應(yīng)激性心肌病

應(yīng)激性心肌病

StressCardiomyopathy，SC

Diagnosis,Pathophysiology,Management,andPrognosis1History1991年日本學(xué)者Dote等報(bào)道心理或軀體應(yīng)激狀態(tài)可以誘發(fā)一過(guò)性左心室功能不全，由于在收縮末期左心室造影呈底部圓隆、頸部狹小的圖像，類似日本古代捉捕章魚(yú)的簍子，而被命名為“Tako-tsudo”(章魚(yú)瘺)心肌病1997年法國(guó)的心臟病學(xué)家DominiquePavin報(bào)道了2例類似的病例，指出應(yīng)激狀態(tài)時(shí)兒茶酚胺水平升高和該病明顯相關(guān)，并且提出了應(yīng)激性心肌病的概念2006年AHA關(guān)于心肌病的科學(xué)聲明中，將其分類為一種獨(dú)立的心肌病，正式命名為應(yīng)激性心肌病2DefinitionSCisareversiblecardiomyopathy,withaclinicalpresentationmimickingAcutecoronarysyndromeintheabsenceofsignificantcoronaryarterydiseaseTako-tsubocardiomyopathy,ApicalBallooningsyndrome,andampullacardiomyopathyBrokenHeartsyndrome，TransientCardiacBallooningsyndrome應(yīng)激性心肌病是應(yīng)激因素誘發(fā)的類似急性冠脈綜合征臨床表現(xiàn)，伴有可逆性左室收縮功能障礙的一種臨床綜合征3MayoCriteriaTransienthypokinesis,akinesis,ordyskinesisintheleftventriclemidsegmentswithorwithoutapicalinvolvement,regionalwallmotionabnormalityextendingbeyondasingleepicardialvasculardistribution,thepresenceofastresstrigger

左心室心尖和中部區(qū)域室壁運(yùn)動(dòng)短暫、超出單一血管供血范圍的可逆性收縮功能喪失或異常，并存在應(yīng)激因素CriteriaproposedbytheMayoClinicin2004andmodifiedin20084Absenceofobstructivecoronarydiseaseorangiographicevidenceofacuteplaquerupture

冠脈造影示冠狀動(dòng)脈管狹窄程度＜50%，或無(wú)急性斑塊破裂證據(jù)Newelectrographicabnormalitiesand/ormodestelevationinserumcardiacenzymes

新出現(xiàn)心電圖異常或心肌酶學(xué)輕度升高Absenceofpheochromocytomaormyocarditis

排除嗜鉻細(xì)胞瘤、心肌炎All4criteriamustbepresent5INCIDENCETheincidenceofSCislikelyunderrecognizedApproximately1%to2%ofpatientspresentingwithaninitialdiagnosisACSactuallyhaveSC發(fā)病率不明確，1%-2%的ACS患者實(shí)為SCUnderestimatedforavarietyofreasons：nonavailabilityofcardiaccatheterizationfacilitiesinmanyregionsthepossibilityfornoncardiacpresentationlackofaconsensusofdiagnosticcriteriamaycontributetomisdiagnosis6PRESENTATIONItoccursmostcommonlyinpostmenopausalWomen（90%）,meanagebetween58and75yrsSCseemstohaveanassociationwithhypertension,COPD,andbronchialasthmaSCmimicsACSinmostpatients，acutesubsternalchestpainanddyspnea.shock,syncope,andcardiacarresthavebeenreportedrarely2/3ofpatientswithemotionalorphysicalstress7ECGFINDINGSSTelevationintheprecordialanddiffuseTwavearethemostcommonfindings胸前導(dǎo)聯(lián)ST段抬高及多導(dǎo)聯(lián)T波倒置最為常見(jiàn)8DifferentiateSCfromanteriorSTEMIPresenceofSTsegmentdepressioninleadavRandabsenceofSTsegmentelevationinleadV1identifiedSCwith91%sensitivity,96%specificity,and95%predictiveaccuracy9LABORATORYFINDINGSElevationsintroponinandcreatinekinaseMBaretypicallymild

SeverehemodynamiccompromiseisoutofproportionandincontrasttothedegreeofcardiacenzymeelevationTroponinTlevelsrangedfrom0.01to5.2ng/mL10CARDIACCATHETERIZATIONCoronaryangiographyLeftventriculographyARAOendsystolicleftventriculogramintypicalvariant(apicalballooning)ofSC.BRAOend-diastolicventriculogramintypicalvariantofSC.CRAOend-systolicleftventriculograminatypicalvariant(basalballooning)ofSC.DRAOend-diastolicventriculograminatypicalvariantofSC.1112IMAGINGEchocardiographyventricularballooning，wallmotionabnormalities，decreaseinEFNuclearImagingusingTc-99m，impairmentofmyocardialperfusionMagneticResonanceImagingpatientswithSCdonotshowhyper-enhancementondelayedcontrastenhancementMRI13PATHOPHYSIOLOGYThecausalmechanismsremainuncertain機(jī)制不明確Stunnedmyocardiumresultingfrombriefperiodsofischemiaowingtovasospasmisonepossibility心肌頓抑（冠脈痙攣引起短暫心肌缺血所致）是一種可能的機(jī)制14Coronarymicrovasculardysfunction冠狀動(dòng)脈微血管功能障礙

Increasingplasmalevelsofcatecholamines交感神經(jīng)過(guò)度興奮和血漿兒茶酚胺水平增高Reductioninestrogenlevelsfollowingmenopause雌激素水平降低15MANAGEMENTThetreatmentofpatientswithSCismainlysupportive

目前尚無(wú)標(biāo)準(zhǔn)化的治療方案,去除誘發(fā)因素很關(guān)鍵,加強(qiáng)對(duì)癥支持治療Patientswithshock,cautioususeofinotropicagentssuchasdobutamineanddopamine

謹(jǐn)慎使用β受體興奮劑以及多巴胺或多巴酚丁胺，必要時(shí)可考慮IABP支持ItisreasonabletotreatSCwithβ-blocker,ACEinhibitorandifpulmonaryedemaevelops,diuretics

β受體阻滯劑、ACEI或ARB被推薦使用，β受體阻滯劑可預(yù)防2.7%-8%的病人復(fù)發(fā)16PROGNOSISSChasafavorableprognosiswithin-hospitalmortality1%,withdeathmorecommoninthesettingofoutflowobstructionThe4-yearrecurrencerateofSChasbeenreportedtobe11.4%,butwithoutanysignificantdifferenceinsurvivalinanageandgender-matchedpopulationoverthesameduration

SC長(zhǎng)期預(yù)后相對(duì)較好,避免情緒激動(dòng),在預(yù)防復(fù)發(fā)中非常重要17CaseReview王得清，男/66歲，

住院號(hào)：654098主訴：胸痛2天，暈厥一次現(xiàn)病史：2013.11.2日突發(fā)胸痛，位于下段胸骨后，壓迫感，持續(xù)約半小時(shí)好轉(zhuǎn)，于當(dāng)?shù)卦\所診治過(guò)程中突發(fā)黑朦、暈厥，數(shù)秒后意識(shí)恢復(fù)。11.3日14:00再發(fā)胸痛，性質(zhì)同前，程度較前劇烈伴出汗，持續(xù)不能緩解，當(dāng)?shù)蒯t(yī)院診斷“AMI”，給予藥物治療（ASA300mg,波立維300mg,立普妥20mg）及杜冷丁肌注后好轉(zhuǎn)。18既往史、個(gè)人史及家族史無(wú)特殊。入院查體：T36.6℃，P98bpm，R20bpm，BP140/80mmHg，肺部以及查體無(wú)陽(yáng)性體征；HR104次/分，律絕對(duì)不齊，S1強(qiáng)弱不等，各瓣膜聽(tīng)診區(qū)未聞及雜音；雙下肢無(wú)水腫院前輔助檢查：2013年11月4日我院ECG:1.心房顫動(dòng)2.前壁導(dǎo)聯(lián)ST-T改變。UCG:1.雙房擴(kuò)大室間隔,左室前壁室壁運(yùn)動(dòng)幅度減低,三尖瓣輕度反流,左室收縮功能稍減低,心包腔少量積液心律不齊;2.先天性心臟?。悍块g隔小缺損（篩孔型，左向右分流）。cTnI0.096ng/ml19急診室UCG20入院診斷冠狀動(dòng)脈粥樣硬化性心臟病急性前壁心肌梗死心房顫動(dòng)心功能I級(jí)（Killip分級(jí)）21監(jiān)測(cè)ECG12013.11.0422監(jiān)測(cè)ECG211.0511.0623監(jiān)測(cè)cTnI24冠脈CTALADLCXRCA25應(yīng)激因素