应激性心肌病ppt课件.ppt

应激性心肌病StressCardiomyopathy SCDiagnosis Pathophysiology Management andPrognosis History 1991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 章鱼瘘 心肌病1997年法国的心脏病学家DominiquePavin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 SCisareversiblecardiomyopathy withaclinicalpresentationmimickingAcutecoronarysyndromeintheabsenceofsignificantcoronaryarterydiseaseTako tsubocardiomyopathy ApicalBallooningsyndrome andampullacardiomyopathyBrokenHeartsyndrome TransientCardiacBallooningsyndrome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 MayoCriteria Transienthypokinesis akinesis ordyskinesisintheleftventriclemidsegmentswithorwithoutapicalinvolvement regionalwallmotionabnormalityextendingbeyondasingleepicardialvasculardistribution thepresenceofastresstrigger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 CriteriaproposedbytheMayoClinicin2004andmodifiedin2008 Absenceofobstructivecoronarydiseaseorangiographicevidenceofacuteplaquerupture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Newelectrographicabnormalitiesand ormodestelevationinserumcardiacenzymes新出现心电图异常或心肌酶学轻度升高Absenceofpheochromocytomaormyocarditis排除嗜铬细胞瘤 心肌炎 All4criteriamustbepresent INCIDENCE TheincidenceofSCislikelyunderrecognizedApproximately1 to2 ofpatientspresentingwithaninitialdiagnosisACSactuallyhaveSC发病率不明确 1 2 的ACS患者实为SCUnderestimatedforavarietyofreasons nonavailabilityofcardiaccatheterizationfacilitiesinmanyregionsthepossibilityfornoncardiacpresentationlackofaconsensusofdiagnosticcriteriamaycontributetomisdiagnosis PRESENTATION ItoccursmostcommonlyinpostmenopausalWomen 90 meanagebetween58and75yrsSCseemstohaveanassociationwithhypertension COPD andbronchialasthmaSCmimicsACSinmostpatients acutesubsternalchestpainanddyspnea shock syncope andcardiacarresthavebeenreportedrarely2 3ofpatientswithemotionalorphysicalstress ECGFINDINGS STelevationintheprecordialanddiffuseTwavearethemostcommonfindings胸前导联ST段抬高及多导联T波倒置最为常见 DifferentiateSCfromanteriorSTEMI PresenceofSTsegmentdepressioninleadavRandabsenceofSTsegmentelevationinleadV1identifiedSCwith91 sensitivity 96 specificity and95 predictiveaccuracy LABORATORYFINDINGS ElevationsintroponinandcreatinekinaseMBaretypicallymildSeverehemodynamiccompromiseisoutofproportionandincontrasttothedegreeofcardiacenzymeelevationTroponinTlevelsrangedfrom0 01to5 2ng mL CARDIACCATHETERIZATION CoronaryangiographyLeftventriculography ARAOendsystolicleftventriculogramintypicalvariant apicalballooning ofSC BRAOend diastolicventriculogramintypicalvariantofSC CRAOend systolicleftventriculograminatypicalvariant basalballooning ofSC DRAOend diastolicventriculograminatypicalvariantofSC IMAGING Echocardiographyventricularballooning wallmotionabnormalities decreaseinEFNuclearImagingusingTc 99m impairmentofmyocardialperfusionMagneticResonanceImagingpatientswithSCdonotshowhyper enhancementondelayedcontrastenhancementMRI PATHOPHYSIOLOGY Thecausalmechanismsremainuncertain机制不明确Stunnedmyocardiumresultingfrombriefperiodsofischemiaowingtovasospasmisonepossibility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 Coronarymicrovasculardysfunction冠状动脉微血管功能障碍Increasingplasmalevelsofcatecholamines交感神经过度兴奋和血浆儿茶酚胺水平增高Reductioninestrogenlevelsfollowingmenopause雌激素水平降低 MANAGEMENT ThetreatmentofpatientswithSCismainlysupportive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Patientswithshock cautioususeofinotropicagentssuchasdobutamineanddopamine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ItisreasonabletotreatSCwith blocker ACEinhibitorandifpulmonaryedemaevelops 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 PROGNOSIS SChasafavorableprognosiswithin hospitalmortality1 withdeathmorecommoninthesettingofoutflowobstructionThe4 yearrecurrencerateofSChasbeenreportedtobe11 4 butwithoutanysignificantdifferenceinsurvivalinanageandgender matchedpopulationoverthesamedurationSC长期预后相对较好 避免情绪激动 在预防复发中非常重要 CaseReview 王得清 男 66岁 住院号 654098主诉 胸痛2天 晕厥一次现病史 2013 11 2日突发胸痛 位于下段胸骨后 压迫感 持续约半小时好转 于当地诊所诊治过程中突发黑朦 晕厥 数秒后意识恢复 11 3日14 00再发胸痛 性质同前 程度较前剧烈伴出汗 持续不能缓解 当地医院诊断 AMI 给予药物治疗 ASA300mg 波立维300mg 立普妥20mg 及杜冷丁肌注后好转 既往史 个人史及家族史无特殊 入院查体 T36 6 P98bpm R20bpm BP140 80mmHg 肺部以及查体无阳性体征 HR104次 分 律绝对不齐 S1强弱不等 各瓣膜听诊区未闻及杂音 双下肢无水肿院前辅助检查 2013年11月4日我院ECG 1 心房颤动2 前壁导联ST T改变 UCG 1 双房扩大室间隔 左室前壁室壁运动幅度减低 三尖瓣轻度反流 左室收缩功能稍减低 心包腔少量积液心律不齐 2 先天性心脏病 房间隔小缺损 筛孔型 左向右分流 cTnI0 096ng ml 急诊室UCG 入院诊断冠状动脉粥样硬化性心脏病急性前壁心肌梗死心房颤动心功能I级 Killip分级 监测ECG1 2013 11 04 监测ECG2 11 05 11 06 监测cTnI 冠脉CTA LAD LCX RCA 应激因素 SMA栓塞 入院后治疗方案 抗血小板聚集 阿