应激性心肌病.pptx

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2018/7/20,#,应激性心肌病,Stress Cardiomyopathy,，,SC,Diagnosis,Pathophysiology,Management,and Prognosis,1,History,1991,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,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,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,2,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,，,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,3,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 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 2008,4,Absence,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 present,5,INCIDENCE,The incidence of SC is likely,underrecognized,Approximately,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,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,6,PRESENTATION,It occurs most commonly 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,.shocksyncope,and cardiac arrest have been reported rarely,2/3,of patients with emotional or physical stress,7,ECG FINDINGS,ST 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,8,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%sensitivity,96%specificity,and 95%predictive accuracy,9,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,10,CARDIAC CATHETERIZATION,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-diastolic ventriculogram in atypical variant of SC.,11,12,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 enhancement MRI,13,PATHOPHYSIOLOGY,The 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14,Coronary 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,15,MANAGEMENT,The 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,16,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 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,17,Case Review,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：,T 36.6,，,P 98bpm,，,R 20bpm,，,BP 140/80mmHg,，,肺部以及查体无阳性体征；,HR 104,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）,。,cTnI 0.096ng/ml,19,急诊室,UCG,20,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,ECG 1,201311.04,22,监测,ECG 2,11.05,11.06,23,监测,cTnI,24,冠脉,CTA,LAD,LCX,RCA,25,应激因素,-SMA,栓塞,入院后治疗方案：,抗血小板聚集（阿司匹林,+,波立维,+,替罗非班）、抗凝,病情变化：,D2,解暗红色血便,5,次，上腹部压痛,D3,解,暗红色血,便,3,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,CTA,：,SMA,栓塞，肠管缺血改变,26,腹部血管,CTA,结论：,SMA,栓塞，肠管缺血改变,27,28,下次预告,Percutaneous Rheolytic Thrombectomy for Treatment of Acute SMA Thrombosis,Chengyi XU Xi SU,29,