自发性冠状动脉壁内血肿致急性心肌梗死诊疗分析
|
摘要
目的分析自发性冠状动脉壁内血肿(SCIMH)致急性心肌梗死患者临床资料,探讨诊疗方案。方法回顾性分析2015年4月至2017年7月双中心临床诊断为急性心肌梗死的2027例患者影像学资料,依靠血管内超声(IVUS)或光学相干断层扫描(OCT)共检出33例急性心肌梗死为冠状动脉壁内血肿所致,分析其病变特点、诊疗方案和临床转归。结果 33例SCIMH患者中,29例(87.9%)表现为典型胸痛症状。所有患者血清肌酸激酶同工酶及肌钙蛋白Ⅰ均升高,分别为(21.86±5.12)ng/mL、(7.38±6.67)ng/mL。45%的患者心电图表现为非ST段抬高型心肌梗死,21%为急性下壁心肌梗死。33例患者共发现37处血肿,主要分布于左前降支近段(19%)、中远段(35%)及右冠状动脉中远段(22%),70%的血肿TIMI血流分级为Ⅲ级。2例(6%)予冠脉支架植入,31例(94%)行药物保守治疗。随访过程中,1例(3.0%)因血肿进展予支架植入,2例(6.1%)血肿较前吸收,2例(6.1%)血肿完全吸收。所有患者均未发生心血管不良事件。结论 IVUS及OCT是自发性冠状动脉壁内血肿可靠的早期诊断方法,血流动力学稳定的自发性冠状动脉壁内血肿患者予药物治疗是安全有效的治疗方法。早期诊断与合理药物治疗是改善预后的关键。
Objective To analyze the clinical data of patients with acute myocardial infarction caused by spontaneous coronary intramural hematoma(SCIMH),and to explore the strategy of diagnosis and treatment.Methods This retrospective study was performed based on imaging data of 2027 patients with acute myocardial infarction diagnosed in the two-center clinical trial from April 2015 to July 2017. A total of 33 patients with acute myocardial infarction were caused by intracoronary hematoma,diagnosed with intravascular ultrasound(IVUS)or optical coherence tomography(OCT). Their clinical characteristics,treatment strategies and outcomes were analyzed.Results Among 33 patients with SCIMH,29(87.9%)patients showed typical chest pain symptoms. All 33 patients had elevated serum creatine kinase isoenzyme and troponin Ⅰ,(21.86±5.12)ng/mL and(7.38 ± 6.67)ng/mL,respectively.In 45% patients,the electrocardiogram showed non-ST-segment elevation myocardial infarction. 21% patients were acute inferior myocardial infarction. A total of 37 hematomas were found in all 33 patients,mainly in the proximal left anterior descending artery(19%),the middle and distal segments(35%),and the distal segment of the right coronary artery(22%). Grade Ⅲ TIMI blood flow was found in 70% of the hematoma. Among the patients,2 cases(6%)underwent coronary stent implantation,and 31 cases(94%)underwent conservative drug therapy. During follow-up,1 patient(3.0%)underwent stent implantation due to hematoma progression,2 cases(6.1%)had hematoma absorbed partly,and another 2 paitents(6.1%)had complete hematoma absorbed. No cardiovascular adverse events occurred in all patients.Conclusion IVUS and OCT are reliable early diagnostic methods for spontaneous intracoronary intrahepatic hematoma. For SCIMH with stable hemodynamy,conservative drug therapy is safe and efficient. Early diagnosis and rational drug treatment are the key ways to improve prognosis of coronary intramural hematoma.
Objective To analyze the clinical data of patients with acute myocardial infarction caused by spontaneous coronary intramural hematoma(SCIMH),and to explore the strategy of diagnosis and treatment.Methods This retrospective study was performed based on imaging data of 2027 patients with acute myocardial infarction diagnosed in the two-center clinical trial from April 2015 to July 2017. A total of 33 patients with acute myocardial infarction were caused by intracoronary hematoma,diagnosed with intravascular ultrasound(IVUS)or optical coherence tomography(OCT). Their clinical characteristics,treatment strategies and outcomes were analyzed.Results Among 33 patients with SCIMH,29(87.9%)patients showed typical chest pain symptoms. All 33 patients had elevated serum creatine kinase isoenzyme and troponin Ⅰ,(21.86±5.12)ng/mL and(7.38 ± 6.67)ng/mL,respectively.In 45% patients,the electrocardiogram showed non-ST-segment elevation myocardial infarction. 21% patients were acute inferior myocardial infarction. A total of 37 hematomas were found in all 33 patients,mainly in the proximal left anterior descending artery(19%),the middle and distal segments(35%),and the distal segment of the right coronary artery(22%). Grade Ⅲ TIMI blood flow was found in 70% of the hematoma. Among the patients,2 cases(6%)underwent coronary stent implantation,and 31 cases(94%)underwent conservative drug therapy. During follow-up,1 patient(3.0%)underwent stent implantation due to hematoma progression,2 cases(6.1%)had hematoma absorbed partly,and another 2 paitents(6.1%)had complete hematoma absorbed. No cardiovascular adverse events occurred in all patients.Conclusion IVUS and OCT are reliable early diagnostic methods for spontaneous intracoronary intrahepatic hematoma. For SCIMH with stable hemodynamy,conservative drug therapy is safe and efficient. Early diagnosis and rational drug treatment are the key ways to improve prognosis of coronary intramural hematoma.
引文
[1] Hayes SN,Kim ESH,Saw J,et al.Spontaneous Coronary Artery Dissection:Current State of the Science:A Scientific Statement From the American Heart Association[J].Circulation,2018,137(19):e523-e557.
[2] Saw J,Humphries K,Aymong E,et al.Spontaneous Coronary Artery Dissection:Clinical Outcomes and Risk of Recurrence[J].J Am Coll Cardiol,2017,70(9):1148-1158.
[3] Maehara A,Mintz GS,Bui AB,et al.Incidence,morphology,angiographic findings,and outcomes of intramural hematomas after percutaneous coronary interventions:an intravascular ultrasound study[J].Circulation,2002,105(17):2037-2042.
[4]陈启,单兴华,刘宇,等.自发性冠状动脉壁内血肿二例诊治分析[J].中华急诊医学杂志,2014,23(4):450-453.
[5]黄浙勇,杨虹波,葛均波,等.基于单中心的中国人群自发性冠状动脉夹层临床特征与治疗策略[J].中国临床医学,2018,25(2):188-193.
[6]张云雁.女性急性心肌梗死的特点研究进展[J].东南国防医药,2018,20(3):276-280.
[7]李建华,程训民,杭涛,等.不同年龄层次急性心肌梗死患者临床特点对比观察[J].东南国防医药,2016,18(4):358-360.
[8] Tweet MS,Kok SN,Hayes SN.Spontaneous coronary artery dissection in women:What is known and what is yet to be understood[J].Clin Cardiol,2018,41(2):203-210.
[9] Aslan AN,Süygün H,Sivri S,et al.Low-dose oral contraceptiveinduced acute myocardial infarction[J].Eur J Contracept Reprod Health Care,2016,21(6):499-501.
[10] Ghani AR,Inayat F,Ali NS,et al.Spontaneous Coronary Artery Dissection:A Case Series of 9 Patients With Literature Review[J].J Investig Med High Impact Case Rep,2018,6:1-7.
[11] Alfonso F,Bastante T,García-Guimaraes M,et al.Spontaneous coronary artery dissection:new insights into diagnosis and treatment[J].Coron Artery Dis,2016,27(8):696-706.
[12] Nishiguchi T,Tanaka A,Taruya A,et al.Prognosis of spontaneous coronary artery dissection treated by percutaneous coronary intervention with optical coherence tomography[J].J Cardiol,2017,70(6):524-529.
[13] Malclès G,Souteyrand G,Motreff P.Recent insights on spontaneous coronary artery dissection(SCAD):From diagnosis suspicion to long-term outcomes[J].Ann Cardiol Angeiol(Paris),2016,65(6):451-456.
[14]?ato M,Gomez-Lara J,Romaguera R,et al.One-year optical coherence tomography findings in patients with late and very-late stent thrombosis treated with intravascular imaging guided percutaneous coronary intervention[J]. Int J Cardiovasc Imaging,2018,34(10):1511-1520.
[15]秦涛,许飚,丛壮壮,等.老年冠心病患者冠脉旁路移植及冠脉支架术后生活质量比较[J].东南国防医药,2015,17(3):259-262.
[16]朱冰冰,程训民,王璟.急诊介入治疗高龄急性心肌梗死患者的疗效及近期安全性评价[J].医学研究生学报,2014,27(11):1172-1175.
[2] Saw J,Humphries K,Aymong E,et al.Spontaneous Coronary Artery Dissection:Clinical Outcomes and Risk of Recurrence[J].J Am Coll Cardiol,2017,70(9):1148-1158.
[3] Maehara A,Mintz GS,Bui AB,et al.Incidence,morphology,angiographic findings,and outcomes of intramural hematomas after percutaneous coronary interventions:an intravascular ultrasound study[J].Circulation,2002,105(17):2037-2042.
[4]陈启,单兴华,刘宇,等.自发性冠状动脉壁内血肿二例诊治分析[J].中华急诊医学杂志,2014,23(4):450-453.
[5]黄浙勇,杨虹波,葛均波,等.基于单中心的中国人群自发性冠状动脉夹层临床特征与治疗策略[J].中国临床医学,2018,25(2):188-193.
[6]张云雁.女性急性心肌梗死的特点研究进展[J].东南国防医药,2018,20(3):276-280.
[7]李建华,程训民,杭涛,等.不同年龄层次急性心肌梗死患者临床特点对比观察[J].东南国防医药,2016,18(4):358-360.
[8] Tweet MS,Kok SN,Hayes SN.Spontaneous coronary artery dissection in women:What is known and what is yet to be understood[J].Clin Cardiol,2018,41(2):203-210.
[9] Aslan AN,Süygün H,Sivri S,et al.Low-dose oral contraceptiveinduced acute myocardial infarction[J].Eur J Contracept Reprod Health Care,2016,21(6):499-501.
[10] Ghani AR,Inayat F,Ali NS,et al.Spontaneous Coronary Artery Dissection:A Case Series of 9 Patients With Literature Review[J].J Investig Med High Impact Case Rep,2018,6:1-7.
[11] Alfonso F,Bastante T,García-Guimaraes M,et al.Spontaneous coronary artery dissection:new insights into diagnosis and treatment[J].Coron Artery Dis,2016,27(8):696-706.
[12] Nishiguchi T,Tanaka A,Taruya A,et al.Prognosis of spontaneous coronary artery dissection treated by percutaneous coronary intervention with optical coherence tomography[J].J Cardiol,2017,70(6):524-529.
[13] Malclès G,Souteyrand G,Motreff P.Recent insights on spontaneous coronary artery dissection(SCAD):From diagnosis suspicion to long-term outcomes[J].Ann Cardiol Angeiol(Paris),2016,65(6):451-456.
[14]?ato M,Gomez-Lara J,Romaguera R,et al.One-year optical coherence tomography findings in patients with late and very-late stent thrombosis treated with intravascular imaging guided percutaneous coronary intervention[J]. Int J Cardiovasc Imaging,2018,34(10):1511-1520.
[15]秦涛,许飚,丛壮壮,等.老年冠心病患者冠脉旁路移植及冠脉支架术后生活质量比较[J].东南国防医药,2015,17(3):259-262.
[16]朱冰冰,程训民,王璟.急诊介入治疗高龄急性心肌梗死患者的疗效及近期安全性评价[J].医学研究生学报,2014,27(11):1172-1175.