTTCandanACSineverydayclinicalpractice.ThetimecourseoftheseECGchangesinTTCseemssimilartothatobservedinpatientswithearlyreperfusedST-elevationacutemyocardialinfarction,withT-waveinversionpersistingforatleast2-3weeksMinimallyelevatedcardiacmarkersCardiacimagingstudiesusuallyrevealextensiveapicaland/ormid-ventricularakinesisorhypokinesiswithbasalsparing,discordantwiththeminimallyincreasedcardiacenzymes.Thesewallmotionabnormalitiestypicallyextendbeyondthevascularterritoryofasinglecoronaryartery,suggestingthatmyocardialstunningratherthannecrosisistheunderlyingmechanismoftheacuteleftventriculardysfunction.冠脉造影Thetypicalfindingistheabsenceofobstructivecoronaryarterydisease.However,Ibanezetalwereabletodescribethepresenceofrupturedatheroscleroticplaquesinsomepatientswiththeuseofintravascularultrasound.Whetherthisfindingisofanypathophysiologicrelevanceremainscurrentlyunknown.左室造影MRITreatmentTheoptimaltreatmentforTTCremainsunknown.

Initialmanagementshouldbethetreatmentofmyocardialischemia（aspirin,clopidogrel,nitrates,intravenousheparinandβ-blockers）sendthepatientimmediatelytothecatheterizationlaboratoryClosemonitoringforthedevelopmentofheartfailure,cardiogenicshockormalignantarrhythmiasAfterthediagnosisofTTChasbeenestablished,antiplateletagentsandnitratesshouldbediscontinued.Ontheotherhand,sincethisiscatecholamine-inducedclinicalsyndrome,β-blockersshouldbekeptonboardandACEIshouldalsobestarteduntiltherecoveryofcardiacfunction.Diureticsareappropriateinthecasethatcongestiveheartfailuredevelops.Anticoagulationshouldalsobeconsideredinthecaseofseveresystolicdysfunctiontoreducetheriskofthromboembolism.PrognosisTTCusuallyhasabenigncoursewithfullrecoveryofleftventricularfunctionwithin2-4week