以心外症状首发的老年急性心肌梗死临床误诊分析

Clinical Misdiagnosis of Acute Myocardial Infarction in the Elderly with Extracardiac Symptoms

目的探讨老年急性心肌梗死(AMI)不典型表现,分析以心外症状首发的老年AMI患者误诊原因及防范措施。方法回顾性分析2020年2月—2023年2月收治的曾误诊的老年AMI 12例的临床资料。结果本组12例,年龄61~75岁。4例因有支气管炎病史,出现咳嗽、胸闷、心悸、呼吸困难、发热,肺纹理增多、增粗,初步诊断为肺炎;8例于饱食高脂肪食物后和饮酒后发病各3例,急性上腹部疼痛、恶心、呕吐,伴发热4例,头晕、乏力和剑突下压痛各3例,腹部B超检查示胆囊壁增厚、毛糙2例,初步诊断为急性肠炎6例、急性胆囊炎2例。误诊时间6~27 h。12例予相应治疗后病情无明显缓解;后经查体及实验室、心电图、冠状动脉造影检查等最终诊断为AMI;皆行冠状动脉介入术治疗;住院10~14 d病情好转出院;随访2~6个月,预后良好。结论老年AMI患者病情复杂多样,早期表现多不典型,以心外症状首发者,若心电图正常或早期未行心电图或心肌酶检查,极易误诊。详细问诊,仔细查体,及时行心电图和心肌酶检查,认真鉴别诊断,全面分析病情,可减少或避免不典型老年AMI误诊误治。

Objective To investigate the atypical manifestations of acute myocardial infarction(AMI)in the elderly,and to analyze the causes of misdiagnosis and preventive measures of AMI patients with extracardiac symptoms.Methods The clinical data of 12 patients with misdiagnosed AMI admitted from February 2020 to February 2023 were retrospectively an⁃alyzed.Results Twelve patients were aged 61⁃75 years.Due to the history of bronchitis,4 patients had cough,chest tight⁃ness,palpitation,dyspnea,fever,increased lung texture,and thickening,and were initially diagnosed with pneumonia.Of 8 patients,3 cases had onset of disease after high⁃fat meal and 3 cases after alcohol consumption.There were 4 patients with a⁃cute upper abdominal pain,nausea and vomiting,accompanied by fever,and 3 cases with dizziness,fatigue and subxiphoid tenderness.Abdominal B⁃ultrasonography showed thickening and rough gallbladder wall in 2 patients,and the preliminary di⁃agnosis was acute enteritis in 6 patients and acute cholecystitis in 2 patients.The duration of misdiagnosis was 6⁃27 h.There was no obvious remission in 12 patients after corresponding treatment.AMI was diagnosed by physical examination,laboratory examination,electrocardiogram(ECG)and coronary angiography.Coronary intervention was performed in all patients.They were hospitalized for 10⁃14 d and discharged with improved condition.They were followed up for 2⁃6 months and the prognosis was favorable.Conclusion AMI in elderly patients is complicated and varied,with atypical manifestations in the early stage,which showed extracardiac symptoms initially.It is more likely to be misdiagnosed if the ECG is normal or the myocardial en⁃zyme test is not performed in the early stage.Detailed interview,careful physical examination,timely ECG and myocardial en⁃zyme examination,careful differential diagnosis and comprehensive analysis of the disease can help reduce or avoid misdiagno⁃sis and mistreatment of atypical AMI in the elderly.