應激性心肌病

StressCardiomyopathy，SC

Diagnosis,Pathophysiology,Management,andPrognosis12020/3/15History1991年日本學者Dote等報道心理或軀體應激狀態可以誘發一過性左心室功能不全，由于在收縮末期左心室造影呈底部圓隆、頸部狹小的圖像，類似日本古代捉捕章魚的簍子，而被命名為“Tako-tsudo”(章魚瘺)心肌病1997年法國的心臟病學家DominiquePavin報道了2例類似的病例，指出應激狀態時兒茶酚胺水平升高和該病明顯相關，并且提出了應激性心肌病的概念2006年AHA關于心肌病的科學聲明中，將其分類為一種獨立的心肌病，正式命名為應激性心肌病22022/10/28DefinitionSCisareversiblecardiomyopathy,with

aclinicalpresentationmimickingAcutecoronarysyndromeintheabsenceofsignificantcoronaryarterydiseaseTako-tsubo

cardiomyopathy,ApicalBallooningsyndrome,and

ampulla

cardiomyopathyBrokenHeartsyndrome，TransientCardiacBallooningsyndrome應激性心肌病是應激因素誘發的類似急性冠脈綜合征臨床表現，伴有可逆性左室收縮功能障礙的一種臨床綜合征32022/10/28MayoCriteriaTransienthypokinesis,akinesis,ordyskinesisintheleftventriclemidsegmentswithorwithoutapicalinvolvement,regionalwallmotionabnormalityextendingbeyondasingleepicardialvasculardistribution,thepresenceofastresstrigger

左心室心尖和中部區域室壁運動短暫、超出單一血管供血范圍的可逆性收縮功能喪失或異常，并存在應激因素CriteriaproposedbytheMayoClinicin2004andmodifiedin200842022/10/28Absenceofobstructivecoronarydiseaseorangiographicevidenceofacuteplaquerupture

冠脈造影示冠狀動脈管狹窄程度＜50%，或無急性斑塊破裂證據Newelectrographicabnormalitiesand/ormodestelevationinserumcardiacenzymes

新出現心電圖異常或心肌酶學輕度升高Absenceofpheochromocytomaormyocarditis

排除嗜鉻細胞瘤、心肌炎All4criteriamustbepresent52022/10/28INCIDENCETheincidenceofSCislikelyunderrecognizedApproximately1%to2%ofpatientspresentingwithaninitialdiagnosisACSactuallyhaveSC發病率不明確，1%-2%的ACS患者實為SCUnderestimatedforavarietyofreasons：nonavailabilityofcardiaccatheterizationfacilitiesinmanyregionsthepossibilityfornoncardiacpresentationlackofaconsensusofdiagnosticcriteriamaycontributetomisdiagnosis62022/10/28PRESENTATIONItoccursmostcommonlyinpostmenopausalWomen（90%）,

meanagebetween58and75yrsSCseemstohaveanassociationwithhypertension,COPD,andbronchialasthmaSCmimicsACSinmostpatients，acutesubsternalchestpainanddyspnea

.shock,syncope,andcardiacarresthavebeenreportedrarely2/3ofpatientswithemotionalorphysicalstress72022/10/28ECGFINDINGSSTelevationintheprecordial

anddiffuseTwavearethemostcommonfindings胸前導聯ST段抬高及多導聯T波倒置最為常見82022/10/28DifferentiateSCfromanteriorSTEMIPresenceofSTsegmentdepressioninleadavRandabsenceofSTsegmentelevationinleadV1identifiedSCwith91%sensitivity,96%specificity,and

95%predictiveaccuracy92022/10/28LABORATORYFINDINGSElevationsintroponinandcreatine

kinaseMBaretypicallymild

SeverehemodynamiccompromiseisoutofproportionandincontrasttothedegreeofcardiacenzymeelevationTroponinTlevelsrangedfrom0.01to5.2ng/mL102022/10/28CARDIACCATHETERIZATIONCoronaryangiographyLeftventriculographyARAOendsystolicleftventriculogramintypicalvariant(apicalballooning)ofSC.BRAOend-diastolicventriculogramintypicalvariantofSC.CRAOend-systolicleftventriculograminatypicalvariant(basalballooning)ofSC.DRAOend-diastolicventriculograminatypicalvariantofSC.112022/10/28122022/10/28IMAGINGEchocardiographyventricularballooning，wallmotionabnormalities，decreaseinEFNuclearImagingusingTc-99m，impairmentofmyocardialperfusionMagneticResonanceImagingpatientswithSCdonotshowhyper-enhancementondelayedcontrastenhancementMRI132022/10/28PATHOPHYSIOLOGYThecausalmechanismsremainuncertain機制不明確Stunnedmyocardiumresultingfrombriefperiodsofischemiaowingtovasospasmisonepossibility心肌頓抑（冠脈痙攣引起短暫心肌缺血所致）是一種可能的機制142022/10/28Coronarymicrovascular

dysfunction冠狀動脈微血管功能障礙

Increasingplasmalevelsofcatecholamines交感神經過度興奮和血漿兒茶酚胺水平增高Reductioninestrogenlevelsfollowingmenopause雌激素水平降低152022/10/28MANAGEMENTThetreatmentofpatientswithSCismainlysupportive

目前尚無標準化的治療方案,去除誘發因素很關鍵,加強對癥支持治療Patientswithshock,cautioususeofinotropicagentssuchasdobutamineanddopamine

謹慎使用β受體興奮劑以及多巴胺或多巴酚丁胺，必要時可考慮IABP支持ItisreasonabletotreatSCwithβ-blocker,ACEinhibitorandifpulmonaryedemaevelops,diuretics

β受體阻滯劑、ACEI或ARB被推薦使用，β受體阻滯劑可預防2.7%-8%的病人復發162022/10/28PROGNOSISSChasafavorableprognosiswithin-hospitalmortality1%,withdeathmorecommoninthesettingofoutflowobstructionThe4-yearrecurrencerateofSChasbeenreportedtobe11.4%,butwithoutanysignificantdifferenceinsurvivalinanageandgender-matchedpopulationoverthesameduration

SC長期預后相對較好,避免情緒激動,在預防復發中非常重要172022/10/28CaseReview王得清，男/66歲，

住院號：654098主訴：胸痛2天，暈厥一次現病史：2013.11.2日突發胸痛，位于下段胸骨后，壓迫感，持續約半小時好轉，于當地診所診治過程中突發黑朦、暈厥，數秒后意識恢復。11.3日14:00再發胸痛，性質同前，程度較前劇烈伴出汗，持續不能緩解，當地醫院診斷“AMI”，給予藥物治療（ASA300mg,波立維300mg,立普妥20mg）及杜冷丁肌注后好轉。182022/10/28既往史、個人史及家族史無特殊。入院查體：T36.6℃，P98bpm，R20bpm，BP140/80mmHg，肺部以及查體無陽性體征；HR104次/分，律絕對不齊，S1強弱不等，各瓣膜聽診區未聞及雜音；雙下肢無水腫院前輔助檢查：2013年11月4日我院ECG:1.心房顫動2.前壁導聯ST-T改變。UCG:1.雙房擴大室間隔,左室前壁室壁運動幅度減低,三尖瓣輕度反流,左室收縮功能稍減低,心包腔少量積液心律不齊;2.