《应激性心肌病》-ppt课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2016-10-24,#,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,人的差异在于业余时间,应激性心肌病ppt课件,应激性心肌病ppt课件人的差异在于业余时间应激性心肌病ppt课件应激性心肌病Stress Cardiomyopathy，SCDiagnosis,Pathophysiology,Management,and Prognosis武汉亚洲心脏病医院,徐承义History1991年日本学者Dote等报道心理或躯体应激状态可以诱发一过性左心室功能不全，由于在收缩末期左心室造影呈底部圆隆、颈部狭小的图像，类似日本古代捉捕章鱼的篓子，而被命名为“Tako-tsudo”(章鱼瘘)心肌病,1997年法国的心脏病学家Dominique Pavin报道了2例类似的病例，指出应激状态时儿茶酚胺水平升高和该病明显相关，并且提出了应激性心肌病的概念,2006年AHA关于心肌病的科学声明中，将其分类为一种独立的心肌病，正式命名为应激性心肌病,Absence,of,obstructive coronary,disease or angiographic evidence of acute plaque,rupture,冠,脉,造影,示冠状动脉,管狭窄程度,50%,，或无急性斑块破裂证据,New,electrographic abnormalities and/or modest elevation in,serum cardiac enzymes,新出现心电图异常或心肌酶学轻度升高,Absence,of pheochromocytoma or,myocarditis,排除嗜铬细胞瘤、心肌炎,All 4 criteria must be present,INCIDENCE,The incidence of,SC is,likely,underrecognized,Approximately,1,%to,2%,of patients presenting with an initial diagnosis,ACS actually,have,SC,发病率不明确，,1%-2%,的,ACS,患者实为,SC,Underestimated,for a variety of,reasons,：,nonavailability of cardiac catheterization facilities in many regions,the possibility for noncardiac presentation,l,ack of a consensus of diagnostic criteria may contribute to misdiagnosis,PRESENTATION,It,occurs most commonly in,postmenopausal Women,（,90%,）,mean age between 58,and 75,yrs,SC seems to have an association with,hypertension,COPD,and bronchial,asthma,SC mimics ACS in,most,patients,，,acute,substernal chest pain,and dyspnea,.,shock,syncope,and cardiac arrest have been,reported rarely,2/3,of,patients with emotional,or physical,stress,ECG,FINDINGS,ST elevation,in the precordial,and,diffuse,T wave are,the most common,findings,胸前导联,ST,段抬高及多导联,T,波倒置最为常见,Differentiate,SC,from anterior STEMI,Presence,of,ST segment,depression in lead avR and absence of ST segment,elevation in,lead V1 identified SC with 91%sensitivity,96%,specificity,and,95%predictive accuracy,LABORATORY FINDINGS,Elevations in troponin and creatine kinase MB are typically,mild,S,evere hemodynamic compromise is out of proportion and in contrast to the degree of cardiac enzyme elevation,Troponin T levels,ranged from 0.01 to 5.2 ng/mL,CARDIAC CATHETERIZATION,Coronary angiography,Left,ventriculography,A,RAO,end systolic left,ventriculogram in typical variant(apical ballooning)of SC.,B,RAO,end-diastolic ventriculogram in typical variant of SC.,C,RAO,end-systolic left ventriculogram in atypical,variant(basal,ballooning)of SC.,D,RAO,end-diastolic,ventriculogram in,atypical variant of SC.,IMAGING,Echocardiography,ventricular,ballooning,，,wall motion,abnormalities,，,decrease,in EF,Nuclear,Imaging,using,Tc-99m,，,impairment,of myocardial,perfusion,Magnetic Resonance,Imaging,patients,with SC do,not show hyper-enhancement on delayed,contrast enhancement MRI,PATHOPHYSIOLOGY,The,causal mechanisms,remain,uncertain,机制,不,明确,Stunned myocardium resulting from brief periods of ischemia owing to vasospasm is one possibility,心肌,顿,抑（冠脉痉挛引起短暂心肌缺血所致）是一种可能的机制,Coronary,microvascular,dysfunction,冠状动脉微血管功能障碍,Increasing plasma,levels of,catecholamines,交感神经过度兴奋和血浆儿茶酚胺水平增高,Reduction in estrogen levels following menopause,雌激素水平降低,MANAGEMENT,The treatment of patients with SC is mainly,supportive,目前尚无标准化的治疗方案,去除诱发因素很关键,加强对症支持治疗,Patients with shock,cautious use of inotropic agents such as dobutamine and dopamine,谨慎使用,受体兴奋剂以及多巴胺或多巴酚丁胺，必要时可考虑,IABP,支持,It is reasonable to treat SC with -blocker,ACE inhibitor and if pulmonary edema evelops,diuretics,受体阻滞剂、,ACEI,或,ARB,被推荐使用，,受体阻滞剂可预防,2.7%-8%,的病人复发,PROGNOSIS,SC has a favorable prognosis with in-hospital mortality 1%,with death more common in the setting of outflow obstruction,The 4-year recurrence rate of SC has been reported to be 11.4%,but without any significant difference in survival in an age and gender-matched population over the same duration,SC,长期预后相对较好,避免情绪激动,在预防复发中非常重要,Case Review,王得清,，男,/66,岁,，,住院号：,654098,主诉：,胸痛,2,天，晕厥一次,现病史：,2013.11.2,日,突发,胸痛，,位于下段胸骨后，压迫感，,持续,约,半小时好转，于当地诊所,诊治,过程中突发黑朦、晕厥，数秒后意识恢复,。,11.3,日,14:00,再发胸痛，性质同前，程度较前剧烈伴出汗，持续不能缓解，,当地医院,诊断“,AMI,”，给予药物治疗（,ASA300mg,波立维,300mg,立普妥,20mg,）及杜冷丁肌注后好转。,既往史、个人史及家族史,无特殊。,入院查体：,T 36.6,，,P 98bpm,，,R 20bpm,，,BP 140/80mmHg,，,肺部以及查体无阳性体征；,HR 104,次,/,分，律绝对不齐，,S1,强弱不等，,各瓣膜听诊区未闻及杂音,；,双下肢无水肿,院前,辅助检查：,2013,年,11,月,4,日我院,ECG:1.,心房颤动,2.,前壁导联,ST-T,改变,。,UCG:1.,双房扩大 室间隔,左室前壁室壁运动幅度减低,三尖瓣轻度反流,左室收缩功能稍减低,心包腔少量积液 心律不齐,;2.,先天性心脏病：房间隔小缺损（筛孔型，左向右分流）,。,cTnI 0.096ng/ml,急诊室,UCG,入院诊断,冠状动脉粥样硬化性心脏病,急性前壁心肌梗死,心房颤动 心功能,I,级（,Killip,分级）,监测,ECG 1,2013.11.04,监测,ECG 2,11.05,11.06,监测,cTnI,冠脉,CTA,LAD,LCX,RCA,应激因素,-SMA,栓塞,入院后治疗方案：,抗血小板聚集（阿司匹林,+,波立维,+,替罗非班）、抗凝,病情变化：,D2,解暗红色血便,5,次，上腹部压痛,D3,解,暗红色血,便,3,次，诉腹痛伴出汗，查体腹肌紧张，全腹压痛，肠鸣音弱,腹部血管,CTA,：,SMA,栓塞，肠管缺血改变,腹部血管,CTA,结论：,SMA,栓塞，肠管缺血改变,下次预告,Percutaneous Rheolytic Thrombectomy for Treatment of Acute SMA Thrombosis,Chengyi XU Xi SU,谢谢,46,、我们若已接受最坏的，就再没有什么损失。,卡耐基,47,、书到用时方恨少、事非经过不知难。,陆游,48,、书籍把我们引入最美好的社会，使我们认识各个时代的伟大智者。,史美尔斯,49,、熟读唐诗三百首，不会作诗也会吟。,孙洙,50,、谁和我一样用功，谁就会和我一样成功。,莫扎特,