心脏磁共振钆对比剂延迟强化的临床意义及判断预后的价值

钆对比剂延迟强化磁共振成像(LGE-MRI)具有高度的组织特异性和良好的空间分辨力,能够准确识别梗死心肌或瘢痕组织。钆对比剂延迟强化(LGE)可见于缺血性心脏病,如急性或慢性心肌梗死,也可见于非缺血性心肌病、炎症性心脏病和浸润性心肌病。延迟强化的有无及其部位和程度在心血管疾病的诊断、治疗和预后判断方面起着重要作用。     

应激性心肌病与急性心肌梗死患者肌钙蛋白检查结果差异性

目的分析应激性心肌病与急性心肌梗死患者肌钙蛋白检查结果差异性。方法收集分析本院2018年1月至2020年6月收治的10例应激性心肌病患者(应激性心肌病组)以及100例急性心肌梗死患者(急性心肌梗死组)临床资料,对两组患者肌钙蛋白(肌钙蛋白T、肌钙蛋白I)、心肌酶谱(ALT、AST、CK、CK-MB、LDH)、心电图表现(I导联抬高、aVL导联抬高、V2-V5导联ST段抬高)进行对比,利用Spreaman相关性分析法检验以上指标与应激性心肌病的相关性,绘制受试者工作特征曲线计算应激性心肌病与急性心肌梗死肌钙蛋白的cut-off值。结果两组患者肌钙蛋白检测结果比较,应激性心肌病组CTNT及CTNI值分别为(0.46±0.05)μg/L,(3.67±0.41)μg/L,高于急性心肌梗死组的(1.27±0.11)μg/L,(24.38±1.42)μg/L,差异有统计学意义(P<0.05),心肌酶谱检测结果、心电图表现相比较,差异无统计学意义(P>0.05);Spreaman相关性分析结果显示,肌钙蛋白与应激性心肌病有关,心肌酶谱、心电图表现与与应激性心肌病无关;受试者工作特征曲线显示:应激性心肌病与急性心肌梗死肌钙蛋白T的cut-off值为0.97μg/L、肌钙蛋白I的cut-off值为7.71μg/L。结论肌钙蛋白检查结果可以作为应激性心肌病、急性心肌病梗死的初步诊断。     

The prehospital electrocardiogram

Although widely used in Europe, the prehospital 12-lead electrocardiogram (EKG) has seen only limited use in this country. Reported benefits of the 12-lead EKG include shortening the door-to-needle time, accelerating the initiation of reperfusion therapy, and overall improving the prehospital and hospital management and outcome of patients with acute myocardial infarction. The field EKG also provides the basis for prehospital fibrinolysis. Concerns still exist, however, regarding the best means of providing real-time field interpretation of the prehospital EKG and the potential for inappropriate field time delay, triage, and treatment of patients. Moreover, questions remain about the overall clinical and cost benefit of expanding this resource universally. The following article reviews the role of prehospital EKG in caring for patients with acute coronary syndromes.     

Differential diagnosis of the association of gastrointestinal symptoms and ST segment elevation,in the absence of chest pain

This is a review of the underlying causes of the association of ST segment elevation and gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and anorexia, in patients who do not have chest pain. The review was based on anecdotal reports in Googlescholar and Pubmed using the search terms, abdominal pain, nausea, vomiting, anorexia, ST elevation, myocardial infarction, and Takotsubo cardiomyopathy. Those patients who did not have acute myocardial infarction as the cause of the association of ST segment elevation and gastrointestinal symptoms were compared with counterparts with similar symptoms who had well authenticated acute myocardial infarction or Takotsubo cardiomyopathy as the underlying cause of ST segment elevation. The underlying causes of gastrointestinal symptoms which could be associated with ST segment elevation in the absence of either acute myocardial infarction or Takotsubo cardiomyopathy comprised pneumonia, pulmonary embolism, perforated gastric ulcer, intestinal obstruction, acute appendicitis, acute pancreatitis, acute cholecystitis, pheochromocytoma, bacterial meningitis, diabetic keto acidosis, and cannabis abuse. However, each of those disorders could also coexist either with acute myocardial infarction or with Takotsubo cardiomyopathy. The coexistence of ST segment elevation and gastrointestinal symptoms(without chest pain) was also documented in patients with esophageal perforation, mesenteric ischaemia, aortic dissection, Kounis syndrome, and in electrolyte disorders. In the context of presentation with gastroenterological symptoms but without concurrent chest pain, echocardiography appeared to be useful in distinguishing between “pseudo” myocardial infarction characterised by ST segment elevation in the absence of cardiac disease vs ST segment elevation attributable either to acute myocardial infarction or to Takotsubo cardiomyopathy.     

Electrocardiographic manifestations: acute inferior wall myocardial infarction

The 12-lead electrocardiogram (EKG) is an important tool in evaluating the patient with acute myocardial infarction (MI). Patients with acute inferior wall myocardial infarction (IWMI) represent a heterogeneous group in terms of morbidity, mortality, Emergency Department (ED) management, and site of occlusion in the culprit coronary artery. The standard 12-lead EKG, right-sided chest leads and posterior chest leads, in conjunction with clinical findings often provide the necessary information for the Emergency Physician (EP) to predict complications, morbidity and mortality. IWMI patients may have associated right ventricular infarction (RVI) or lateral and posterior wall extension. Each of these entities is associated with specific hemodynamic abnormalities and increased mortality. In addition, various atrioventricular (AV) blocks are commonly associated with IWMI. This article presents several cases of IWMI with EKGs and a discussion of EKG interpretation in the setting of IWMI.     

Tako Tsubo cardiomyopathy in a patient with multiple trauma

Tako Tsubo cardiomyopathy has been described in a variety of stress situations, including several critical illness settings. We report the first case of this syndrome in a patient with multiple trauma. Tako Tsubo is an unusual cause of circulatory failure in such patients, to be distinguished from myocardial contusion and myocardial infarction. Prolonged ST segment elevation on EKG, minor troponin release, and transient left ventricular apical ballooning on transthoracic echocardiography are among the features to be recognized. Full recovery occurs spontaneously within several weeks.     

脑-心综合征419例临床分析

急性脑血管病时约30％病例发生急性心肌梗死或冠状动脉供血不足、心律失常。本组资料显示,77.2％(419/543)发生脑-心综合征。据分析与急性脑血管病后意识障碍程度、病变部位、血糖及电解质变化等因素相关。出血量大于60ml或/及破入脑室者脑心综合征的发病率明显增多。心电图改变类型,急性脑出血组以ST段、T波改变及窦性心动过速为主,脑梗死组主要以ST段及T波改变和窦性心动过缓比较明显,两组均可发生心肌梗死。本组资料显示:脑-心综合征的发生与急性脑血管愈后呈正相关。一旦出现脑-内脏联合综合征,死亡率达80％以上。     

Electrocardiographic ST-segment elevation: Takotsubo cardiomyopathy versus ST-segment elevation myocardial infarction—A case series

Takotsubo cardiomyopathy, or left ventricular apical ballooning syndrome, is a newly described disorder in which patients develop anginal symptoms, often times with acute congestive heart failure, during periods of stress. The electrocardiogram demonstrates ST-segment and/or T-wave abnormalities similar to those findings seen in acute coronary events; on occasion, serum markers can be abnormal. As an extreme, acute pulmonary edema with or without cardiogenic shock can also be encountered. At cardiac catheterization, these patients are found to have abnormal left ventricular function yet normal coronary arteries. We compared 2 populations encountered in the emergency department (ED) population—Takotsubo cardiomyopathy and ST-segment elevation myocardial infarction. In the ED, features of the presentation and management were similar between the 2 groups with the exception of the presence of female sex and abnormal QT interval occurring more often in Takotsubo cardiomyopathy subgroup. These 2 cardiovascular maladies present in very similar fashion in the ED; distinction in the ED may not be possible.     

Electrocardiographic manifestations: right ventricular infarction

The 12-lead electrocardiogram (EKG) is an essential tool when evaluating the Emergency Department (ED) patient with suspected cardiac ischemia. The standard EKG has limitations when evaluating "remote" areas of the heart such as the left posterior wall or right ventricular wall. Diagnosis of right ventricular infarction (RVI) in the presence of acute inferior wall myocardial infarction (MI) is made utilizing right-sided chest leads with high sensitivities and specificities. RVI is a serious ED problem because morbidity and mortality is higher in acute MIs associated with RVI.     

Thunderclap headache as the presenting symptom of myocardial infarction

Headache as the presenting symptom of myocardial ischemia has been reported in more than 20 cases. These headaches have been described as of gradual onset, associated with exertion and with EKG changes. We present herein the first case of thunderclap headache occurring at rest as the sole symptom of an acute myocardial infarction.     

Takotsubo cardiomyopathy mimicking an acute myocardial infarction

BACKGROUND: Takotsubo cardiomyopathy is characterized by a transient left ventricular dysfunction. The resulting acute symptoms including electrocardiographic changes and elevated myocardial biomarkers often mimic an acute myocardial infarction. However, obstructive coronary artery disease can be excluded by angiography. There is only little information available in the literature. The precise pathophysiology is still unknown. CASE REPORT: The case of a 56-year-old woman with typical manifestation of a highly symptomatic Takotsubo cardiomyopathy is described. The diagnosis was suspected by angiographic absence of obstructive coronary disease. During the following days, Takotsubo cardiomyopathy was confirmed by cardio-MRI and echocardiography. The patient was treated with drugs. 12 days after admission, cardiac function was completely restored. The patient was discharged without showing any symptoms. CONCLUSION: Although takotsubo cardiomyopathy is rather rare, it should be considered as a relevant differential diagnosis mimicking acute myocardial infarction. Despite a generally good prognosis under conservative treatment, complications are reported in 17.7% of all cases in the literature. Therefore, intensive treatment and monitoring are mandatory.     

酷似心肌梗死的心电图预激心电分析

[目的]分析酷似心肌梗死心电图的预激综合征（WPW）体表心电图（EKG）的特征.[方法]15例诊断为WPW患者,其中5例EKG表现酷似心肌梗死,均行心脏电生理检查（EPS）明确旁道位置.[结果]5例酷似心肌梗死的WPW综合征中：2例为左侧壁房室旁道、2例为左后壁房室旁道、1例为后间隔房室旁道.[结论]不同房室旁道位置会导致EKG出现类似心肌梗死表现,临床工作中应予以重视     

Persistent ST segment elevation: a new ECG finding in hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy is a primary disease of myocardium resulting in myocardial hypertrophy without any inciting pressure or volume overload. The typical triad of symptoms includes exertional angina, syncope, and shortness of breath. Sudden cardiac death, the most dreadful complication of this disorder, can be the first manifestation of the disease and is more common in young patients. Elderly patients, on the other hand, may have a relatively benign course with normal or near-normal life span. The electrocardiogram (ECG) and echocardiography are the two most useful measures to diagnose hypertrophic cardiomyopathy. The electrocardiographic features of hypertrophic cardiomyopathy are numerous, including ST segment elevation that may simulate other ST segment elevation syndromes, including acute myocardial infarction, variant angina pectoria, acute pericarditis, bundle branch blocks, ventricular paced rhythm, dyskinetic ventricular segment, ventricular aneurysm, left ventricular hypertrophy, Wolff-Parkinson-White syndrome, and early repolarization syndrome. This report describes a case of an asymptomatic patient who presented with ST segment elevation of acute injury type and, therefore, was admitted to rule out silent myocardial infarction. Myocardial infarction was ruled out by cardiac enzyme levels, but ST segment elevation remained persistent in all of the subsequent ECGs. Echocardiography was performed, which clearly showed hypertrophic cardiomyopathy with left ventricular outflow tract obstruction and a high intracavity pressure gradient. Subsequently, retrieval of old ECGs showed a similar type of ST segment elevation in the patient's previous ECGs.     

应激性心肌病1例分析

休克在重症患者中是很常见的,以往认为心源性休克多源自于急性冠状动脉事件,同时,感染性休克患者也可合并心肌抑顿,导致心源性休克。上述两种情况一旦出现,往往预后不良,但2007年初我们收治了1例心源性休克的患者,并不是由于急性心肌梗死或严重感染等情况所致,更富有戏剧性的是经过支持治疗,该患者的心脏功能在短期内完全恢复。经过文献回顾我们认为,患者应考虑合并了应激性心肌病,该疾病在重症医学领域少有报道,但由于此类患者的心脏功能经过积极干预可在短期内痊愈,此点不同于其他原因引起的心源性休克,故我们应提高对应激性心肌病的认识,早期诊断、积极干预,争取患者的良好预后。     

Electrocardiographic manifestations: patterns that confound the EKG diagnosis of acute myocardial infarction-left bundle branch block, ventricular paced rhythm, and left ventricular hypertrophy

The 12-lead electrocardiogram (EKG), a powerful tool used in evaluating the chest pain patient, has its shortcomings. One such failing is encountered in a patient with one of the following electrocardiographic patterns: left bundle branch block (LBBB), ventricular paced rhythm (VPR), and left ventricular hypertrophy (LVH). These patterns reduce the ability of the EKG to detect acute coronary ischemic change and acute myocardial infarction (AMI). Several strategies are available to assist in the correct interpretation of these complicated electrocardiographic patterns, including a knowledge of the ST segment-T wave changes associated with these confounding patterns, performance of serial EKGs, and comparison with previous EKGs if available. This article suggests guidelines and interpretive tools for diagnosing AMI on EKG in patients with these confounding patterns.     

Treatment of the patient with acute myocardial infarction: reducing time delays

There is a critical relationship of time to treatment and myocardial salvage in the patient with acute myocardial infarction (AMI). The challenge lies in developing a process that minimizes delays in assessment and initiation of reperfusion therapy. Three target areas were identified-time to EKG. thrombolytic therapy, and primary PTCA. A multidisciplinary team reviewed the existing standard of care and identified critical areas that were causing delays. An emergency department algorithm was developed to minimize delays, while data analysis tracked our progress. A collaborative multidisciplinary effort can reduce delays in the treatment for the patient with AMI.     

Takotsubo or stress cardiomyopathy: role of nuclear cardiology using 123I-MIBG

Takotsubo cardiomyopathy, also known as broken heart syndrome or stress cardiomyopathy, is a very interesting syndrome of acute transient left ventricular dysfunction, usually following significant emotional stress. It was first described in Japan nearly two decades ago and many aspects of its pathogenesis still remain poorly understood. The incidence of out-of-hospital sudden death related to Takotsubo is currently unknown. Excess catecholamines following stress seem to trigger Takotsubo and play an important role. The clinical presentation resembles acute myocardial infarction, including chest tightness and/or dyspnea, ECG changes and elevated cardiac enzymes. However, in contrast to a typical acute myocardial infarction, no significant coronary lesions or thrombi are found on coronary angiography. Differentiating Takotsubo from acute myocardial infarction is important to avoid the unnecessary risks of thrombolytic therapy. Typically, left ventriculography shows marked abnormalities with akinesia in the mid-distal anterior wall and apex (occasionally involving other heart regions), giving a balloon shape to the left ventricle. The name Takotsubo originates from the shape of the left ventricle, which resembles a Japanese octopus-trapping pot. Hospital mortality is low but death can be caused by severe acute heart failure and/or ventricular arrhythmias. Typically, a stressful life event is reported preceding the acute symptoms. Takotsubo is most common in menopausal women although young individuals, including men, can also be affected. The autonomic nervous system has a defined role in the process. In this article, we will review the role of imaging the heart using ¹²³I-meta-iodobenzylguanidine, a radioactive marker allowing mapping of the autonomic nervous system of the heart, in cases of suspected Takotsubo.     

Distinguishing a heart attack from the "broken heart syndrome" (Takotsubo cardiomyopathy)

Takotsubo cardiomyopathy (TC) is a neurocardiological disorder presumed to be triggered by stress, which may cause reversible heart failure, usually in postmenopausal women. It may mimic an acute myocardial infarction, accompanied by minimal elevation of cardiac enzymes, usually without evidence of obstructive coronary artery disease. Most clinicians are unfamiliar with this disorder. Therefore, some TCs are misdiagnosed as acute myocardial infarction. The modified Mayo Clinic criteria usually confirm a diagnosis, although the diagnostic criteria for TC remain controversial. Enhanced awareness by clinicians is important when encountering patients with chest pain and elevated cardiac enzymes. Takotsubo cardiomyopathy is usually associated with a favorable prognosis, although in rare instances it may be associated with life-threatening complications. Supportive care is especially important in the TC management. Our aim was to describe TC, characterize its clinical features, and extensively review the relevant literature.     

栓塞致扩张型心肌病患者AMI急诊干预一例

冠状动脉急性栓塞导致的AMI在临床工作中并不少见,但常因临床症状的非特异性而导致误诊,最常误诊为缺血性心肌病合并AMI。该文报道1例因突发胸痛就诊于急诊的老年女性,急性非ST段抬高型心肌梗死（ NSTEMI ）诊断明确,合并心脏扩大、心房颤动。初诊为缺血性心肌病合并AMI,后经急诊介入干预,修正诊断为扩张型心肌病合并冠状动脉急性血栓栓塞。并根据其临床及介入干预特点,对该类患者如何识别及如何干预进行了分析和阐述。该例提示急诊介入医生,对于栓塞高危患者发生AMI时,应考虑到冠状动脉栓塞的可能性。     

Future aspects of BMIPP

Iodinated fatty acid compounds have an important role in early detection of myocardial abnormalities and provide insights into pathological states in the heart. Among them, 15-(p-iodophenyl)-3R,S-methyl pentadecanoic acid (BMIPP) has been most widely used providing excellent images of the left ventricular myocardium due to high myocardial uptake and long retention. The previous chapters have focused on the basic characters and clinical applications of this compound. However, the precise mechanisms of myocardial kinetics should be further investigated under various conditions. Most of the studies showed reduced BMIPP uptake relative to perfusion in a variety of myocardial disorders, whereas an increase in BMIPP uptake relative to perfusion is often reported. The potential mechanisms of such conflicting results are discussed, but basic studies should be performed to clarify such results in detail. There are a number of clinical values of this compound. Since alteration of fatty acid is observed in the repetitive ischemia, BMIPP can be used for detecting severe ischemic episodes. The concept of ‘ischemic memory’ imaging can be applied for patients with unstable or vasospastic angina at rest and for those with acute myocardial infarction with successful revascularization to identify the risk area. The discordant decrease in BMIPP uptake relative to perfusion is often seen in ischemic but viable myocardium, and therefore, the combined imaging of BMIPP and perfusion can be used for assessment of tissue viability. Furthermore, abnormal BMIPP uptake is most often observed in hypertrophic cardiomyopathy, and thus, this compound can be used for an early detection and differential diagnosis of the cardiomyopathy. Although BMIPP imaging seems to be quite promising in many fields, the number of patient data remain limited. In this respect, a multicenter study with a vast majority of patients is warranted to confirm these important values of BMIPP. In addition, this attractive tracer should be available all over the world to confirm its clinical value in the near future.