应激性心肌病

应激性心肌病

StressCardiomyopathy，SC

Diagnosis,Pathophysiology,Management,andPrognosis1History1991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2DefinitionSCisareversiblecardiomyopathy,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3MayoCriteriaTransienthypokinesis,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CriteriaproposedbytheMayoClinicin2004andmodifiedin20084Absenceofobstructivecoronarydiseaseorangiographicevidenceofacuteplaquerupture

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All4criteriamustbepresent5INCIDENCETheincidenceofSCislikelyunderrecognizedApproximately1%to2%ofpatientspresentingwithaninitialdiagnosisACSactuallyhaveSC发病率不明确，1%-2%的ACS患者实为SCUnderestimatedforavarietyofreasons：nonavailabilityofcardiaccatheterizationfacilitiesinmanyregionsthepossibilityfornoncardiacpresentationlackofaconsensusofdiagnosticcriteriamaycontributetomisdiagnosis6PRESENTATIONItoccursmostcommonlyinpostmenopausalWomen（90%）,meanagebetween58and75yrsSCseemstohaveanassociationwithhypertension,COPD,andbronchialasthmaSCmimicsACSinmostpatients，acutesubsternalchestpainanddyspnea.shock,syncope,andcardiacarresthavebeenreportedrarely2/3ofpatientswithemotionalorphysicalstress7ECGFINDINGSSTelevationintheprecordialanddiffuseTwavearethemostcommonfindings胸前导联ST段抬高及多导联T波倒置最为常见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14Coronarymicrovasculardysfunction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15MANAGEMENTThetreatmentofpatientswithSCismainlysupportive

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β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ItisreasonabletotreatSCwithβ-blocker,ACEinhibitorandifpulmonaryedemaevelops,diuretics

β受体阻滞剂、ACEI或ARB被推荐使用，β受体阻滞剂可预防2.7%-8%的病人复发16PROGNOSISSChasafavorableprognosiswithin-hospitalmortality1%,withdeathmorecommoninthesettingofoutflowobstructionThe4-yearrecurrencerateofSChasbeenreportedtobe11.4%,butwithoutanysignificantdifferenceinsurvivalinanageandgender-matchedpopulationoverthesameduration

SC长期预后相对较好,避免情绪激动,在预防复发中非常重要17CaseReview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。18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/ml19急诊室UCG20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）21监测ECG12013.11.0422监测ECG211.0511.0623监测cTnI24冠脉CTALADLCXRCA25应激因素