应激性心肌病ppt课件.pptx

应激性心肌病应激性心肌病Stress Cardiomyopathy，SCDiagnosis,Pathophysiology,Management,and Prognosis1History1991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”(章鱼瘘章鱼瘘)心肌病心肌病1997年法国的心脏病学家Dominique Pavin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2DefinitionSC is a reversible cardiomyopathy,with a clinical presentation mimicking Acute coronary syndrome in the absence of significant coronary artery diseaseTako-tsubo cardiomyopathy,Apical Ballooning syndrome,and ampulla cardiomyopathyBroken Heart syndrome，Transient Cardiac Ballooning syndrome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3Mayo CriteriaTransient hypokinesis,akinesis,or dyskinesis in the left ventricle midsegments with or without apical involvement,regional wall motion abnormality extending beyond a single epicardial vascular distribution,the presence of a stress trigger 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Criteria proposed by the Mayo Clinic in 2004 and modified in 20084Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture 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New electrographic abnormalities and/or modest elevation in serum cardiac enzymes 新出现心电图异常或心肌酶学轻度升高Absence of pheochromocytoma or myocarditis 排除嗜铬细胞瘤、心肌炎All 4 criteria must be present5INCIDENCEThe incidence of SC is likely underrecognizedApproximately 1%to 2%of patients presenting with an initial diagnosis ACS actually have SC 发病率不明确，1%-2%的ACS患者实为SCUnderestimated for a variety of reasons：nonavailability of cardiac catheterization facilities in many regions the possibility for noncardiac presentationlack of a consensus of diagnostic criteria may contribute to misdiagnosis6PRESENTATIONIt occurs most commonly in postmenopausal Women（90%）,mean age between 58 and 75 yrsSC seems to have an association with hypertension,COPD,and bronchial asthmaSC mimics ACS in most patients，acute substernal chest pain and dyspnea.shock,syncope,and cardiac arrest have been reported rarely2/3 of patients with emotional or physical stress7ECG FINDINGSST elevation in the precordial and diffuse T wave are the most common findings胸前导联ST段抬高及多导联T波倒置最为常见8Differentiate SC from anterior STEMIPresence of ST segment depression in lead avR and absence of ST segment elevation in lead V1 identified SC with 91%sensitivity,96%specificity,and 95%predictive accuracy9LABORATORY FINDINGSElevations 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 elevationTroponin T levels ranged from 0.01 to 5.2 ng/mL10CARDIAC CATHETERIZATION Coronary angiography Left ventriculographyA RAO end systolic leftventriculogram 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-diastolic ventriculogram in atypical variant of SC.1112IMAGINGEchocardiographyventricular ballooning，wall motion abnormalities，decrease in EFNuclear Imagingusing Tc-99m，impairment of myocardial perfusionMagnetic Resonance Imagingpatients with SC do not show hyper-enhancement on delayed contrast enhancement MRI13PATHOPHYSIOLOGYThe causal mechanisms remain uncertain 机制不明确 Stunned myocardium resulting from brief periods of ischemia owing to vasospasm is one possibility 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14Coronary microvascular dysfunction 冠状动脉微血管功能障碍 Increasing plasma levels of catecholamines 交感神经过度兴奋和血浆儿茶酚胺水平增高 Reduction in estrogen levels following menopause 雌激素水平降低15MANAGEMENTThe treatment of patients with SC is mainly supportive 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Patients with shock,cautious use of inotropic agents such as dobutamine and dopamine 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It is reasonable to treat SC with -blocker,ACE inhibitor and if pulmonary edema evelops,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16PROGNOSISSC has a favorable prognosis with in-hospital mortality 1%,with death more common in the setting of outflow obstructionThe 4-year recurrence rate of SC has been reported to be 11.4%,but without any significant difference in survival in an age and gender-matched population over the same duration 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17Case Review王得清王得清，男，男/66岁岁，住院号：住院号：654098主诉：主诉：胸痛胸痛2天，晕厥一次天，晕厥一次现病史：现病史：2013.11.2日日突发突发胸痛，胸痛，位于下段胸骨后，压迫感，位于下段胸骨后，压迫感，持续持续约约半小时好半小时好转，于当地诊所转，于当地诊所诊治诊治过程中突发黑朦、晕厥，数秒后意识恢复过程中突发黑朦、晕厥，数秒后意识恢复。11.3日日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，再发胸痛，性质同前，程度较前剧烈伴出汗，持续不能缓解，当地医院当地医院诊断诊断“AMI”，给予药物治疗（，给予药物治疗（ASA300mg,波立维波立维300mg,立普妥立普妥20mg）及杜冷）及杜冷丁肌注后好转。丁肌注后好转。18既往史、个人史及家族史既往史、个人史及家族史无特殊。无特殊。入院查体：入院查体：T 36.6，P 98bpm，R 20bpm，BP 140/80mmHg，肺部以及查体无阳肺部以及查体无阳性体征；性体征；HR 104次次/分，律绝对不齐，分，律绝对不齐，S1强弱不等，强弱不等，各瓣膜听诊区未闻及杂音各瓣膜听诊区未闻及杂音；双下双下肢无水肿肢无水肿院前院前辅助检查：辅助检查：2013年年11月月4日我院日我院ECG:1.心房颤动心房颤动2.前壁导联前壁导联ST-T改变改变。UCG:1.双双房扩大房扩大 室间隔室间隔,左室前壁室壁运动幅度减低左室前壁室壁运动幅度减低,三尖瓣轻度反流三尖瓣轻度反流,左室收缩功能稍减低左室收缩功能稍减低,心心包腔少量积液包腔少量积液 心律不齐心律不齐;2.先天性心脏病：房间隔小缺损（筛孔型，左向右分流）先天性心脏病：房间隔小缺损（筛孔型，左向右分流）。cTnI 0.096ng/ml19急诊室急诊室UCG20入院诊断入院诊断冠状动脉粥样硬化性心脏病冠状动脉粥样硬化性心脏病 急性前壁心肌梗死急性前壁心肌梗死 心房颤动心房颤动 心功能心功能I I级（级（KillipKillip分级）分级）21监测监测ECG 12013.11.0422监测监测ECG 211.0511.0623监测监测cTnI24冠脉冠脉CTALADLCXRCA25应激因素应激因素-SMA栓塞栓塞入院后治疗方案：入院后治疗方案：抗血小板聚集（阿司匹林抗血小板聚集（阿司匹林+波立维波立维+替罗替罗非班）、抗凝非班）、抗凝病情变化：病情变化：D2 解暗红色血便解暗红色血便5次，上腹部压痛次，上腹部压痛D3 解解暗红色血暗红色血便便3次，诉腹痛伴出汗，查体腹肌紧张，全腹压痛，肠鸣音弱次，诉腹痛伴出汗，查体腹肌紧张，全腹压痛，肠鸣音弱腹部血管腹部血管CTA：SMA栓塞，肠管缺血改变栓塞，肠管缺血改变26腹部血管腹部血管CTA结论：结论：SMA栓塞，肠管缺血改变栓塞，肠管缺血改变2728下次预告下次预告Percutaneous Rheolytic Thrombectomy for Treatment of Acute SMA ThrombosisChengyi XU Xi SU29