基于单中心的中国人群自发性冠状动脉夹层临床特征与治疗策略

目的：基于单中心的临床资料探讨中国人群自发性冠状动脉夹层(spontaneous coronary artery dissection,SCAD)的临床特点、治疗选择和临床转归。方法：对2015年3月至2016年12月复旦大学附属中山医院单中心行冠状动脉造影（coronary angiography,CAG）的16 526例连续性患者进行回顾性分析,筛选出17例SCAD患者。分析其危险因素、临床表现、病变特点、治疗方案和临床转归。结果：17例SCAD患者年龄26～67岁,平均（49.06±10.73）岁;男性4例、女性13例。所有患者均以急性冠脉综合征起病,其中ST段抬高型心肌梗死10例、非ST段抬高型心肌梗死3例、不稳定型心绞痛4例。17例患者共发现20处夹层,夹层主要发生于左前降支（10例,50%）和右冠状动脉（7例,35%）,少数累及对角支（2例,10%）和回旋支（1例,5%）。20处夹层Ⅰ型5处、ⅡA型7处、ⅡB型6处、Ⅲ型2处。夹层远段的心肌梗死溶栓治疗（TIMI）血流分级0级4处、1级2处、3级14处。7例患者保守治疗,1例患者行单纯球囊扩张治疗,临床随访均无心绞痛发作。9例患者接受支架植入,每例平均（2.44±1.13）枚。介入过程中共5例患者出现血肿扩展,其中1例出现新发急性心肌梗死,另1例死亡。结论：缺乏冠心病危险因素的中青年女性急性冠脉综合征患者要考虑SCAD可能;临床应熟悉SCAD的造影表现,必要时行血管内超声确诊;确诊后一般采用药物保守治疗,高危患者接受经皮冠状动脉介入治疗(PCI)时要慎防夹层扩展。     

自发性冠状动脉夹层

目的：自发性冠状动脉夹层是心肌缺血的少见原因。通过分析我院所见3例患者，探讨其发病率、病因及治疗方法。结果：5014例行冠状动脉造影的患者中，发现自发性冠状动脉夹层患者3例(0．6％)，临床表现为不稳定性心绞痛和急性心肌梗塞，均经内科保守治疗症状缓解。其中1例急性心肌梗塞患者造影见：左前降支远端D型夹层，，TIMI血流1级。6月后造影显示：夹层自然愈合。结论：自发性冠状动脉夹层是心肌缺血的少见原因，表现为稳定性心绞痛，不稳定性心绞痛，急性心肌梗塞，甚至猝死。自发性冠状动脉夹层可自然愈合，所以对自发性冠状动脉夹层是否采用冠状动脉介人或外科手术(CABG)治疗，应根据造影时夹层的范围、形态及对血流的影响等因数来决定。     

成功救治自发性冠状动脉夹层一例

正自发性冠状动脉夹层(spontaneous coronary artery dissection,SCAD)为一种少见的可导致急性冠状动脉综合征、甚至猝死的冠状动脉疾病。其主要表现为冠状动脉内膜自发撕裂或冠状动脉壁内滋养血管出血形成血管夹层,影响正常冠状动脉血液供应。常常与冠状动脉粥样硬化、围产期女性体内激素水平改变、动脉壁中层结构变异、剧烈运动等因素相关。往往被误诊为冠心病心绞痛、心肌梗死或腹痛。故早期诊断、及时治     

1例自发性冠状动脉夹层患者的护理

自发性冠状动脉夹层(spontaneous coronary artery dissec-tion,SCAD)是一种少见的冠状动脉疾病,主要表现为冠状动脉内膜自发撕裂或冠状动脉壁内出血造成血管夹层,影响或阻断冠状动脉血流,是年轻妇女急性心肌梗死或猝死的重要     

青年急性心肌梗死24例临床分析

目的 探讨青年人急性心肌梗死的临床及冠状动脉造影特点.方法 回顾性分析24例青年人急性心肌梗死患者的临床资料、治疗及转归.结果 24例青年急性心肌梗死患者,前驱症状少,发病急,症状重,伴有吸烟、过度劳累及精神紧张等诱发因素,具有临床表现典型、冠状动脉造影血管病变简单、介入治疗成功率高、预后相对良好等特点.结论 针对青年人心肌梗死特点,应尽早明确诊断,及早予以介入治疗,降低死亡率,改善预后.     

性别对急性ST段抬高心肌梗死直接经皮冠状动脉介入治疗预后的影响

目的 探讨性别对急性ST段抬高心肌梗死(STEMI)直接经皮冠状动脉介入(PCI)治疗预后的影响.方法 分析比较478例男性和101例女性急性ST段抬高心肌梗死患者的危险因素、冠状动脉造影特点和预后情况.结果 不同年龄段STEMI发病率的性别差异有统计学意叉(P<0.01),女性发病较男性晚10年以上,≥71岁女性发病率升高更明显;女性多合并原发性高血压、2型糖尿病,且2型糖尿病明显高于男性(P<0.01);女性多支病变明显高于男性(P<0.01).女性院内病死率、假性动脉瘤/血肿发生率明显高于男性(P<0.05,P<0.01).结论 直接PCI治疗STEMI女性患者的住院病死率及穿刺血管并发症发生率较男性高.     

体外膜肺氧合辅助下无保护左主干急性闭塞合并心源性休克急诊介入治疗一例

正无保护左主干(unprotected left main coronary artery,ULMCA)急性闭塞导致的急性ST段抬高型心肌梗死约占急诊经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)的0.8%,患者往往会出现严重的血流动力学异常、心源性休克、恶性心律失常,甚至猝死[1]。体外膜肺氧合     

不同的梗死相关血管急性下壁心肌梗死特点

目的分析不同梗死相关血管的急性下壁心肌梗死患者的临床特点。方法根据冠状动脉造影结果将急性下壁心肌梗死患者分2组,A组76例为右冠状动脉(RCA)闭塞,B组24例为左回旋支冠状动脉(LCX)闭塞,并进行比较分析。结果心电图ST段抬高STⅢ>STⅡA组显著高于B组(P<0.05);ST段抬高STⅢ0.1mVA组显著高于B组(P<0.05);合并左前降支冠状动脉(LAD)病变的患者数在胸前导联ST段压低的患者中显著多于无胸前导联ST段压低患者(P<0.05);左室射血分数(LVEF)A组显著低于B组[(51±14)%vs(57±10)%,P<0.05];合并右室心肌梗死A组显著高于B组(P<0.05);心源性休克,心力衰竭,Ⅱ度、Ⅲ度房室传导阻滞,室性心动过速/心室颤动,住院死亡率等两组比较差异无统计学意义(P>0.05)。结论心电图Ⅲ、Ⅱ及V4R导联ST段变化能预测急性下壁心肌梗死患者梗死相关血管,急性下壁心肌梗死患者伴胸前导联ST段压低提示LAD病变,RCA闭塞所致下壁心肌梗死LVEF低于LCX闭塞者,但临床并发症两组间差异无统计学意义。     

临床罕见的A型主动脉夹层致冠状动脉闭塞一例诊治反思

目的提高对A型主动脉夹层致冠状动脉闭塞的认识,防范误诊误治。方法对我院收治的1例A型主动脉夹层临床资料进行回顾性分析。本例因持续性心前区疼痛2 h入院,经心电图及实验室检查结合临床症状诊断为急性下壁、右室、正后壁心肌梗死。冠状动脉造影示右冠状动脉起始部狭窄。结果患者行支架植入术中突然呼吸停止,心搏骤停,抢救无效死亡。回放冠状动脉造影图像示大量心包积液,确诊为主动脉夹层致右冠状动脉闭塞形成急性下壁、右室、正后壁心肌梗死,术中夹层破裂,心包填塞致死。结论主动脉夹层致冠状动脉闭塞非常罕见,一旦确诊,需急诊手术治疗。     

青年急性冠脉综合征患者临床特点的回顾性分析

目的探讨青年急性冠状动脉综合征(acute coronary syndrome,ACS)的临床特点。方法选取≤45岁ACS患者174例为青年ACS组,同期60~75岁ACS患者191例为老年ACS组,比较两组患者的危险因素、临床特点、冠脉病变特征及主要心血管不良事件。结果青年ACS患者中男性、超重/肥胖、吸烟者比例、总胆固醇、甘油三酯尿酸水平以及低高密度脂蛋白水平高于老年组。青年ACS组中ST段抬高心肌梗死占比最高,老年ACS组中不稳定心绞痛占比最高,组间比较差异有统计学意义(P<0.05)。结论青年ACS患者多为男性,超重/肥胖、吸烟和血脂异常、ST段抬高心肌梗死在青年ACS患者中占优势,主要不良心血管事件发生率和老年患者无差异。     

Spontaneous coronary artery dissection causing acute coronary syndrome: an early diagnosis implies a good prognosis

Spontaneous coronary artery dissection is an unusual cause of acute coronary syndrome. We describe a series of cases that with an early diagnosis and aggressive treatment, which includes percutaneous angioplasty with stent implantation and cardiac surgery, had a good outcome. The objective was to study the demographic characteristics, clinical settings, treatments, and inhospital course of patients with spontaneous coronary artery dissection. We studied a retrospective case series in 3 coronary care units in third-level university hospitals. The spontaneous coronary artery dissection diagnosis was made by coronary angiography. Seven cases of spontaneous coronary artery dissections were recorded. They were 5 women and 2 men. The age range was 28 to 64 years. Two of them took oral contraceptives and one case occurred in the postpartum period. An acute anterior wall myocardial infarction was the most frequent clinical presentation, occurring in 4 of the 7 cases. In fact, the left anterior descending artery was involved in 6 cases. An urgent coronary angiogram was performed in all cases. Definitive treatment included percutaneous angioplasty and stent implantation in 3 cases, coronary artery bypass surgery in 2 case, and cardiac transplantation in another case. One patient was treated medically. None of the patients died in the hospital. Spontaneous coronary artery dissection remains an unusual cause of acute coronary syndrome. It should be included in the differential diagnosis of acute myocardial infarction, especially when it affects young, healthy females. An early clinical suspicion and diagnosis with urgent coronary angiography and aggressive treatment that includes percutaneous angioplasty with stent implantation and cardiac surgery could improve the prognosis of these patients.     

Spontaneous coronary artery dissection: a rare threat to young women

Spontaneous coronary artery dissection not associated with underlying coronary artery disease is rare. When the dissection does occur, it most often is manifested as an acute ST-elevation myocardial infarction in young women. Although the condition can occur in men, most often it involves women who are in their third trimester of pregnancy or the early postpartum period or are engaging in vigorous exercise. Because little is known about spontaneous coronary artery dissection in this population of women, recommendations for treatment are the same as for treatment of acute myocardial infarction associated with atherosclerotic coronary disease.     

冠状动脉心肌桥的诊断及临床意义

目的探讨冠状动脉心肌桥的诊断以及临床意义.方法对486例行冠状动脉造影(CAG)检查资料进行了回顾性分析.结果共检出13例心肌桥,检出率为2.67%;其中位于左前降支(LAD)12例,左回旋支(LCX)1例;合并冠状动脉粥样硬化症2例;临床表现急性心肌梗死1例,心绞痛4例.结论冠脉造影是冠状动脉心肌桥的特异性诊断方式;局部冠状动脉收缩期狭窄是心肌桥的主要征象;心肌桥患者多数无临床症状,严重者可致心绞痛甚至心肌梗死.     

Spontaneous coronary artery dissection

A 45-year-old female athlete with no history of cardiovascular disease or coronary risk factors presented with a non-ST-segment elevation myocardial infarction due to spontaneous right coronary artery dissection. She was treated medically with resolution of her symptoms. Repeat angiography due to recurrent exertional chest discomfort showed TIMI-3 flow and no evidence of dissection. Intravascular ultrasound documented discrete areas of resolving hematoma, but no dissection flap or impingement of the lumen >30%. A coronary computed tomography 6 months later revealed absence of any vascular abnormalities. This rare but potentially lethal condition should be considered in the differential diagnosis of young patients with chest pain, myocardial infarction, or sudden cardiac death, especially if it involves women either in the peripartum period or those using oral contraceptives, or patients without evidence of coronary atherosclerosis or traditional cardiovascular risk factors.     

Rapid progression of coronary artery disease in the setting of chronic cocaine abuse

Two cases of rapidly progressing coronary artery disease in the setting of chronic cocaine abuse are presented. One patient, a 39-year-old female, developed a significant left anterior descending artery (LAD) stenosis over a 10-month period and suffered an acute myocardial infarction (MI). The second patient, a 35-year-old male, developed significant progression of three vessel coronary artery disease (CAD) over 16 months and also suffered an MI temporally related to cocaine use. Though recent cocaine use is typically considered a risk factor for acute cardiac events, chronic use may contribute to the development or rapid progression of coronary artery disease in young patients.     

冠状动脉夹层的造影诊断与内支架治疗

目的　评价冠状动脉造影 (CAG)和内支架置入 (CASI)治疗对冠状动脉夹层的诊断及治疗价值。方法　10 82例冠状动脉造影及 434例冠状动脉成形术 (PTCA)检出 12例冠状动脉夹层患者 ,均行内支架置入治疗。结果　 12例冠状动脉夹层患者全部成功置入内支架 ,夹层闭合 ,患者症状缓解。结论　冠脉造影是诊断冠状动脉夹层的最佳方法 ,而内支架置入对治疗冠脉夹层安全有效     

Long-term follow-up of coronary artery dissection due to blunt chest trauma with spontaneous healing in a young woman

We report a previously healthy 17-year-old woman who experienced coronary artery dissection with an acute transmural anterior myocardial infarction and myocardial contusion following blunt chest trauma in a motorcycle accident. A chest roentgenogram on admission was normal, and an electrocardiogram showed an acute transmural anterior myocardial infarction with complete right-bundle-branch block. A 2D echocardiogram revealed an akinesis of the anterior wall and a hypokinesis of the posterior wall in the left ventricle. Initial coronary angiography demonstrated severe stenosis with delayed antegrade filling in the proximal left anterior descending artery. Technetium-99m pyrophosphate myocardial scintigraphy demonstrated diffuse tracer uptake in the left ventricular wall. Follow-up coronary angiography performed 1 year after the accident showed a minor stenosis without any filling defects. We describe long-term follow-up of the coronary artery dissection following blunt chest trauma with spontaneous healing.     

Spontaneous coronary dissection should not be ignored in patients with chest pain in autosomal dominant polycystic kidney disease: A case report

BACKGROUNDWhen autosomal dominant polycystic kidney disease (ADPKD) presents with acute coronary syndrome (ACS), the possibility of spontaneous coronary artery dissection (SCAD) should be highly considered. In some cases, SCAD is considered an extrarenal manifestation of ADPKD depending on the pathological characteristics of the unstable arterial wall in ADPKD. CASE SUMMARYHere, we report a 46-year-old female patient with ADPKD who presented with ACS. Coronary angiography revealed no definite signs of dissection, while intravascular ultrasound revealed a proximal to distal dissection of the left circumflex. After a careful conservative medication treatment, the patient exhibited favorable prognosis. CONCLUSIONIn cases of ADPKD co-existing with ACS, differential diagnosis of SCAD should be considered. Moreover, when no clear dissection is found on coronary angiography, IVUS should be performed to prevent missed diagnosis.     

超声心动图对冠心病冠脉受累的评价及意义

【目的】探讨超声心动图（EcH0）评价冠心病（CAD）的价值。【方法】对111例拟诊为冠心病的病人行超声心动图检查和冠状动脉造影术（CAG）检查,以冠状动脉狭窄≥50％为CAG阳性来评价ECHO对冠心病的诊断价值。【结果】ECH0诊断CAD的敏感性和特异性分别为54．5％和91．7％;诊断心肌梗死的敏感性为83．7％（其中诊断急性心梗的敏感性90．3％;诊断陈旧性心梗的敏感性66．7％）;ECHO诊断单支病变和多支病变的敏感性分别29．0％和67．6％。【结论】ECH0对CAD和单支病变的敏感性较低,对心肌梗死和评价CAD严重程度有较高的诊断价值。     

冠状动脉造影正常急性心肌梗死患者临床分析

目的分析冠状动脉造影正常的急性心肌梗死（AMI）患者临床特点,探讨其发病机制、危险因素和预后。方法回顾分析了447例AMI患者冠状动脉造影（CAG）结果及临床资料,根据CAG结果分为冠状动脉正常组（A组）57例和冠状动脉异常组（B组）390例。分析2组患者冠心病的危险因素,比较2组左室射血分数（LVEF）、心脏事件发生率。结果A组年龄均小于B组,心绞痛、高血压、糖尿病、血脂异常、家族史均低于B组（均P〈0.05）;吸烟、大量饮酒者高于B组（P〈0.01）。Logistic多变量分析发现,吸烟、大量饮酒为CAG正常AMI患者独立危险因子。住院期间,严重心律失常、心力衰竭发生情况2组比较差异无统计学意义（P〉0.05）;A组总心脏事件发生率明显低于B组,LVEF值大于B组（均P〈0.05）。随访结果：再次AMI、心力衰竭、严重心律失常、复合终点事件比较,A组均低于B组（均P〈0.05）;2组心绞痛、心源性死亡比较差异无统计学意义（P〉0.05）。结论冠状动脉造影正常AMI患者是高危人群;大量吸烟、饮酒是其危险因素或诱因之一;CAG正常者与CAG异常者总心血管事件预后无明显差异。