又是一例疑似心梗，最后诊断出人意料……

2018-05-16 人间世医学界心血管频道

xujie.L

医生/

急诊室江湖险恶、危象重生，还有一个隐匿的模仿者需要我们提高警惕。这次依然从一个病例讲起。

急诊室江湖险恶、危象重生，还有一个隐匿的模仿者需要我们提高警惕。这次依然从一个病例讲起。

这例是急性心梗吗？

患者66岁女性，因"急性胸痛、呼吸困难6小时"就诊。查体：P113次/分，R 32次/分，BP 120/70mmHg，心电图（见图1）：III、aVF、V3-4R导ST段抬高，I、aVL导镜像性压低。cTn轻度升高。

图1：心电图示III、aVF、V3-4R导ST段抬高，I、aVL导镜像性压低

作为一个心内科医生，遇见“胸痛+ST段抬高+cTnI升高”这熟悉的三联征，脑海里自然而然就会跳出急性心梗这个诊断，而且会很快地识别出这个罪犯血管就是右冠，随后的处理可算是条件性反射了-急诊PCI。

确实，这个患者急诊上台行冠脉造影（见图2），但是并没有见到预料中闭塞的右冠，右冠反而几乎是正常冠脉。

图2：冠脉造影示基本正常的右冠

随后该接诊医生仔细查体，有了新的发现：双下肢不对称性水肿，于是行下肢静脉超声示下肢深静脉血栓形成。紧接着超声心动示左心结构及功能基本正常，右室轻度扩张，右室游离壁运动幅度减低，估测肺动脉收缩压40mmHg。最终肺动脉CT（见图3）揭晓了谜底：双侧肺动脉栓塞。

图3：肺动脉CT示双侧肺栓塞

急性肺栓塞 or 急性心梗

同样的疑问又再次摆在大家的面前，一个完全满足急性心梗诊断标准的患者，其最终诊断却再次不是急性心梗，那我们今天的谜底-急性肺栓塞又是如何成功地模仿了急性心梗呢？

急性肺栓塞引起心电图ST段抬高的原因比较复杂，具体有：

肺栓塞使肺动脉血流受阻，导致肺动脉压和右心压力增高，右房右室扩大，右心室壁增高可导致局部心肌缺血。

肺栓塞会引起肺血管内皮受损，释放大量的缩血管物质，如大内皮素、前列环素等，导致冠脉痉挛，产生心肌缺血。

肺栓塞也是一个应激状态，会引起儿茶酚胺释放增加，从而引起心肌细胞水平的缺血。另一方面，肺栓塞会引起右心后负荷增加，会伴有右心心肌损伤，因此也会引起cTn升高。

就这样，急性肺栓塞戴上了急性心梗的面具，走上了冠脉造影的手术台。

那么，我们该何去何从？

1. 注意有无血栓的危险因素

任何可以导致静脉血流瘀滞、血管内皮损伤和血液高凝状态的因素均可以引起肺栓塞，又可分为遗传性和获得性2类，具体见表1。

表1：肺栓塞的危险因素

2. 勿忘重点查体

如上述患者表现的不对称性双下肢水肿就是肺栓塞的一个非常重要的指向性体征，其他的如肺动脉高压及右心功能不全相关的一系列征象也是需要我们关注的。

3. 用好手头的辅助检查

D-Dmier的敏感性一直是我们津津乐道的，但是特异性在老年人中还是偏低的。而超声心动在提示急性肺栓塞的诊断中有着重要的价值，常见的表现有右心扩大、右心室游离壁运动减低、室间隔平直、TPASE减低等右心室后负荷过重征象，少数患者可能“幸运”地直接发现右心系统的血栓。其他的还有心电图、血气分析等。

4. 掌握常用的评分系统

根据临床综合因素进行临床可能性评估可以提高疑诊肺栓塞的准确性，现最常用的评分表有简化Wells评分和修改版Geneva评分，见表2。

表2：肺栓塞的常见评分系统

当下次胸痛+ST段抬高+cTn升高这三联征再次找上门的时候，我们要绷紧急性心梗这一根弦的同时，也不要忘了我们这一隐匿的模仿者-急性肺栓塞！

原始出处：

[1] Bozorgi A， et al. Pulmonary thromboembolisminitially mistaken for inferior STEMI[J]. Herz. 2013 Aug；38(5)：553-5.

[2] 中华医学会呼吸病学分会肺栓塞与肺血管病学组.肺栓塞栓塞症诊治与预防指南[J]. 中华医学杂志，2018，98（14）：1060-86.

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2018-05-17 明月清辉

谢谢分享.学习了

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2018-05-17 哈哈869

学了

129 0
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2018-05-16 flysky120

急性肺栓塞和急性心肌梗塞的鉴别.心电图有时候难区别.患者的症状有啥区别?

88 0
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2018-05-16 明月清辉

谢谢分享.学习了

138 0
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2018-05-16 龙胆草

学习谢谢分享

126 0
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2018-05-16 wzb521zf

一起学习学习

48 0
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2018-05-16 张新亮1853311252142e2fm

好文献学习了

46 0
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2018-05-16 神功盖世

阅

72 0
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2018-05-16 一个字-牛

学习了谢谢分享

74 0
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2018-05-16 哈哈869

学了

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