目的:通过1例患者的临床实践并复习文献,阐述冠状动痉挛导致心肌梗死的诊断要点、治疗手段及可能机制。方法:回顾性分析1例5个月前有胸闷、胸痛症状,造影提示冠脉心肌桥且有冠状动脉痉挛的患者,突发持续性胸骨后胸痛2天,于2021-08-11急诊收治,发生心肌梗死患者的临床资料。结果:经给予抗血小板聚集,稳定斑块,强化改善血管痉挛等药物治疗,急诊冠状动脉造影(CAG)、冠状动脉内推注抗痉挛药物等措施,成功抢救,1周后病情稳定。既往冠状动脉造影及本次冠状动脉造影、心肌酶谱及动态心电图对比提示,患者左前降支痉挛,引发ST段抬高型心肌梗死。结论:冠状动脉痉挛是ST段抬高型心肌梗死的原因之一,规范的药物治疗是预防急性心血管事件发作最根本的手段。 Aim: Through the clinical practice of 1 patient and the literature review, to explain the main points of diagnosis, treatment and possible mechanism of myocardial infarction caused by coronary spasm. Methods: A retrospective analysis of a patient with chest tightness and chest pain symptoms 5 months ago, coronary myocardial bridge and coronary artery spasm revealed by angiography, sudden and persistent retrosternal chest pain for 2 days, was admitted to the emergency department on August 11, 2021. Clinical data of patients with myocardial infarction were analyzed. Results: After treatment with anti-platelet aggregation, stabilization of plaques, intensified treatment of vasospasm, emergency coronary angiography (CAG), intracoronary bolus injection of antispasmodic drugs and other measures, the rescue was successful and the condition was stable after 1 week. The comparison of previous coronary angiography and this coronary angiography, myocardial enzyme spectrum and dynamic electrocardiogram indicated that the patient’s left anterior descending artery spasm caused ST-segment elevation myocardial infarction. Conclusion: Coronary artery spasm is a cause of ST-segment elevation myocardial infarction. The appropriate medication plays a crucial role in prevention of acute cardiovascular events related to coronary artery spasm.
目的:通过1例患者的临床实践并复习文献,阐述冠状动痉挛导致心肌梗死的诊断要点、治疗手段及可能机制。方法:回顾性分析1例5个月前有胸闷、胸痛症状,造影提示冠脉心肌桥且有冠状动脉痉挛的患者,突发持续性胸骨后胸痛2天,于2021-08-11急诊收治,发生心肌梗死患者的临床资料。结果:经给予抗血小板聚集,稳定斑块,强化改善血管痉挛等药物治疗,急诊冠状动脉造影(CAG)、冠状动脉内推注抗痉挛药物等措施,成功抢救,1周后病情稳定。既往冠状动脉造影及本次冠状动脉造影、心肌酶谱及动态心电图对比提示,患者左前降支痉挛,引发ST段抬高型心肌梗死。结论:冠状动脉痉挛是ST段抬高型心肌梗死的原因之一,规范的药物治疗是预防急性心血管事件发作最根本的手段。
冠状动脉痉挛,ST段抬高型心肌梗死,马尼地平
Yutian Mi1,2, Siyuan Huo1,2, Gaochao Wang1,2, Zhiming Song1,2,3*
1Department of Cardiology, The First Affiliated Hospital, Henan University, Kaifeng Henan
2Kaifeng Key Laboratory of Cardiac Function Modulation and Rehabilitation, Kaifeng Henan
3Institute on Aging and Disease, Henan University, Kaifeng Henan
Received: Oct. 13th, 2022; accepted: Nov. 11th, 2022; published: Nov. 18th, 2022
Aim: Through the clinical practice of 1 patient and the literature review, to explain the main points of diagnosis, treatment and possible mechanism of myocardial infarction caused by coronary spasm. Methods: A retrospective analysis of a patient with chest tightness and chest pain symptoms 5 months ago, coronary myocardial bridge and coronary artery spasm revealed by angiography, sudden and persistent retrosternal chest pain for 2 days, was admitted to the emergency department on August 11, 2021. Clinical data of patients with myocardial infarction were analyzed. Results: After treatment with anti-platelet aggregation, stabilization of plaques, intensified treatment of vasospasm, emergency coronary angiography (CAG), intracoronary bolus injection of antispasmodic drugs and other measures, the rescue was successful and the condition was stable after 1 week. The comparison of previous coronary angiography and this coronary angiography, myocardial enzyme spectrum and dynamic electrocardiogram indicated that the patient’s left anterior descending artery spasm caused ST-segment elevation myocardial infarction. Conclusion: Coronary artery spasm is a cause of ST-segment elevation myocardial infarction. The appropriate medication plays a crucial role in prevention of acute cardiovascular events related to coronary artery spasm.
Keywords:Coronary Artery Spasm, ST-Segment Elevation Myocardial Infarction, Manidipine
Copyright © 2022 by author(s) and Hans Publishers Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
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患者,男,54岁。2021.3.1日凌晨以“突发胸痛1小时”为主诉入我院,伴左上肢反射痛,伴双下颌酸胀,伴胸闷、出汗,偶伴头晕,持续数分钟,舌下含服“复方丹参滴丸”后症状可自行缓解,入院心电图提示:室性期前收缩,部分st-t改变(图1)。急查心肌酶谱未见异常,发病6小时后再次复查心肌酶谱结果提示肌钙蛋白0.06 ng/ml,考虑患者急性非st段抬高型心肌梗死,给予冠脉造影检查,结果提示LM未见明显狭窄;LAD中段可见心肌桥形成,造影过程中左冠痉挛,给予硝酸甘油后缓解;LCX未见明显狭窄;RCA近中段狭窄30%~40% (图2)。患者在院治疗期间症状未再发,出院给药方案阿司匹林100 mg qd,瑞舒伐他汀钙片10 mg qd,尼可地尔5 mg bid,麝香保心丸45 mg qd及必要时,参松养心胶囊3粒tid。患者吸烟、饮酒多年,嘱患者戒烟、戒酒,按时服药。
2021.6.7日上述症状再次发作,以“间断胸闷、胸痛3月,再发2天”收入我科,2天前胸痛症状再发,伴左上肢反射痛,伴双下颌酸胀,伴出汗,偶伴头晕,心肌酶谱未见异常,行运动平板检查结果提示阴性,结合患者住院病史,考虑冠脉痉挛,调整治疗方案,加用地尔硫卓60 mg bid,加药后患者症状缓解,追问患者病史,患者未戒烟,再次告知患者按时服药,戒烟、戒酒。
2021-08-11患者于当地中医院进行中药调理,停服“地尔硫卓”,期间再次出现心前区疼痛,伴大汗、下颌酸,因在佩戴动态心电图期间,患者未含服“速效救心丸”并抽烟,症状缓解后突然出现意识丧失,皮肤苍白,大汗,立即抢救后患者意识恢复。急查心肌酶谱提示:肌红蛋白(MYO) 144.2 ng/ml (0~60 ng/ml),肌酸激酶同工酶(CK-MB) 2.334 ng/ml (0~5 ng/ml),高敏肌钙蛋白T (hs-TnT) 0.114 ng/ml (0~0.1 ng/ml)。动态心电图:1) 窦性心律 + 异搏心律,2) 偶发房性早搏,3) 频发室性早搏,4) 间断广泛st-t改变有动态变化,5) 心率变异性测定正常(图3)。2021-08-12于我院行心电图提示:窦性心律,侧壁st-t异常,心率52次/分。检验结果示:肌红蛋白(MYO) 21.7 ng/ml (15.2~91.2 ng/ml),肌酸激酶同工酶 (CK-MB) 1.6 ng/ml (0.5~5.0 ng/ml),高敏肌钙蛋白(hs-TnI) 53.2 pg/ml (0~17.82 pg/ml),其余未见明异常。2021-08-13行冠状动脉造影术结果示:LM未见明显狭窄;LAD中段可见心肌桥形成(收缩显时狭窄50%~60%),TIMI3级;LCX多发斑块形成,中远段狭窄30%,TIMI3级;RCA近中段可见斑块形成,TIMI3级(图4)。对比发现,较前未见明显进展,仍考虑是由于冠脉痉挛引起的相关症状,给予改善循环,抗血小板聚集,稳定斑块等药物治疗,患者胸闷症状较前好转,但是仍有发作,给予“马尼地平、尼可地尔、地尔硫卓”强化改善血管痉挛,余原方案治疗。
图1. 首次入院心电图
图2. 患者冠脉造影结果((a):左冠弥漫性痉挛导致狭窄;(b):冠脉内推注硝酸甘油后痉挛解除)
图3. 2021-08-11动态心电图(提示:一过性下壁、广泛前壁ST段抬高)
图4. 第3次入院冠脉造影结果
冠状动脉痉挛(coronary artery spasm, CAS)是一种病理生理状态,根据冠状动脉发生痉挛的不同部位、严重程度以及有无侧支循环等差别可以有不同的临床表现,包括:典型变异型心绞痛、非典型CAS性心绞痛、急性心肌梗死(AMI)、猝死、各类心律失常、心力衰竭和无症状性心肌缺血等,统称为冠状动脉痉挛综合征(coronary artery spasm syndrome, CASS) [
冠状动脉痉挛在临床上比较常见,当出现冠脉痉挛时常常引起心肌缺血,从而出现心绞痛等症状。而且,冠状动脉痉挛在进行CAG和PCI时容易看到。大多数情况下,冠状动脉痉挛持续的时间较短,不足以引起心肌梗死,但如果诱因一直存在,冠状动脉发生广泛且严重的持续痉挛,则能引起心肌梗死 [
随着冠脉介入诊疗的普及,冠状动脉持续痉挛引起急性心肌梗死的病例不断增多,统计发现发生急性心肌梗死的患者中10%左右的患者的冠状动脉无明显狭窄,而认为冠脉痉挛是急性心肌梗死的主要原因之一 [
该患者持续胸痛2天,结合患者症状、心肌酶谱、心电图表现提示急性广泛前壁、下壁心肌梗死,行冠脉造影示:LM未见明显狭窄;LAD中段可见心肌桥形成(收缩时狭窄50%~60%),TIMI3级;LCX多发斑块形成,中远段狭窄30%,TIMI3级;RCA近中段可见斑块形成,TIMI3级。较半年前的冠状动脉造影结果未见明显异常,考虑由于LAD中段心肌桥形成,引发前降支持续痉挛导致急性广泛前壁、下壁心肌梗死。本文患者抽烟后多次出现急性冠脉痉挛而导致的心绞痛和胸闷,及时行心电图及心肌酶谱未见明显异常,给予地尔硫卓后缓解,但是效果逐渐减弱,后续患者抽烟量依旧较大,且病情发作后,未及时用药,故而引起急性心肌梗死。鉴于该患者对运用单一非二氢吡啶类钙通道阻滞剂(地尔硫卓)反应减弱。且据报道,如果使用单一钙通道阻滞剂患者结局不理想,可加用另一种钙通道阻滞剂或长效硝酸盐 [
不同类型及阶段的冠状动脉痉挛综合症在急性发作期的处理重点略有不同,但总体原则是迅速缓解持续性冠状动脉痉挛状态,及时处理并发症。对于处于稳定期的各种类型CASS,应坚持长期治疗,防止复发,减少冠状动脉痉挛性心绞痛和无症状性心肌缺血的发作,降低CAS诱发的急性心脏事件。
CASS患者中绝大多数以心绞痛为主要表现,此类患者的长期管理在于去除危险因素、坚持药物治疗、严格戒烟、戒酒基础上坚持长期药物治疗。最近研究发现,日本和中国的长期随访死亡率均在1%左右 [
河南省医学科技攻关计划(SB201901065),开封市科技发展计划(2207001),河南大学医学青年人才科研能力提升计划(CX3011A0960017),河南大学研究生教育创新与质量提升计划(SYL20060190)。
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