肺栓塞误诊为急性冠状动脉综合征66例临床分析

Clinical analysis of 66 cases with pulmonary embolism misdiagnosed as acute coronary syndrome

目的分析急性肺动脉栓塞误诊为急性冠状动脉综合征的原因,以提高对急性肺动脉栓塞的早期识别和处理。方法回顾性分析66例以急性冠状动脉综合征入院患者的临床表现,超声心动图、心肌酶及肌钙蛋白、血气分析、D-二聚体、X线胸片及冠状动脉造影等临床资料。总结分析误诊的原因。结果66例患者均以急性冠状动脉综合征入院,诊为不稳定型心绞痛39例,非ST段抬高/非Q波心肌梗死23例,急性前壁心肌梗死3例,急性下壁心肌梗死1例;最终通过肺核素通气/灌注扫描或螺旋计算机断层摄影术、核磁共振、肺动脉造影确诊为急性肺栓塞,其中大面积肺栓塞17例,次大面积42例,小面积7例。超声心动图示右心室功能障碍59例(89.4%),无右心室功能障碍7例(10.6%)。确定诊断行放射性核素肺扫描32例、螺旋CT检查18例、磁共振检查9例、肺动脉造影7例。分析发现66例患者均伴有非特异性临床表现,心电图呈特征性改变,多有心肌肌钙蛋白升高,少数患者心肌酶升高。结论①肺栓塞患者胸闷、胸痛的非特异性临床症状,伴心电图的T波深倒置、QⅢTⅢ型以及心肌肌钙蛋白、心肌酶的升高,是急性肺动脉栓塞误诊为急性冠状动脉综合征的主要原因。②认真分析病史及全面体检,血气分析、D-二聚体测定、超声多普勒心动图检查对鉴别诊断有帮助,及早行肺核素或螺旋CT确诊有助于早期诊断治疗。

Objective To analyze the reason that acute pulmonary embolism （ APE ） was prone to be misdiagnosed as acute coronary syndrome （ ACS ） so as to enhance the management of APE. Methods Clinical data of 66 cases admitted because of ACS, including clinical manifestation, echocardiogram, cardiac enzyme, troponin, blood gas analysis, D-dimer, x - ray and angiography were retrospectively analyzed. The reasons for misdiagnosis were summarized. Results 66 cases were admitted because of the diagnosis of ACS, including 39 cases of unstable angina, 23 cases of non-ST segment elevation/non-Q wave myocardial infarction （ NSTE/NQMI ） , 3 cases of acute anterior myocardial infarction and 1 case of acute inferior myocardial infarction, but the cases were finally diagnosed as APE by means of pulmonary ventilation/perfusion scanning, spiral computed tomography, magnetic resonance imaging and pulmonary artery angiography. There were 17, 42 and 7 cases with massive, submassive and small PE, respectively. UCG showed that there were 59 cases （89.4%） with right ventricular dysfunction and 7 cases （ 10.6% ） with normal right ventricular function by UCG. Pulmonary ventilation/perfusion scanning was necessarily used for 32 patients, spiral CT scanning for 18 cases, MR/for 9 cases and pulmonary artery angiography for 7 cases. All 66 patients had non - specific clinical manifestations with specific changes in electrocardiogram, and most of them had increased cardiac troponin levels but a few cases had increased cardiac enzyme levels. Conclusions ① The main reasons that APE is prone to be misdiagnosed as acute coronary syndrome are non - specific clinical manifestations, changes of electrocardiogram such as T wave deep inversion, and S Ⅰ QⅢ TⅢ type, increased cardiac troponin and cardiac enzyme levels in most PE patients;②Careful and full examination, blood gas analysis, D - dimmer measure and color Doppler echocardiography will contribute to differential diagnosis, and examinations of pulmonary ventilation/perfusion scanning, spiral computed tomography would be helpful to early treatment.