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病例分享:间断胸痛怀疑心梗,原因却是另一种致命性疾病

2017-10-25 卢芳 中国循环杂志

江西省南昌大学第二附属医院游志刚、黄琳等报道了这样一例“一曲三折”的病例。

江西省南昌大学第二附属医院游志刚、黄琳等报道了这样一例“一曲三折”的病例。

患者为41岁男性,因“突发胸痛4 h”急诊入院。

这位男士有高血压病史4年,最高血压170/130 mmHg,常规治疗后血压控制良好,无烟酒等不良嗜好。

患者入院前4 h无诱因突发胸骨后压榨样疼痛,并向后背放射,伴恶心、大汗、面色苍白、持续不能缓解。综合体格检查、急诊心电图、心肌酶检查,拟诊“急性ST段抬高型广泛前壁、高侧壁心肌梗死”。

冠脉造影示,前降支、回旋支开口至中段弥漫性狭窄,最重狭窄80%,TIMI血流3级。予择期冠脉介入治疗。术后心电图V4~6 导联T波低平;D-二聚体14.1μg/ml;肌钙蛋白T 7.11 ng/ml;CK-MB 36.73 U/L;彩色超声心动图示左心室前壁及侧壁动度减低。

3天后,患者胸痛再发,呈濒死感。心电图示V4~6导联ST段压低0.05~0.1mV,V2~4导联T波高耸。急诊复查冠脉造影:前降支、回旋支狭窄较前明显加重,无血栓影;冠脉内注射硝酸甘油后,未见狭窄减轻;光学相干断层成像示前降支、回旋支内膜光滑,无斑块破裂及血栓;考虑“冠脉痉挛”致急性心梗。

又过两日,患者发热39℃,伴咳嗽咳痰,胸部CT示右侧胸膜下少量炎症,主动脉双腔影;胸腹主动脉CT造影示主动脉夹层(Stanford A 型),累及冠窦部、冠脉近端高度可疑。

心胸外科建议主动脉内膜多个破口,手术风险大,暂保守治疗。严格控制患者血压、心率后病情稳定,出院前复查胸腹主动脉CT造影:主动脉、假腔血栓形成。随访2 个月,患者无胸痛发作,继续降压及冠心病药物治疗。

作者总结说,这是一例以急性胸痛起病,经证实为急性主动脉夹层诱发冠脉痉挛致急性心梗。他们认为有几点经验供同道交流:

(1)患者有高血压病史,突发剧烈胸痛向肩背部放射,需警惕急性主动脉夹层。

(2)急性主动脉夹层缺乏特异性心电图,一旦累及冠脉,心肌坏死标记物、心电图的改变酷似急性心梗,而主动脉夹层却不易被察觉。故在门诊时间及病情允许的前提下,还需完善胸片、超声心动图、胸部CTA 等其他检查。

此外,D- 二聚体有助于提高急性主动脉夹层诊断筛查率。急性主动脉夹层早期D-二聚体增高较急性心梗更明显,尤其发病1 h 内。急性主动脉夹层危险评分中危以上,D-二聚体>5 μg/ml,需进一步检查明确是否为急性主动脉夹层。

(3)急性主动脉夹层诱发急性心梗时,急性冠脉介入治疗(PCI)或可作为外科术前一种有效桥接治疗。

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    2018-03-23 TZF0811
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    2017-10-25 131****1460

    学习了受益匪浅

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