冠状动脉痉挛合并粥样硬化性狭窄患者的临床特点分析及诊治策略

Clinical characteristics analysis,diagnosis and treatment strategies for patients with coronary artery spasm complicated with atherosclerotic stenosis

目的分析冠状动脉痉挛(coronary artery spasm,CAS)合并粥样硬化性狭窄患者的临床特点,并依患者的病情特点选择个体化诊治策略。方法采取回顾性研究方法,选取玉林市第一人民医院2015年6月至2016年5月期间收治且被确定为存在CAS同时合并粥样硬化性狭窄(固定狭窄)的患者36例作为研究对象。主要分析其危险因素、临床症状、心电图表现、冠状动脉造影(CAG)结果等情况,以及经药物治疗或联合支架植入术后的疗效。结果 36例患者中有30例(83.3%)存在长期大量吸烟习惯,15例(41.7%)血液中高敏C-反应蛋白(high sensitivity C-reactive protein,hs-CRP)浓度偏高于正常范围值,3例(8.3%)存在血压偏低或处于临界值状态。36例患者中15例(41.6%)胸痛表现明显,且其症状出现时心电图有典型的ST段抬高或明显压低的缺血表现;18例(50%)胸闷胀;3例(8.3%)无明显症状。冠状动脉造影提示CAS明显且同时合并严重狭窄(固定狭窄≥75%)8例,此8例患者均为男性,其中2例年龄<40岁、5例年龄>60岁;8例中有7例(包括2例年龄<40岁)长期大量吸烟;此8例患者均于首次冠状动脉造影后予植入冠状动脉支架,术后常规药物治疗,随访半年随访显示治疗均有效。CAS合并轻-中度狭窄(20%≤固定狭窄<75%)28例,综合考虑均无需植入冠状动脉支架但均尝试药物治疗,观察半年显示治疗有效26例,而其中2例(1男,1女)合并中度狭窄治疗无效,且半年后复查冠状动脉造影提示原固定狭窄程度较前加重,遂予植入冠状动脉支架,术后继续药物治疗,随访半年显示治疗有效。结论对于CAS合并狭窄患者,吸烟为其重要的危险因素,hs-CRP亦为重要的预测因子,而病变严重需植入支架者则与其同时存在年老、糖尿病等其他高危因素有较大关系。药物仍是治疗的有效手段,对于血管痉挛且合并较明显粥样硬化性狭窄的患者,选择药物联合支架植入可获得较良好的疗效,但方案的选择应该个体化。

Objectives To study and analyze the clinical characteristics of patients with coronary artery spasm（CAS） complicated with atherosclerotic stenosis ,and to make diagnosis and treatment strategies according to their disease char-acteristics. Methods Totally 36 hospitalized patients with CAS complicated with atherosclerotic stenosis（fixed steno-sis）in period of June 2015 to May 2016 were retrospectively studied. The risk factors,clinical symptoms,electrocar-diogram manifestations and the results of coronary angiography （CAG） were carefully studied and analyzed. Mean-while,the curative effects by medicine-only or by medicine combined with coronary stenting were observed in these cases. Results Among the 36 cases,30 cases（83.3%）had a long history of smoking,15（41.7%）cases had a high-er concentration of high sensitivity C-reactive protein （hs-CRP） than the normal range value ,and 3 （8.3%） cases were in a relative low or at a critical value state of blood pressure. Of the 36 cases,15 cases（41.6%）showed obvious chest pain and presented a typical and notable ST segment elevation or depression in electrocardiogram when the symp-toms appeared,18 cases（50%）showed chest tightness or chest distension,and 3（8.3%）cases had no chest symp-toms. There were 8 male cases with obvious CAS and severe stenosis （fixed stenosis≥75%） indicated by CAG ,of which 2 cases were younger than 40 years and 5 cases were older than 60 years,and 7 cases（including the 2 cases that younger than 40 years）among them had a long history of smoking. The 8 cases received intracoronary stent implan-tation after primary CAG ,and medications were also given after coronary stenting. An half year follow-up showed that the curative effect of the 8 cases were satisfactory and encouraging. There were 28 cases with CAS and light-moderate stenosis（20%≤fixed stenosis〈75%）had no need of intracoronary stent implantation,but all of them were treated by medication only. After half a year ,26 cases of them received good curative effects ,and 2 cases with moderate stenosis had no expectant curative effect but became satisfactory after intracoronary stent implantation. Conclusions Smoking is a very important risk factor for patients with CAS complicated with atherosclerotic stenosis ,and hs-CRP is also an important predictive factor for them. The severe cases that needed intracoronary stent implantation relate to old age ,dia-bete mellitus ,etc. Medication is still the main and effective way for treating CAS. For patients with CAS complicated with severe atherosclerotic stenosis ,medication combines with intracoronary stenting is an effective way and is worth promoting,but the treatment plans should be individualized.