变异型心绞痛40例分析

目的 分析变异型心绞痛的临床特点及治疗方法.方法 回顾性分析大庆油田总医院集团五官医院2005-01-2010-12收治的40例变异型心绞痛患者的临床资料.结果 显效24例,有效12例,无效4例.总有效率90％.结论 夜间及清晨时发生胸痛的患者,胸痛时应及时行心电图检查以确定是否为变异型心绞痛,确诊后需及时诊断治疗,钙通道阻滞剂与硝酸酯类药物可有效防止复发.     

经皮冠状动脉介入治疗后冠状动脉痉挛致变异型心绞痛一例

目的分析经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)后反复发作变异型心绞痛的原因及防治措施。方法 本文报告1例先后2次行PCI治疗后反复发作心绞痛。患者6年前因冠心病心绞痛行PCI,术后未坚持抗血小板治疗,6年后经冠状动脉造影检查证实右冠状动脉开口原支架部位90%狭窄,置入药物洗脱支架。但术后仍有胸痛、晕厥发生,再次冠状动脉造影检查证实支架内无血栓形成,提示冠状动脉痉挛所致变异型心绞痛。结果应用地尔硫卓和硝酸酯类药物后患者病情控制,随访6个月,胸痛未再发作。结论 PCI治疗的同时,合理应用非二氢吡啶类钙拮抗剂和硝酸酯类药物,可改善患者病情。     

1例变异型心绞痛患者突发室颤的护理

正变异型心绞痛是指胸痛发作时心电图相应导联表现为ST段抬高的一类特殊类型的心绞痛。与其他类型的心绞痛由冠状动脉固定性狭窄或不稳定性斑块作为病理基础有所不同的是,变异型心绞痛系由冠状动脉痉挛引起的心肌缺血性病变[1]。冠脉痉挛导致心肌供血不足,缺血区域心肌传导抑制,心肌内电生理稳定性减退,易形成激动折返而导致室速、室颤等恶性心律     

心脏X综合征28例诊治分析

目的 探讨心脏X综合征的诊断与治疗方法.方法 对28例心脏X综合征患者临床资料进行回顾性分析.结果 心电图检查显示19例正常,24 h动态心电图均监测到一过性缺血性ST段压低,平板运动试验阳性率100％,冠状动脉造影证实患者左、右冠状动脉及其分支未见明显狭窄;应用硝酸酯类药物、钙离子通道阻滞剂、β受体阻滞剂和/或盐酸曲美他嗪治疗有效;随访6个月～1.5a,患者均朱出现心血管事件.结论 心脏X综合征确诊需结合临床表现、平板运动试验结果等进行判断,必要时行冠状动脉造影术;其治疗以缓解心绞痛症状、改善生活质量和提高疾病预后为目的.     

Holter监测变异型心绞痛的临床研究

目的:探讨24h动态心电图监测对变异型心绞痛冠脉病变的诊断价值。方法:对29例确诊变异型心绞痛患者的动态心电图监测(DCG)和选择性冠状动脉造影(CAG)检查结果进行回顾性分析。结果:CAG检查示:23例有冠状动脉狭窄,其分布部位依次为左前降支13例,右冠状动脉7例和左回旋支3例,其中75%以上狭窄15例(65.5%)。DCG监测:ST段抬高时间与胸痛发作时间基本一致,ST段抬高并发各类型心律失常的有:室性心律失常14例,房性心律失常5例,心房纤颤1例,窦性停搏、房室传导阻滞及窦房传导阻滞5例,心室颤动1例。阵发性ST段抬高≥0.20mv者18例,其中狭窄程度≥75%者12例(66.7%),抬高最长持续时间≥3min者24例,其中狭窄程度≥75%者16例(75%)。结论:变异型心绞痛更易在冠状动脉狭窄病变的基础上发生冠脉痉挛,冠状动脉痉挛所致心律失常可能与ST段抬高的程度、持续时间呈正相关,而其类型与发生痉挛的血管部位有关。DCG可明显提高变异型心绞痛的诊断率。     

硝苯地平控释片治疗自发型心绞痛的近期疗效

按照世界卫生组织心绞痛分类标准,心绞痛分为劳力型和自发型,自发型心绞痛中包括发作时心电图ST段抬高的变异型心绞痛。本文着重探讨在使用硝酸酯类、β阻滞剂的基础上,加用拜心通(硝苯地平控释片)治疗发作时ST段不抬高的自发型心绞痛的近期疗效。1 资料与方法1.1 病例选择 选择3年来住院的自发型心绞痛患者80例,剔除窦房结功能差、心率较慢、严重心功能不全、发作时心电图ST段抬高的变异型心绞痛,以及主动脉瓣病变、严重贫血、休克等非冠状动脉原因导致的冠脉供血、供氧不足的病例。80例患     

变异型心绞痛发病机制及临床特点研究进展

变异型心绞痛主要由冠状动脉痉挛引起,患者胸痛发作时,伴有心电图ST段一过性抬高。变异型心绞痛发病与冠状动脉内皮细胞功能障碍、炎性反应及自主神经系统失衡、Mg~(2+)缺失等有关,临床表现除胸痛外,还可有各种心律失常、晕厥甚至猝死。深入了解变异型心绞痛的发病机制、临床特点,有助于指导临床用药及介入方法的选择。本文就变异型心绞痛发病机制、临床特点的研究进展作一综述。     

光学相干断层成像指导治疗变异型心绞痛1例并文献复习

目的 探讨变异型心绞痛的临床特点,以期提高对该病的诊疗与认识。方法 回顾性分析1例由光学相干断层成像指导治疗的变异型心绞痛患者临床资料,并以“变异型心绞痛”以及“光学相干断层成像”等关键词,通过检索中国知网、PubMed及万方数据库,筛选公开发表的中英文文献,以分析变异型心绞痛的临床特点。结果 本例患者老年男性,因间断胸闷2年余,加重10余天就诊,发作时心电图检查提示Ⅱ、Ⅲ、aVF导联ST段抬高,其余导联ST段显著压低,症状缓解后ST段回落,于光学相关断层成像指导下行冠状动脉造影结果示右冠状动脉近中段狭窄20%～30%,中段第二转折狭窄70%,远段可见支架影,右冠状动脉行麦角新碱激发试验,可见弥漫痉挛,给予硝酸甘油及硝普钠后痉挛解除,考虑患者胸闷症状反复发作,药物控制欠佳,且术中冠脉痉挛明显,遂给予右冠状动脉支架置入,经治疗患者胸闷症状未再发作,治疗效果良好。结论 变异型心绞痛疾病特点及治疗方法与冠状动脉粥样硬化不同,临床易误诊误治,因此提高对其的警惕性及认识,及早行腔内影像学检查及激发试验可明确诊断,有助于选择合适的治疗方案并改善患者预后。     

变异型心绞痛患者动态心电图与冠状动脉病变分析

目的 分析变异型心绞痛患者的动态心电图ST段变化特点及冠状动脉病变情况.方法 对36例动态心电图显示ST段抬高型心绞痛患者进行冠状动脉造影检查冠状动脉病变情况.结果 36例变异型心纹痛发作时ST段呈多种形态上抬,最大ST段上抬约0.1～0.6 mV,平均0.45 mV,表现为斜上型、斜下型、水平型、弓背向上型、弓背向下型等形态,且不同时间不断演变.冠状动脉造影检查显示36例患者均有有意义的冠状动脉狭窄,其中中度狭窄14例(1支血管病变6例,2支血管病变8例),重度狭窄22例(2支血管病变14例,3支血管病变8例).经对照比较发现冠状动脉狭窄程度与ST段上抬幅度并非一一对应关系.结论 冠状动脉狭窄的基础上发生的痉挛可能是ST段抬高型心绞痛患者的发病基础,心纹痛发作时ST段形态不断演变,值得进一步研究.     

冠状动脉心肌桥诱发心绞痛一例报告

目的:探讨冠状动脉心肌桥诱发的心绞痛诊断策略.方法:本例以活动后胸痛进行性加重入院,心电图检查见ST段压低、T波倒置,并有动态改变,曾考虑为不稳定性心绞痛、急性心肌梗死,应用硝酸酯类药物疗效不确切,心肌醇正常.病人在位院期间再次出现气短、胸痛,心电图V1-4导联ST-T动态改变,曾怀疑肺栓塞,但血气分析、D-二聚体结果正常,CT肺动脉造影除外肺栓塞.结果:经冠状动脉造影为左前降支心肌桥.结论:对于心肌桥诱发的心绞痛,应用冠状动脉造影不仅是最简捷、准确的确诊方法.而且有助于与常见的冠心病心绞痛鉴剐.     

Symptomless myocardial ischemia: feasibility of diagnostic mistakes

AIM: To examine feasibility of ST segment depression on ECG in treadmill exercise test and 24-h ECG monitoring in subjects with coronarographically intact coronary arteries. MATERIALS AND METHODS: 9 males aged 41 to 52 years with chest pains unrelated to muscular load. They had neither stenosis of coronary arteries, nor arterial hypertension, valvular defects, disturbance of electrolyte metabolism. All of them have undergone treadmill exercise test and 24-h ECG monitoring. RESULTS: The exercise test provoked chest pain in none of the examinees. ST segment was depressed in one patient. 24-h monitoring registered depression of ST segment in one more patient. The rest 7 patients showed no changes in ST segment either in exercise test or 24-h ECG monitoring. CONCLUSION: It is confirmed that typical ischemic ECG changes (horizontal depression of ST segment) in healthy persons can occur and may be mistaken for silent myocardial ischemia.     

Chest pain in a young female

Acute Coronary Syndrome (ACS) is a common diagnosis in the emergency department (ED), the most severe manifestation of which is ST elevation on electrocardiogram (ECG). ST elevation reflects obstruction of flow through the coronary arteries, most commonly due to coronary atherosclerotic plaque rupture. However, alternative causes of coronary obstruction causing ST elevation are possible. Spontaneous coronary artery dissection (SCAD) is an unusual cause of ST elevation in ED patients which providers may encounter in patients without traditional atherosclerosis risk factors. Patients presenting with SCAD as a cause of ST elevation require unique management from traditional ACS. Here we report a case of a 43?year old female presenting with chest pain and unusual ECG findings including accelerated idioventricular rhythm followed by subtle ST segment elevation and resolution of abnormalities. This case illustrates subtle clinical and ECG findings suggestive of SCAD which emergency physicians should consider when evaluating patients for ACS in the absence of traditional clinical presentations. Such considerations may prompt physicians to avoid therapy for coronary plaque rupture which is not indicated in patients with SCAD.     

不伴心肌梗死的冠状动脉完全闭塞病变心绞痛的临床分析

目的：探讨不伴心肌梗死的冠状动脉完全闭塞病变心绞痛患者的临床特点。方法：对24例不伴心肌梗死的冠状动脉完全闭塞患者的临床表现、心电图、超声心动图及冠状动脉造影资料进行回顾分析。结果：中、高危险组主要表现为静息心绞痛，低危险组和稳定性心绞痛组主要表现为劳力型心绞痛。冠状动脉造影显示左前降支闭塞10例（37％），右冠状动脉闭塞7例（26％），左回旋支闭塞6例（22％），合并多支血管病变23例（95．8％）。心电图ST段异常14例（58．3％）。62．5％的患者进行经皮冠脉血运重建术。结论：不伴心肌梗死的冠状动脉完全闭塞主要表现为劳力型心绞痛，心电图ST段异常是预测冠脉病变严重程度的主要危险因素。经皮冠状动脉介入治疗正成为慢性冠状动脉闭塞的主要手段之一。     

动态心电图监测在变异性心绞痛中的应用

目的探讨动态心电图在变异性心绞痛诊断中的价值。方法对经我院确诊的70例变异性心绞痛患者进行常规12导联心电图和Marquette Holter心电监测仪检查,比较两种检测方法中ST段、T波、室性早搏等指标的变化,并对患者行冠状动脉造影（CAG）,对其检测结果进行回顾性分析。结果冠状动脉造影检查示冠状动脉无明显病变10例,轻度狭窄15例,中度狭窄37例,重度狭窄8例,而且阵发性ST段抬高的高度、持续时间与冠脉狭窄的程度呈正相关。同时常规心电图对变异性心绞痛的检测率明显低于动态心电图,两者相比差异有统计学意义（P〈0.05）。结论动态心电图准确完整地记录变异性心绞痛发作的全过程,对诊断变异性心绞痛具有重要的临床应用价值。     

Role of "Ischemia modified albumin", a new biochemical marker of myocardial ischaemia, in the early diagnosis of acute coronary syndromes

Background: Diagnosis of cardiac ischaemia in patients attending emergency departments (ED) with symptoms of acute coronary syndromes is often difficult. Cardiac troponin (cTn) is sensitive and specific for the detection of myocardial damage but may not rise during reversible myocardial ischaemia. Ischemia Modified Albumin (IMA) has recently been shown to be a sensitive and early biochemical marker of ischaemia. Methods and Results: This study evaluated IMA in conjunction with ECG and cTn in 208 patients presenting to the ED within three hours of acute chest pain. At presentation, a 12-lead ECG was recorded and blood taken for IMA and cardiac troponin T (cTnT). Patients underwent standardised triage, diagnostic procedures, and treatment. Results of IMA, ECG, and cTnT, alone and in combination, were correlated with final diagnoses of non-ischaemic chest pain, unstable angina, ST segment elevation, and non-ST segment elevation myocardial infarction. In the whole patient group, sensitivity of IMA at presentation for an ischaemic origin of chest pain was 82%, compared with 45% of ECG and 20% of cTnT. IMA used together with cTnT or ECG, had a sensitivity of 90% and 92%, respectively. All three tests combined identified 95% of patients whose chest pain was attributable to ischaemic heart disease. In patients with unstable angina, sensitivity of IMA used alone was equivalent to that of IMA and ECG combined. Conclusions: IMA is highly sensitive for the diagnosis of myocardial ischaemia in patients presenting with symptoms of acute chest pain.     

The consistency of emergency physicians' and cardiologists' ECG interpretation and likelihood classification of chest pain patients

Patients presenting to the emergency department with chest pain are evaluated by emergency physicians in hospitals without cardiology cover 24 h a day. The purpose of this study is to determine the consistency of electrocardiography (ECG) interpretation and chest pain likelihood classification between emergency physicians and cardiologists. This randomised prospective cross-sectional study was performed in a tertiary care university hospital emergency department. The study form included ECG interpretation and chest pain likelihood classification according to American College of Cardiology (ACC)/American Heart Association (AHA) guideline which were recorded by emergency physicians and cardiologists separately in a blinded fashion. All chest pain patients who consulted with a cardiologist were enrolled into the study during the study period. The consistency between the two groups and the kappa value were calculated. Recorded study forms of 133 patients with cardiology consultations were evaluated. The consistency in the interpretation of ECG between the emergency physicians and cardiologists was found to be 94.6% (kappa = 0.85) for ST segment elevation, 78.6% (kappa = 0.57) for ischaemic ECG findings and 79.3% (kappa = 0.36) for dynamic ECG changes. The consistency for the likelihood classification between two groups for predicting the pain as angina or non-cardiac was 90.8% (kappa = 0.30), for classifying as acute coronary syndrome or stable angina pectoris (SAP) was 95.6% (kappa = 0.26) and for classifying patients as low likelihood or intermediate-high likelihood was 86.3% (kappa = 0.61). A strong consistency was shown between the emergency physicians' and cardiologists' ECG interpretation especially in determining the ST segment elevation. And also, there is a strong concordance in the likelihood classification of chest pain patients.     

The effect of single doses of antianginal preparations on the correlation of the time of the onset of typical pain and the electrocardiographic signs of myocardial ischemia in patients with stenocardia of effort

Altogether 359 paired bicycle ergometries coupled with administration of single doses of antianginal drugs were carried out in 62 men suffering from angina pectoris of effort, functional classes II and III. A study was made of the indicator characterizing the time that elapsed since the onset of a typical angina pectoris attack till the appearance of the signs of ischemia on the ECG. Administration of effective single doses of antianginal drugs raised the time elapsed since the pain onset till the appearance of the ST segment greater than or equal to 1.0 mm fall during the exercise. Administration of ineffective doses of nitrates, calcium antagonists and placebo entailed a decline of that indicator, a rise of the number of cases where the segment ST greater than or equal to 1.0 mm fall was recordable before the onset of painful sensations. Administration of propranolol in ineffective single doses failed to provoke a decrease of the time elapsed since the typical pain onset till the appearance of the ST segment greater than or equal to 1.0 mm fall. Intake of ineffective single doses of nitrates, calcium antagonists and placebo may deprive certain patients of early signalization and appearance of the ECG signs of myocardial ischemia.     

The initial electrocardiogram in patients seen by a mobile coronary care unit

The advent of thrombolytic therapy for patients with suspected acute myocardial infarction has highlighted the importance of the initial electrocardiogram (ECG) in decision making. Thus we analysed the initial ECGs of 94 consecutive cases with suspected myocardial infarction who were seen within six hours after the onset of chest pain by a mobile coronary care unit. The study included 91 patients (three patients admitted twice) (61 male), aged 27-83 years (mean 60.5). Median time from onset of chest pain to arrival of the mobile coronary care unit was 75 minutes (range 15-345), and mean mobile coronary care unit response time was 12.3 +/- 7 (SD) minutes (range 5-45). The majority of cases (65 of 94, 69.1 per cent) were seen within two hours of the onset of symptoms. A final diagnosis of myocardial infarction was made in 48 of 94 (51.1 per cent) cases; 38 had unstable angina and eight other diagnoses. Of the 48 with myocardial infarction the initial ECG showed ST segment elevation in 37, ST depression and or T wave inversion in six, Q waves only in three and left bundle branch block in two. No patient with an initially normal ECG had a myocardial infarction. Thrombolytic therapy was given out of hospital to 33 of 38 patients with ST segment elevation. In seven patients with ST elevation (median delay time to intensive care 60 minutes), rapid resolution of ST segment elevation occurred following thrombolytic therapy and there was no significant elevation of cardiac enzymes, suggesting that the infarct had been aborted.(ABSTRACT TRUNCATED AT 250 WORDS)     

Risk stratification and therapeutic decision making in patients with acute coronary syndrome--the role of cardiac troponin T.

Patients with chest pain represent an inhomogeneous group with greatly varying severity of coronary artery disease and cardiac risk. The proper selection of different treatment strategies in these patients requires reliable risk assessment. Patients with definitive myocardial infarction: in patients with ST-segment elevation on ECG, a positive troponin T (cTnT) on admission identifies a group of patients having a threefold higher mortality rate than patients with a negative cTnT test. The differences in risk based on cTnT are found for patients treated with thrombolytic as well as mechanical recanalization therapy. These differences in mortality based on admission cTnT may be explained by more severe coronary artery disease, worse left ventricular function, and less efficient microvascular reperfusion in the cTnT-positive patients. Patients with rest angina: in patients with angina at rest, a positive cTnT value on admission identifies a subgroup having a threefold higher cardiac event rate than cTnT-negative patients. The cTnT-positive patients seem to benefit from treatment with low molecular weight heparin and fibrinogen receptor antagonists, while cTnT-negative patients do not. The differences in risk and response to therapy may be due to more severe coronary artery disease, more critical coronary artery stenoses, and a higher rate of intracoronary thrombus formation in the cTnT-positive versus negative patients. Low risk chest pain patients: in low risk chest pain patients, (i.e. no rest angina, no ECG-changes) cTnT-positive patients on admission have a twofold higher cardiac event rate than cTnT-negative patients. The proper treatment strategy for the low risk cTnT-positive patients remains to be determined. Troponin T versus troponin 1: many of the findings on cTnT also relate to troponin I. However, there is a high interassay variability of troponin I assays, which has to be taken into consideration.     

急诊经皮冠状动脉介入治疗ST段抬高心肌梗死的护理

目的研究ST段抬高心肌梗死急诊经皮冠状动脉介入治疗(急诊PCI)的护理要点。方法43例ST段抬高急性心肌梗死行急诊PCI术,观察胸痛、血压、心率、心律失常、再灌注心律失常、出血并发症,密切配合医生做好术前准备,术中监护和术后护理。结果25例术中出现再灌注心律失常,3例出现穿刺部位血肿,所有43例顺利出院。结论快速的术前准备,术中密切监测症状、心电图和血流动力学改变,术后及时发现并发症,做好心理护理与健康指导,有助于手术的安全和成功率。