急性主动脉夹层早期快速诊断及用药的选择

Early rapid diagnosis and rational choice of the first-line agents for acute aortic dissection in the emergency department： ses

目的 探讨急性主动脉夹层（acute aortic dissection,AAD）早期快速诊断及在急诊部处置时早期急救药物的合理选择.方法 回顾性分析2007年3月至2013年3月360例患者的临床资料,并对338例疑似AAD的患者分别进行胸片、经胸超声心动图（transthoracic echocardiography,TTE）及计算机体层摄影血管造影（computed tomography angiography,CTA）检查,以手术结果为金标准,对每种诊断手段分别进行验证并比较其诊断潜能.结果 胸片、TTE及CTA对AAD术前诊断的敏感性分别为64％、77％、100％;特异性分别为86％、90％、100％;准确性分别为70％、78％、100％;阳性预测值分别为93％、99％、100％;阴性预测值分别为46％、27％、100％.对疑似AAD的所有患者,首选急诊床边无创性TrE或CT初步筛查,再进一步行CTA检查确诊是最佳选择.早期及时确诊,镇痛、通过速效短时的血管舒张药降压及用p受体阻滞剂减慢心率是早期治疗的关键.小剂量冬眠疗法是一种有益的辅助治疗,早期联合用药比单一用药降压效果好.本组242例治愈,42例死亡,死亡原因为夹层破裂失血性休克及多器官功能衰竭等.结论 AAD是最常见心血管潜在的灾难性疾病,发生率少但比较致命,医生诊断时应提高警惕.早期快速诊断是治疗关键,联合使用TTE、CTA及磁共振血管造影（magnetic resonance angiography,MRA）检查有助于确诊.及时正确的诊断和早期严格降压治疗是减少病死率,改善预后的重要因素.

Objective To explore the rapid diagnosis and the rational chice of the first-line agents for acute aortic dissection （AAD） in the emergency department.Methods The clinical data of 360 patients with AAD treated at our hospital from March 2007 to March 2013 were retrospectively analyzed.Of them,338 patients with suspected AAD were examined by chest radiography,trans-thoracic echocardiography （TTE）,and computed tomography angiography （CTA） successively.The reliabilities of results from each diagnostic method were verified by the ＂gold standard＂ of intra-operative findings and the comparisons of their diagnostic potential were carried out.Results The preoperative diagnostic sensitivity of chest radiography,TTE and CTA in the assessment of AAD were 64%,77% and 100%,respectively;the specificity is 86%,90% and 100%,respectively;the accuracy rats were 70%,78% and 100%,respectively;the positive predictive values were 93%,99% and 100%,respectively;the negative predictive values were 46%,27% and 100%,respectively.In the work-up of any patient with suspected AAD,the emergency bedside non-invasive TTE or computed tomography was the first-line initial diagnostic screening,and the best method for the accurate diagnosis of AAD was CTA.Medical management included pain control and deliberate hypotension therapy by using rapidly short-acting vasodilator and beta blockers to lower heart rate,and the hibernation therapy in small dose of specific agents might serve as a useful adjuvant method,and the early combination of vasodilatation medicines was better than the single one.Of them,242 patients fortunately survived on treatment,and 42 died of hypovolemic shock after rupture of AAD and multiorgan failure.Conclusions Acute aortic dissection is the most potentially life-threatening cardiovascular disease,though it is extremely rare in the hypertensive patients,attending doctors should pay more attention.Early rapid diagnosis is the key to AAD treatment.The best method for correctly diagnosing AAD is complementary use of TTE,CTA and magnetic resonance angiography （MRA）.Correct and timely diagnosis and strictly deliberate hypotension treatment are the essential determinant of decreasing mortality and improving prognosis of AAD.