中国与欧美Takotsubo综合征患者临床特征的比较

Comparison on the clinical characteristics of patients with Takotsubo syndrome from China and from Europe/North America

目的总结中国Takotsubo综合征(TTS)患者的临床特征,并与欧美患者进行比较,分析二者的异同。方法该研究为病例汇总分析。以“应激性心肌病”“心尖气球样变综合征”“心碎综合征”“Takotsubo综合征”“Takotsubo syndrome”“stress cardiomyopathy”为关键词,检索万方数据、中国知网、Pubmed和Web of Science数据库1990至2020年发表的相关文献,剔除非病例报道、诊断错误、信息不全的文献,最终纳入文献1294篇,其中128篇文献报道了163例中国病例,1166篇文献报道了1256例欧美病例。提取纳入病例的人口学、诱因、症状、心电图、超声心动图、左心室造影、冠状动脉造影、治疗及预后等信息,分析中国TTS患者的临床特征,并与欧美患者进行比较。结果研究纳入163例中国TTS患者,1256例欧美患者。中国TTS患者的年龄为(59.6±16.9)岁,与欧美患者的(59.7±17.4)岁相当(P=0.90),女性患者的比例则低于欧美[128例(78.5%)比1073(85.4%),P=0.02]。中国TTS患者的诱因以精神应激为主[79例(48.5%)],躯体应激者71例(43.6%),13例(7.9%)患者无明显诱因。与欧美比较,中国TTS患者精神应激比例较高,而躯体应激和无诱因者比例较低(P均<0.05)。中国TTS患者的主要症状依次为胸痛[86例(52.8%)]、胸闷[57例(35.0%)]、气促[54例(33.1%)]、头晕[26例(16.0%)]、出汗[25例(15.3%)]、心悸[20例(12.3%)]、晕厥[15例(9.2%)]、腹痛/腹泻[14例(8.6%)]、低血压[12例(7.4%)]和乏力[2例(1.2%)]。与欧美比较,中国TTS患者胸闷、头晕、出汗、心悸、腹痛/腹泻的比率较高,而低血压的比率较低(P均<0.05)。中国TTS患者心电图表现以心肌缺血样改变为主,包括ST段抬高104例(63.8%)、T波倒置75例(46.0%)和ST段压低14例(8.6%)。与欧美比较,中国TTS患者ST段抬高、T波倒置和房室传导阻滞的比率较高(P均<0.05)。超声心动图检查示,中国TTS患者主要表现为心尖部运动障碍[97例(59.5%)]、心尖/左心室球囊样扩张[59例(36.2%)]。与欧美比较,中国TTS患者心尖/左心室球囊样扩张、心尖部运动障碍、二尖瓣反流的比率较高,而其他部位运动障碍、左心室射血分数<50%的比率较低(P均<0.05)。左心室造影示中国TTS患者心尖部运动障碍比率高于欧美(P<0.01),而心尖/左心室球囊样扩张的比率相近(P>0.05)。冠状动脉造影示中国TTS患者冠状动脉无狭窄或狭窄<50%者142例(87.1%),与欧美相当(P>0.05)。中国TTS患者以典型者为主[157例(96.3%)],其次为双室型[5例(3.1%)]、倒置型[1例(0.6%)];典型患者的比率高于欧美,而倒置型、室中型的比率较低(P均<0.01)。中国TTS患者的常用治疗药物依次为β受体阻滞剂[67例(41.1%)]、抗血小板药[61例(37.4%)]、血管紧张素转化酶抑制剂/血管紧张素Ⅱ受体阻滞剂[59例(36.2%)]、抗凝药[44例(27.0%)]和利尿剂[32例(19.6%)]。与欧美比较,中国TTS患者使用抗血小板药、抗凝药、调脂药、利尿剂、硝酸盐类药物的比率较高(P<0.05)。两组患者氧疗和主动脉内球囊反搏的使用率相近(P均>0.05)。中国TTS患者的院内死亡率为5.5%(9/163),平均随访1年,期间复发率为3.7%(6/163),无死亡事件发生,与欧美比较差异均无统计学意义(P均>0.05)。结论中国TTS患者中中老年女性占比较高,大部分患者有精神或躯体应激,以典型的影像学表现为主,有一定的院内死亡率和复发率。相对于欧美患者,中国TTS患者有其特殊性。

Objective To summarize the clinical characteristics of patients with Takotsubo syndrome(TTS)from China and compare these features with patients from Europe/North America.Methods We reviewed case reports published between 1990 and 2020 with the key words of"Takotsubo syndrome""stress cardiomyopathy""apical balloon syndrome"and"broken heart syndrome",in Wanfang,CNKI,Pubmed and Web of Science databases,and 1294 articles were identified,including 128 articles reporting 163 cases in China and 1166 articles reporting 1256 cases in Europe/North America.The characteristics of demographics,triggers,symptoms,electrocardiogram,echocardiography,left ventriculogram,coronary angiography,treatment and prognosis were analyzed and compared between Chinese and European/North American cases.Results A total of 1294 articles(1419 cases:163 from China,1256 from Europe/North America)were included in the final analysis.The characteristics of Chinese cases included:(1)demographic:the age was(59.6±16.9)years,which was similar with that of European/North American((59.7±17.4)years,P=0.90),and female accounting for 78.5%(128/163),which was lower than that of European/North American(85.4%(1073/1256),P=0.02).(2)Triggers:mental triggers accounted for 48.5%(79/163),physical triggers accounted for 43.6%(71/163),and no triggers accounted for 7.9%(13/163),respectively.Compared with Europe/North America,the ratio of patients with mental triggers was higher in China,while the ratio of patients with physical triggers and no triggers was lower(P<0.05).(3)Symptoms:chest pain(52.8%(86/163)),chest tightness(35.0%(57/163)),shortness of breath(33.1%(54/163)),dizziness(16.0%(26/163)),sweating(15.3%(25/163)),palpitations(12.3%(20/163)),syncope(9.2%(15/163))abdominal pain/diarrhea(8.6%(14/163)),hypotension(7.4%(12/163)),and fatigue(1.2%(2/163))were illustrated in sequence.Compared with patients in Europe/North America,the ratio of patients with chest tightness,dizziness,sweating,palpitations,abdominal pain/diarrhea was higher in Chinese patients,while the ratio of patients with hypotension was lower in Chinese patients(P<0.05).(4)Electrocardiogram:main manifestations were myocardial ischemia symptoms,such as ST-segment elevation(63.8%(104/163)),T wave inversion(46.0%(75/163)),ST-segment depression(8.6%(14/163)).Compared with European/North American,the ratio of patients with ST-segment elevation,T wave inversion,and atrioventricular block was higher in Chinese patients(P<0.05).(5)Echocardiography and imaging:apical dyskinesia(59.5%(97/163))and apical/left ventricular bulbar dilation(36.2%(59/163))dominated the echocardiography findings.Compared with European/North American,the ratio of patients with apical dyskinesia,apical/left ventricular bulbar dilation,and mitral regurgitation was higher in Chinese patients,while the ratio of patients with dyskinesia in other parts and left ventricular ejection fraction<50%was lower in Chinese patients(P<0.05).Left ventricular angiography showed 36.2%(59/163)of apical dyskinesia in Chinese patients,which was higher than that reported in European/North American patients,and 38.7%(63/163)of apical/left ventricular bulbar dilation was reported in Chinese patients,which was similar to that reported in European/North American patients.Coronary angiography showed percent of no stenosis or stenosis less than 50%was 87.1%(142/163),which was similar to that reported in European/North American patients(P>0.05).The typical type of TTS accounted for 96.3%(157/163),which was significantly higher than that reported in European/American patients,while the ratio of basal type and midventricular type was lower(P<0.01).(6)Treatment and prognosis:the applied drugs in China were listed in order as following,β-blockers(41.1%(67/163)),antiplatelet agents(37.4%(61/163)),ACEI/ARB(36.2%(59/163)),anticoagulants(27.0%(44/163)),diuretics(19.6%(32/163)),etc.Compared with Europe/North America,the ratio of antiplatelet agents,anticoagulants,statins,diuretics,and nitrates use was higher in China(P<0.05),while the use of oxygen therapy and IABP was similar(P>0.05).The hospital mortality in China was 5.5%(9/163),during 1-year follow-up the recurrence rate was 3.7%(6/163)and the mortality was 0.The prognosis was similar with that in Europe/North America.Conclusions Compared with TTS cases in Europe/North America,TTS cases in China also occur usually in middle-aged and elderly women,most of whom have mental/physical triggers and typical imaging manifestations,followed by a low hospital mortality rate and recurrence rate.