临床诊断急性心梗而冠脉造影正常的24例患者病因分析

Pathogenesis analysis of 24 cases with diagnosed acute myocardial infarction and normal coronary arteriography

目的探讨冠状动脉造影(冠脉造影)正常临床多项指标提示急性心梗(心肌梗死)诊断患者的病因及其相关性。方法 24例入院后有包括心电图在内的两项或两项以上临床指标支持急性心梗诊断,后经冠脉造影检查,造影结果正常,并最终明确诊断的患者,分析其临床特点及病因。结果 24例患者均为初步诊断急性心梗(其中15例为ST段抬高型心梗,9例为非ST段抬高型心梗),其中继发于主动脉瓣狭窄的继发型心梗5例;应激性心肌病又称心尖球囊样综合征,1990年首次在日本被Sato等报道,并命名为Tako-tsubo(章鱼头套样)心肌病,2例;心肌炎4例;继发于主动脉夹层的继发型心梗3例;胆心综合征4例;微血管型心绞痛2例;变异型心绞痛4例。结论依据心梗的诊断标准,典型的临床症状,特征性的心电图改变,结合实验室检查急性心梗可以诊断,但仍有一部分患者符合以上标准,这些患者冠脉造影显示冠状动脉本身并无明显粥样硬化病变,需综合多项临床指标分析多种因素综合考虑,做出正确判断,以免误诊及诊断片面,影响治疗效果。

Objective To investigate the pathogenesis and correlation of acute myocardial infarction supported by number of clinical indicators and normal coronary arteriography.Methods The clinical features and etiology were analyzed in 24 patients with diagnosed acute myocardial infarction. These patients had two or more clinical indicators, including electrocardiogram, showing acute myocardial infarction, while they also had normal coronary arteriography results.Results All 24 cases were diagnosed as acute myocardial infarction （15 cases with ST segment elevation myocardial infarction, 9 cases with non ST segment elevation myocardial infarction）. There were 5 cases of secondary myocardial infarction of aortic valve stenosis. 2 cases of stress cardiomyopathy, known as apical ballooning syndrome, which was reported firstly in Japan in 1990 as Tako-tsubo cardiomyopathy, 4 cases of myocarditis, 3 cases of secondary myocardial infarction in aortic dissection, 4 cases of bilio-cardiac syndrome, 2 cases of microvascular angina, and 4 cases of variant angina pectoris. Conclusion Diagnosis of acute myocardial infarction can be made by diagnostic criteria, clinical manifestations, typical change of electrocardiogram, and laboratory tests. However, there are still some patients who can meet these standards, and their coronary arteriography shows no obvious atherosclerotic lesions. It is necessary to make comprehensive consideration of various clinical indexes and reasons, and to provide right decision, in order to avoid misdiagnosis and incomplete diagnosis that affect curative effect.