急性下壁心肌梗死合并右心室梗死的回顾性分析
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摘要
目的
在急性心肌梗死中,右心室心肌梗死并非少见,由于右心室心肌梗死多伴下壁、后壁心梗,临床表现复杂,往往认识不足,容易误诊、漏诊。回顾性分析探讨单中心急性下壁心肌梗死合并右室心梗患者的危险因素、临床特征、治疗措施,以期提高对急性下壁心肌梗死伴右室梗死的治疗水平。
方法
回顾分析2009-2010年间急性下壁心肌梗死合并右室心梗患者的危险因素、临床特征、冠状动脉病变情况、治疗措施、预后转归等临床资料。
结果
共筛选出急性下壁心梗合并右室心梗病人5例。
临床表现：1例为晕厥起病,1例为心源性休克起病,其余3例均以胸痛为首发症状；另这5例病人中有1例病人出现“右室心梗”三联症；
心电图学表现：4例V3R-V6R为QS型或QR型；2例V3RST段抬高；4例可见Ⅱ、Ⅲ、aVF的ST段抬高,而且STⅢ抬高／STⅢ抬高>1：2例Ⅱ、Ⅲ、aVF出现病理性Q波;有1例合并有Ⅱ°AVB；
心肌酶谱改变：CK-MB峰值的均值为92.4U／L,肌钙蛋白-Ⅰ峰值均值为76.45ng／ml,均符合急性心肌梗死的心肌酶学改变；
心超改变：有1例可以看到左室、下壁、后壁、后间壁节段性运动异常,轻度肺动脉高压。
冠状动脉造影：4例均提示右冠病变,其中3例右冠状动脉全闭,1例右冠状动脉狭窄90%,1例合并有前降支和回旋支病变,另1例患者因合并有肾功能不全,未行冠脉造影。
结论
急性下壁心梗合并右室心梗一般罪犯血管发生在右冠状动脉近中段,且狭窄程度严重,左前降支及回旋支病变不引起右室梗死。
Objective
Right ventricle infarction is not rare in acute myocardial infarction. Because Right ventricle infarction is usually accompanied by inferior infarction and backwall infarction, it is hard to recognize and diagnosis. The risk factors, clinical symptoms and treatments of patients who suffered acute inferior infarction accompanied by right ventricle infarction in single-institutiont is retrospectively analysed.
Methods
The risk factors, clinical symptoms, coronary artery changes, treatments, prognosis and prognosis of patients who suffered acute inferior infarction accompanied by right ventricle infarction in 2009-2010 are retrospectively analysed.
Results
5 patients who suffered acute inferior infarction accompanied by right ventricle infarction are retrospectively analysed. In clinical symptoms,1 patient showed syncope first,1 patient showed cardiogenic shock first,3 patients showed chest pain first.1 patient had the trilogy of right ventricle infarction. In ECG,4 patients V3R-V6R showed QS type or QR type; 2 patients showed V3RST elevated;4 patients not only showed ST elevated inⅡ、Ⅲ、aVF, but also showed the elevated extent of STⅢ/STⅡ＞1; 2 patients showed pathological Q wave inⅡ、Ⅲ、aVF; 1 paitents hadⅡ°AVB. In serum myocardial zymogram, the mean value of the peak value of the CK-MB was 92.4U/L, the mean value of the peak value of the troponin I was 92.4U/L, these values were all in accordance with the serum myocardial zymogram changes in acute myocardial infarction. In UCG,1 patient showed abnormal motion of the left ventricle, inferior, backwall, postero-septal, mild pulmonary hypertension. In coronary angiography,4 patients showed right coronary artery lesions,3 patients showed right coronary artery entirely shut,1 patients
Conclusions
Acute inferior myocardial infarction complicated by right ventricular myocardial infarction usually occurs in the right coronary artery culprit vessel near the middle, and severe stenosis, the left anterior descending artery and circumflex artery disease is not caused by right ventricular infarction.
在急性心肌梗死中,右心室心肌梗死并非少见,由于右心室心肌梗死多伴下壁、后壁心梗,临床表现复杂,往往认识不足,容易误诊、漏诊。回顾性分析探讨单中心急性下壁心肌梗死合并右室心梗患者的危险因素、临床特征、治疗措施,以期提高对急性下壁心肌梗死伴右室梗死的治疗水平。
方法
回顾分析2009-2010年间急性下壁心肌梗死合并右室心梗患者的危险因素、临床特征、冠状动脉病变情况、治疗措施、预后转归等临床资料。
结果
共筛选出急性下壁心梗合并右室心梗病人5例。
临床表现：1例为晕厥起病,1例为心源性休克起病,其余3例均以胸痛为首发症状；另这5例病人中有1例病人出现“右室心梗”三联症；
心电图学表现：4例V3R-V6R为QS型或QR型；2例V3RST段抬高；4例可见Ⅱ、Ⅲ、aVF的ST段抬高,而且STⅢ抬高／STⅢ抬高>1：2例Ⅱ、Ⅲ、aVF出现病理性Q波;有1例合并有Ⅱ°AVB；
心肌酶谱改变：CK-MB峰值的均值为92.4U／L,肌钙蛋白-Ⅰ峰值均值为76.45ng／ml,均符合急性心肌梗死的心肌酶学改变；
心超改变：有1例可以看到左室、下壁、后壁、后间壁节段性运动异常,轻度肺动脉高压。
冠状动脉造影：4例均提示右冠病变,其中3例右冠状动脉全闭,1例右冠状动脉狭窄90%,1例合并有前降支和回旋支病变,另1例患者因合并有肾功能不全,未行冠脉造影。
结论
急性下壁心梗合并右室心梗一般罪犯血管发生在右冠状动脉近中段,且狭窄程度严重,左前降支及回旋支病变不引起右室梗死。
Objective
Right ventricle infarction is not rare in acute myocardial infarction. Because Right ventricle infarction is usually accompanied by inferior infarction and backwall infarction, it is hard to recognize and diagnosis. The risk factors, clinical symptoms and treatments of patients who suffered acute inferior infarction accompanied by right ventricle infarction in single-institutiont is retrospectively analysed.
Methods
The risk factors, clinical symptoms, coronary artery changes, treatments, prognosis and prognosis of patients who suffered acute inferior infarction accompanied by right ventricle infarction in 2009-2010 are retrospectively analysed.
Results
5 patients who suffered acute inferior infarction accompanied by right ventricle infarction are retrospectively analysed. In clinical symptoms,1 patient showed syncope first,1 patient showed cardiogenic shock first,3 patients showed chest pain first.1 patient had the trilogy of right ventricle infarction. In ECG,4 patients V3R-V6R showed QS type or QR type; 2 patients showed V3RST elevated;4 patients not only showed ST elevated inⅡ、Ⅲ、aVF, but also showed the elevated extent of STⅢ/STⅡ＞1; 2 patients showed pathological Q wave inⅡ、Ⅲ、aVF; 1 paitents hadⅡ°AVB. In serum myocardial zymogram, the mean value of the peak value of the CK-MB was 92.4U/L, the mean value of the peak value of the troponin I was 92.4U/L, these values were all in accordance with the serum myocardial zymogram changes in acute myocardial infarction. In UCG,1 patient showed abnormal motion of the left ventricle, inferior, backwall, postero-septal, mild pulmonary hypertension. In coronary angiography,4 patients showed right coronary artery lesions,3 patients showed right coronary artery entirely shut,1 patients
Conclusions
Acute inferior myocardial infarction complicated by right ventricular myocardial infarction usually occurs in the right coronary artery culprit vessel near the middle, and severe stenosis, the left anterior descending artery and circumflex artery disease is not caused by right ventricular infarction.
引文
[1]Cohn JN. Guiha Nit. Broder MI, et al Right ventrieular in farction:clinical and hemodynamic feature5 Am J CardioI 1974.33:209-232
[2]Braat SH, Brugada P, deZwaan C, et al. Value of electrocardiogram in diagnosing right ventricular involvement in patients with acute inferior wall myocardial infarction. Am Heart J,1983,49:368～372.
[3]Terry R, William W. Patterns of coronary compromise resulting in acute right ventricular ischemic dysfunction. Circulation,2002,106(9):1104-1110.
[4]胡大一,马长生.心脏病学实践2004一规范化治疗.北京：人民卫生出版社,2004.316-323.
[5]Chockalingam A, Gnanavelu G, Subramaniam T, et al. Right ventricular myocardial infarction:presentation and acute outcomes. Angiology,2005,56(4): 371-376.
[6]陈国伟,匹泽榆.急性心肌梗死早期诊断经验.中国实用内科杂志,1996,16(2)：65-66.
[7]Gibson RS Non-Q-wave myocardial infarction:diagnosis, prognosis and management. Curr Probl Cardiol,1988,13(1):9-10.
[8]张全贵.右心室梗死的心电图诊断.中国急救医学,1988,8(5)： 25-26.
[9]Khan S, Kundi A, Sharieff S. Prevalence of right ventricular myocardial infarction in patients with acute inferior wall myocardial infarction. Int J Cl in Pract,2004,58(4):354-357.
[10]Bian X, Fu M, Mallet RT, et al, Myocardia oxygen consumption modulates adenosine formation by canine right ventricle in absence of hypoxia. J Mol Cell Cardiol,2000,32(3):345-354.
[11]许家俐,赵志.右心室心肌梗死的诊断和治疗原则.临床内科,2001,18(1)： 15-17.
[12]0'Rourke RA, Dell Italia UJ. Diagnosis and treatment of right ventricular myocardial infarction. Curr Probl Cardiol,2004,19(1):1-47.
[13]Dell'Italia LJ. The right ventricular anatomy:physiology and clinical importance. Curr Probl Cardiol,1991,16:659-661.
[14]Kinch JW. Ryan TS. Right ventricular infarction. N Engl J Med.1994, 330:1211-1215.
[15]Zehender M. Kasper W, Kander E, et al. Eligibility for and benefit of thrOmbolytic thrapy in inferior myocardial infarction:focus on the prognostic importance of right ventricular involvement on mortality and morbidity in patients with inferior myocardial infarction. J Am CollCardiol,1994,24(2):362-369.
[16]Mehta SK, Eikebloom J, Ntarizon M, et al. Impact of right ventricular involvement on mortality and morbidity in patients with inferior myocardial infarction. J Am Coll Cardiol,2001,37(1):37-43.
[17]MaVRIC Z, ZAPUT()VIC I. MATANA A. et al. Porgnostic significance of complete atrioventricular block in patients with acute inferior myocardial infarction with and withour right ventricular involvement. Am J Cardiol,1990,119:823-825.
[18]Shao DB. Chronic sinoatrial node disorder; a possible result of myocardia ischemia. Am Heart J,1989,58.598■600.
[19]詹中群,王崇全,党书毅,等。右心室合并急性下壁心肌梗死患者临床特点分析.中国综合临床,2005,21(12)：1075—1077.
[20]Lee DT, Patel M, Bowers T, et al. Atrioventricular block in inferior myocardial infarction is not due to AV nodal ischemi alone. Circulation,2000,102(supple): 11608-610.
[21]Zehender M. Kasper W, Kander E, et al. Eligibility for and benefit of thrombolytic thrapy in inferior myocardial infarction:focus on the prognostic importance of right ventricular involvement on mortality and morbidity in patients with inferior myocardial infarction. J AⅡ lColl Cardiol,1994,24(2):362-369.
[22]Goldstein JA, Tweddell JS, Barzilai B, et al. Importance of left ventricular function and systol ic interaction to right ventricular performance during acute right heart ischemial. J Am Coll Cardiol,1992,19:704-708.
[23]朱文玲.急性心梗再灌注的循证医学.中国循环杂志,2003,2(18)：64-66.
[1]王吉耀内科学人民卫生出版社2005年5月.
[2]Dell'Italia LJ.The right ventricular anatomy:physiology and clinical importance. Curr Probl Cardiol,1991,16:659-661.
[3]Braat SH, Brugada P, deZwaan C, et al. Value of electrocardiogram in diagnosing right ventricular involvement in patients with acute inferior wall myocardial infarction. Am Heart J,1983,49:368-372.
[4]Kinch jw, Ryan TS. Right ventricular infarction. N Engl J Med,1994,330: 1211-1216.
[5]Goldstein JA. Right heart ischmia:Pathophysiology, natural history, and clinical management. Prog Cardiovasc Dis,1998,40(4):325-331.
[6]吴祥.急性心肌梗死ST段抬高的形态和诊断误区.临床心电学杂志,2007,16(10)：356-360.
[7]Andersen HR. Right ventricular infarction:diagnostic value of ST elevation in lead III exceeding that of lead II during inferior/posterior infarction and comparison with right chest leads V3R to V7R.Am Heart,1989,117:82-85.
[8]Lew AS. Ratio of ST-segment depression in lead V2 to ST segment elevation:An aid to the early recognition of right ventricular ischemia. Am J Cardial,1986,57: 1047.
[9]Rashduni DL, Tannenbaum AK. Utility of ST depression in lead aVL in diagnosis of right ventricular infarction. NEng J Med,2003,100(11):35-37.
[10]Turhan H, Yilmaz MB, Yetkin E, et al. Diagnostic value of aVL derivation for right ventricular involvement in patients with acute inferior myocardial infarction. Ann Noninvasive Electrocardiol,2003,8:185-187.
[11]Erhardt LR. Clinical and pathological observations in different types of acute myocardial infarction:a study of 84 patients decreased after treatment in a coronary care unit. Acta Med Scan Suppl,1974,560:1-78.
[12]Braat SH, Brugada P, Dendulk, et al. Value of lead V4R for the infarct coronery artery in acute inferior myocardial infarction [J]. Am Heart J,1992,123:362.
[13]吴祥心律失常梯形图解法.第1版,杭州：浙江大学出版社,2006,252-260.
[14]王勇李峰急性下壁心肌梗死相关血管特点的临床分析,中国医师杂志2006年3月,第8卷,第3期。
[2]Braat SH, Brugada P, deZwaan C, et al. Value of electrocardiogram in diagnosing right ventricular involvement in patients with acute inferior wall myocardial infarction. Am Heart J,1983,49:368～372.
[3]Terry R, William W. Patterns of coronary compromise resulting in acute right ventricular ischemic dysfunction. Circulation,2002,106(9):1104-1110.
[4]胡大一,马长生.心脏病学实践2004一规范化治疗.北京：人民卫生出版社,2004.316-323.
[5]Chockalingam A, Gnanavelu G, Subramaniam T, et al. Right ventricular myocardial infarction:presentation and acute outcomes. Angiology,2005,56(4): 371-376.
[6]陈国伟,匹泽榆.急性心肌梗死早期诊断经验.中国实用内科杂志,1996,16(2)：65-66.
[7]Gibson RS Non-Q-wave myocardial infarction:diagnosis, prognosis and management. Curr Probl Cardiol,1988,13(1):9-10.
[8]张全贵.右心室梗死的心电图诊断.中国急救医学,1988,8(5)： 25-26.
[9]Khan S, Kundi A, Sharieff S. Prevalence of right ventricular myocardial infarction in patients with acute inferior wall myocardial infarction. Int J Cl in Pract,2004,58(4):354-357.
[10]Bian X, Fu M, Mallet RT, et al, Myocardia oxygen consumption modulates adenosine formation by canine right ventricle in absence of hypoxia. J Mol Cell Cardiol,2000,32(3):345-354.
[11]许家俐,赵志.右心室心肌梗死的诊断和治疗原则.临床内科,2001,18(1)： 15-17.
[12]0'Rourke RA, Dell Italia UJ. Diagnosis and treatment of right ventricular myocardial infarction. Curr Probl Cardiol,2004,19(1):1-47.
[13]Dell'Italia LJ. The right ventricular anatomy:physiology and clinical importance. Curr Probl Cardiol,1991,16:659-661.
[14]Kinch JW. Ryan TS. Right ventricular infarction. N Engl J Med.1994, 330:1211-1215.
[15]Zehender M. Kasper W, Kander E, et al. Eligibility for and benefit of thrOmbolytic thrapy in inferior myocardial infarction:focus on the prognostic importance of right ventricular involvement on mortality and morbidity in patients with inferior myocardial infarction. J Am CollCardiol,1994,24(2):362-369.
[16]Mehta SK, Eikebloom J, Ntarizon M, et al. Impact of right ventricular involvement on mortality and morbidity in patients with inferior myocardial infarction. J Am Coll Cardiol,2001,37(1):37-43.
[17]MaVRIC Z, ZAPUT()VIC I. MATANA A. et al. Porgnostic significance of complete atrioventricular block in patients with acute inferior myocardial infarction with and withour right ventricular involvement. Am J Cardiol,1990,119:823-825.
[18]Shao DB. Chronic sinoatrial node disorder; a possible result of myocardia ischemia. Am Heart J,1989,58.598■600.
[19]詹中群,王崇全,党书毅,等。右心室合并急性下壁心肌梗死患者临床特点分析.中国综合临床,2005,21(12)：1075—1077.
[20]Lee DT, Patel M, Bowers T, et al. Atrioventricular block in inferior myocardial infarction is not due to AV nodal ischemi alone. Circulation,2000,102(supple): 11608-610.
[21]Zehender M. Kasper W, Kander E, et al. Eligibility for and benefit of thrombolytic thrapy in inferior myocardial infarction:focus on the prognostic importance of right ventricular involvement on mortality and morbidity in patients with inferior myocardial infarction. J AⅡ lColl Cardiol,1994,24(2):362-369.
[22]Goldstein JA, Tweddell JS, Barzilai B, et al. Importance of left ventricular function and systol ic interaction to right ventricular performance during acute right heart ischemial. J Am Coll Cardiol,1992,19:704-708.
[23]朱文玲.急性心梗再灌注的循证医学.中国循环杂志,2003,2(18)：64-66.
[1]王吉耀内科学人民卫生出版社2005年5月.
[2]Dell'Italia LJ.The right ventricular anatomy:physiology and clinical importance. Curr Probl Cardiol,1991,16:659-661.
[3]Braat SH, Brugada P, deZwaan C, et al. Value of electrocardiogram in diagnosing right ventricular involvement in patients with acute inferior wall myocardial infarction. Am Heart J,1983,49:368-372.
[4]Kinch jw, Ryan TS. Right ventricular infarction. N Engl J Med,1994,330: 1211-1216.
[5]Goldstein JA. Right heart ischmia:Pathophysiology, natural history, and clinical management. Prog Cardiovasc Dis,1998,40(4):325-331.
[6]吴祥.急性心肌梗死ST段抬高的形态和诊断误区.临床心电学杂志,2007,16(10)：356-360.
[7]Andersen HR. Right ventricular infarction:diagnostic value of ST elevation in lead III exceeding that of lead II during inferior/posterior infarction and comparison with right chest leads V3R to V7R.Am Heart,1989,117:82-85.
[8]Lew AS. Ratio of ST-segment depression in lead V2 to ST segment elevation:An aid to the early recognition of right ventricular ischemia. Am J Cardial,1986,57: 1047.
[9]Rashduni DL, Tannenbaum AK. Utility of ST depression in lead aVL in diagnosis of right ventricular infarction. NEng J Med,2003,100(11):35-37.
[10]Turhan H, Yilmaz MB, Yetkin E, et al. Diagnostic value of aVL derivation for right ventricular involvement in patients with acute inferior myocardial infarction. Ann Noninvasive Electrocardiol,2003,8:185-187.
[11]Erhardt LR. Clinical and pathological observations in different types of acute myocardial infarction:a study of 84 patients decreased after treatment in a coronary care unit. Acta Med Scan Suppl,1974,560:1-78.
[12]Braat SH, Brugada P, Dendulk, et al. Value of lead V4R for the infarct coronery artery in acute inferior myocardial infarction [J]. Am Heart J,1992,123:362.
[13]吴祥心律失常梯形图解法.第1版,杭州：浙江大学出版社,2006,252-260.
[14]王勇李峰急性下壁心肌梗死相关血管特点的临床分析,中国医师杂志2006年3月,第8卷,第3期。