1、應(yīng)激性心肌病Stress Cardiomyopathy，SCDiagnosis, Pathophysiology,Management, and Prognosis,武漢亞洲心臟病醫(yī)院 徐承義,History,1991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的簍子，而被命名為“Tako-tsudo”(章魚瘺)心肌病 1997年法國的心臟病學(xué)家Dominique Pavin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

2、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,Definition,SC is a reversible cardiomyopathy,with a clinical presentation mimicking Acute coronary syndrome in the absence of significant coronary artery disease Tako-tsubo cardiomyopathy, Apical Ballooning syndrome,and ampulla cardiomyopathy Broken Heart syndrome，T

3、ransient Cardiac Ballooning syndrome 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,Mayo Criteria,Transient hypokinesis, akinesis, or dyskinesis in the left ventricle midsegments with or without apical involvement, regional wall motion abnormality extending beyond a single epicardial vascular dis

4、tribution, the presence of a stress trigger 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,Criteria proposed by the Mayo Clinic in 2004 and modified in 2008,Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture 冠脈造影示冠狀動(dòng)脈管狹窄程度50%，或無急性斑塊破裂證據(jù) New electrographic abno

5、rmalities and/or modest elevation in serum cardiac enzymes 新出現(xiàn)心電圖異?；蛐募∶笇W(xué)輕度升高 Absence of pheochromocytoma or myocarditis 排除嗜鉻細(xì)胞瘤、心肌炎,All 4 criteria must be present,INCIDENCE,The incidence of SC is likely underrecognized Approximately 1% to 2% of patients presenting with an initial diagnosis ACS actua

6、lly have SC 發(fā)病率不明確，1%-2%的ACS患者實(shí)為SC Underestimated for a variety of reasons： nonavailability of cardiac catheterization facilities in many regions the possibility for noncardiac presentation lack of a consensus of diagnostic criteria may contribute to misdiagnosis,PRESENTATION,It occurs most commonly

7、 in postmenopausal Women（90%）, mean age between 58 and 75 yrs SC seems to have an association with hypertension, COPD, and bronchial asthma SC mimics ACS in most patients，acute substernal chest pain and dyspnea .shock, syncope, and cardiac arrest have been reported rarely 2/3 of patients with emotio

8、nal or physical stress,ECG FINDINGS,ST elevation in the precordial and diffuse T wave are the most common findings 胸前導(dǎo)聯(lián)ST段抬高及多導(dǎo)聯(lián)T波倒置最為常見,Differentiate SC from anterior STEMI,Presence of ST segment depression in lead avR and absence of ST segment elevation in lead V1 identified SC with 91% sensitivit

9、y, 96% specificity,and 95% predictive accuracy,LABORATORY FINDINGS,Elevations in troponin and creatine kinase MB are typically mild Severe hemodynamic compromise is out of proportion and in contrast to the degree of cardiac enzyme elevation Troponin T levels ranged from 0.01 to 5.2 ng/mL,CARDIAC CAT

10、HETERIZATION,Coronary angiography Left ventriculography,A RAO end systolic left ventriculogram in typical variant (apical ballooning) of SC. B RAO end-diastolic ventriculogram in typical variant of SC. C RAO end-systolic left ventriculogram in atypical variant (basal ballooning) of SC. D RAO end-dia

11、stolic ventriculogram in atypical variant of SC.,IMAGING,Echocardiography ventricular ballooning，wall motion abnormalities，decrease in EF Nuclear Imaging using Tc-99m，impairment of myocardial perfusion Magnetic Resonance Imaging patients with SC do not show hyper-enhancement on delayed contrast enha

12、ncement MRI,PATHOPHYSIOLOGY,The causal mechanisms remain uncertain 機(jī)制不明確 Stunned myocardium resulting from brief periods of ischemia owing to vasospasm is one possibility 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,Coronary microvascular dysfunction 冠狀動(dòng)脈微血管功能障礙 Increasing plasma levels of catecholamines 交感神經(jīng)過度興奮和血

13、漿兒茶酚胺水平增高 Reduction in estrogen levels following menopause 雌激素水平降低,MANAGEMENT,The treatment of patients with SC is mainly supportive 目前尚無標(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 Patients with shock, cautious use of inotropic agents such as dobutamine and dopamine 謹(jǐn)慎使用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 It is reasonabl

14、e to treat SC with -blocker, ACE inhibitor and if pulmonary edema evelops,diuretics 受體阻滯劑、ACEI或ARB被推薦使用，受體阻滯劑可預(yù)防2.7%-8%的病人復(fù)發(fā),PROGNOSIS,SC has a favorable prognosis with in-hospital mortality 1%, with death more common in the setting of outflow obstruction The 4-year recurrence rate of SC has been re

15、ported to be 11.4% ,but without any significant difference in survival in an age and gender-matched population over the same duration SC長期預(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,Case Review,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

16、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)。,既往史、個(gè)人史及家族史無特殊。 入院查體：T 36.6，P 98bpm，R 20bpm，BP 140/80mmHg，肺部以及查體無陽性體征；HR 104次/分，律絕對(duì)不齊，S1強(qiáng)弱不等，各瓣膜聽診區(qū)未聞及雜音；雙下肢無水腫 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）。cTnI 0.096ng/ml,急診室UCG,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)）,監(jiān)測(cè)ECG 1,2013.11.04,監(jiān)測(cè)ECG 2,11.05,11.06,監(jiān)測(cè)cTnI,冠脈CTA