自发性冠状动脉夹层合并急性心肌梗死的治疗选择  

Choice of Therapy for Spontaneous Coronary Artery Dissection with Acute Myocardial Infarction

作　　者：邱旭光[1] 曾和松[1] 马业新[1] 李晟[1] 徐昶[1] 周强[1] 

机构地区：[1]华中科技大学同济医学院附属同济医院心内科,武汉430030

出　　处：《华中科技大学学报（医学版）》2016年第1期78-81,共4页Acta Medicinae Universitatis Scientiae et Technologiae Huazhong

摘　　要：目的回顾分析自发性冠状动脉夹层(SCAD)合并急性心肌梗死患者的临床资料,探讨治疗选择。方法回顾分析2012年9月至2015年5月武汉同济医院冠脉造影(CAG)患者的影像,发现SCAD合并急性心肌梗死8例(包括ST段抬高和非ST段抬高型心肌梗死),用NHLBI标准分类,分析其病变特点,治疗方案和临床转归。结果 8例患者共发现9处SCAD,所有患者均发生急性心肌梗死,有1处SCAD未导致心肌缺血。动脉粥样硬化6例,非动脉粥样硬化2例。发生在右冠状动脉(RCA)3处,左前降支(LAD)5处,左主干-左前降支(LM-LAD)1处。A型2处,B型2处,C型1处,E型2处,F型2处。夹层远段的TIMI血流分级为0级2处,Ⅱ级2处,Ⅲ级5处,血管内超声(IVUS)发现的夹层范围要明显比冠脉造影所见广泛。3例保守治疗的患者有1例发生心绞痛及心衰,再造影发现夹层段闭塞。5例患者进行了经皮冠状动脉介入治疗(PCI),其中1例根据IVUS指导植入支架,其余4例均根据造影结果成功植入支架,随访无心绞痛及心衰。结论该研究中SCAD的病因主要是动脉粥样硬化。IVUS较CAG能够获得更加精确的诊断,PCI时有助于选择合适的支架。NHLBI标准可用于SCAD分型,各型夹层都有血管闭塞的风险。稳定的患者可以考虑药物保守治疗,但必须保证患者对治疗的依从性。PCI是安全有效的选择,冠状动脉搭桥术(CABG)是PCI失败时的选择。Objective To retrospectively analyze the clinical data of patients with spontaneous coronary artery dissection（SCAD）combined with acute myocardial infarction（AMI）and to explore the choice of therapy.Methods The data of patients who underwent coronary angiography（CAG）between Sep.2012 and May 2015 in Tongji Hospital were retrospectively analyzed.Eight patients were found to have both SCAD and AMI（AMI with ST-segment and non-ST-segment elevation）.National Heart,Lung and Blood Institute（NHLBI）criteria were used for classification,and clinical features of disease,treatment programs and clinical outcomes were analyzed.Results Nine SCADs were identified in 8patients with AMI.One SCAD didn＇t cause myocardial ischemia.Atherosclerotic lesions were found in 6patients and no atherosclerotic diseases in 2patients.Three SCADs were located in the right coronary artery（RCA）,5in left anterior descending branch（LAD）and 1in left main（LM）-LAD.All lesions fell into five types：type A（n=2）,type B（n=2）,type C（n=1）,type E（n=2）,and type F（n=2）.The TIMI flow in the distal part of the dissection was classified as follows：class 0（n=2）,classⅡ（n=2）,and classⅢ（n=5）.Intravascular ultrasound（IVUS）showed more extensive dissections than coronary angiography（CAG）did.Among three patients who received conservative therapy,one developed angina and heart failure and CAG showed occluded vessels in the dissection area in this patient.Percutaneous coronary intervention（PCI）was preformed in one patient guided by IVUS and four by CAG.Followup revealed no occurrence of angina and heart failure.Conclusion The primary etiology of SCAD is atherosclerosis.IVUS provides more accurate diagnosis than CAG and it help to select the stents appropriate for patients.NHLBI criteria can be used for SCAD classification.SCAD of different types has the risk of vessel occlusion.Patients with stable conditions and good compliance can be treated by medicines.PCI is safe and effective.Coronary a

关 键 词：自发性冠状动脉夹层 急性心肌梗死 经皮冠状动脉介入治疗 血管内超声 

分 类 号：R543.3[医药卫生—心血管疾病]