酷似急性心肌梗死致错误的溶栓的主动脉夹层及文献复习

A case report of aortic dissection similar to AMI led to incorrect thrombolysis and literature review

本文报道一男性患者因典型胸痛、心电图符合急性心肌梗死(acute myocardial infarction,AMI),在外院诊断AMI并给予溶栓治疗后24小时胸痛无缓解转至我院。入院后观察心电图和心肌酶无动态改变,经B超和CT检查证实为主动脉夹层转外科手术。术中见升主动脉瘤样扩张并夹层形成,但未累及冠状动脉,经升主动脉置换术康复。结合文献分析主动脉夹层误诊AMI见于:一是冠脉未受累而出现典型AMI心电图改变,酶学无异常,此类病例误诊甚至溶栓几乎不可避免;其次为冠脉未受累,心电图仅有不典型改变,其胸痛开始就达到高峰,酶学无显著异常,胸片提示胸腔、心包积液或纵膈影增宽等有助于和AMI鉴别;再次为近端主动脉夹层累及冠脉开口,患者同时出现主动脉夹层和AMI,此类患者病情凶险,如无及时外科干预常迅速死亡。注意以上特点有助提高主动脉夹层的诊断水平。

In this paper we reported a case of aortic dissection similar to AMI led to incorrect thrombolysis. A male patient aged fifty had typical chest pain and ECG showed typical characteristic of AMI, and he was diagnosed AMI and received thrombolysis, but the symptom did not released and so he was transported to our hospital. The patient was diagnosed aortic dissection by CT and echocardiogram examination and received operation. In the operation the ascending aortic aneurysm and dissection were found, but the coronary artery was normal. The patient recovered after ascending aorta replacement. The literature review showed that the aortic dissection was misdiagnosed as AMI in three conditions： ①the patient had typical AMI ECG change with normal coronary artery, in the case of which the thrombolysis was almost inevitable carried but incorrect; ②the patient had untypical AMI ECG change with normal coronary artery, in such a case the incorrect thrombolysis should be avoided as far as possible;③the patient had ascending aortic dissection and the coronary artery was involved, and this kind of patient had the worst prognosis.