PCI术后呼吸困难,再梗?心衰?肺栓塞?药物?

2017-11-15 齐海军 (武汉市中心医院) MedSci原创

患者入院前3周因急性心梗入院,行右冠PCI术,近1周再次出现胸闷、气促。是何原因?如何完善辅助检查?如何调整用药?

患者入院前3周因急性心梗入院,行右冠PCI术,近1周再次出现胸闷、气促。

是何原因?如何完善辅助检查?如何调整用药?

病例:

患者,男,65岁。主诉:反复胸闷、胸痛3周,再发加重伴气喘1周。

现病史

患者入院前3周前因“突发胸闷、胸痛8小时”于我院就诊,“冠心病,急性下壁ST段抬高型心肌梗死诊断明确,行右冠PCI术,出院后规则口服阿司匹林肠溶片、替格瑞洛、阿托伐他汀钙、培哚普利片,美托洛尔缓释片。

近1周上述症状再发加重,位于心前区压迫感,每次持续数分钟,活动后加重,伴明显气喘不适,多于夜间明显,白天亦可发生,吸氧及含服硝酸甘油后有所缓解。

起病来,患者无畏寒、发热,无咳嗽、咳痰,无鼻塞、流涕及咽痛;无紫绀、咯血,无喘息、浮肿;无恶心、呕吐,无明显腹痛、腹泻,无反酸、嗳气等症状。

既往史

冠心病史1年,高血压3级(极高危)病史10余年。

体格检查

BP:120/70 mmHg。神清,颈软,双肺呼吸音粗,未闻及明显干湿罗音,心率:62次/分,律齐,各瓣膜听诊区未闻及明显杂音。腹软,无压痛,双下肢无浮肿。

辅助检查

3周前入院

肌钙蛋白:1.783 ng/ml,肌酸激酶同工酶:7 u/l,肌酸激酶:88 u/l,乳酸脱氢酶:176.4 u/l,羟丁酸脱氢酶:121.2 u/l,谷草转氨酶:23.5 u/l。

此次入院

肌钙蛋白:正常,肌酸激酶同工酶:8 u/l,肌酸激酶:70 u/l,乳酸脱氢酶:156 u/l,羟丁酸脱氢酶:105.2 u/l,谷草转氨酶:19.5 u/l。

空腹血糖:6.86 mmol/l,甘油三酯:3.33 mmol/L,低密度脂蛋白:1.77 mmol/L,糖化血红蛋白:6.5%。

血、尿、粪常规、肝肾功能、凝血功能:均正常。

心电图(3周前入院):


心电图(此次入院):


目前诊断

1、冠心病,亚急性心肌梗死,右冠PCI术后,不稳定型心绞痛,心功能II级;2、高血压病3级,极高危;3、糖耐量异常;4、高脂血症。

风险评估

Grace评分:78。

Crusade评分:10。

用药情况

(3周前入院,术前)阿司匹林:0.3 g,替格瑞洛:180 mg,替罗非班:6 ml/h 静脉泵入。

(3周前入院,术后)阿司匹林:0.1g po qd;替格瑞洛:90 mg po bid;培哚普利片:8 mg po qd;美托洛尔缓释片:47.5 mg po qd;瑞舒伐他汀钙片:10 mg po qn;尼可地尔:5 mg po tid。

3周前 PCI 过程

将2.5×20 mm球囊于右冠中段次全闭塞处以10 atm扩张6 s。上3.5×29 mm(Firebird 2)支架于右冠中段病变出,以12 atm扩张6 s。







用药调整过程

CYP2C19基因型检测:快代谢(1/1)。

(调整后) 阿司匹林:0.1 g po qd;氯吡格雷:75 mg po qd;培哚普利片:8 mg po qd;地尔硫卓缓释胶囊:90 mg qn;美托洛尔缓释片:47.5 mg po qd;瑞舒伐他汀钙片:10 mg po qn;盐酸曲美他嗪:20 mg po tid。

(此次入院更换氯吡格雷后检测)血栓弹力图:MA(血小板功能):72 mm(参考值53-72 mm);ADP%(血小板抑制率):86.2%(参考值30%-90%)。结果提示ADP抑制率达标。

更换药物后,患者胸闷气喘症状完全消失,门诊复诊病情稳定。

临床思辨

虽然,替格瑞洛所致的呼吸困难大多较轻,且持续时间短。但是,临床中不能忽视,需要警惕因替格瑞洛所致的严重呼吸困难,并与术后再发ACS症状相鉴别。

根据CYP2C19基因检测及血栓弹力图等辅助检查结果,及早替换合适剂量的氯吡格雷能为患者带来明显获益。

目前腺苷假说、神经受体假说均不能完全解释替格瑞洛所致呼吸困难的原因,需更多的基础及临床研究来阐明替格瑞洛致不同人群、不同呼吸困难程度的具体作用机制。

用药小贴士

替格瑞洛为环戊基三唑嘧啶类药物,能直接作用、并可逆结合的新型P2Y12抑制剂,其本身为活性药物,不受CYP2C19基因型影响,抗血小板作用强,国内外指南已将其作为ACS患者的I类推荐药物。

随着替格瑞洛在临床中的应用增加,与其相关的呼吸困难逐渐被认识。现有研究证实,替格瑞洛相关性呼吸困难的发生率为10%-20%。

PLATO亚组分析也显示,替格瑞洛组患者的呼吸困难发生率高于氯吡格雷组(13.8% vs 7.8%,P<0.001)。

其发生机制尚未明确,可能与替格瑞洛抑制腺苷重吸收,细胞外腺苷浓度增加,腺苷直接激活肺迷走神经C纤维或与直接抑制神经元细胞P2Y12受体有关。

原始出处:

1. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med, 2009, 361: 1045-1057.

2. 邵春丽,颜红兵,乔树宾等. 替格瑞洛相关呼吸困难的调查分析. 《中华介入心脏病学杂志》,2015, 23(2):85-88.

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  4. [GetPortalCommentsPageByObjectIdResponse(id=1633831, encodeId=1c39163383129, content=<a href='/topic/show?id=578d13843ad' target=_blank style='color:#2F92EE;'>#PCI术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13843, encryptionId=578d13843ad, topicName=PCI术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ea4322051797, createdName=zxl736, createdTime=Mon Jul 23 15:45:00 CST 2018, time=2018-07-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1281857, encodeId=9281128185e23, content=<a href='/topic/show?id=21753963364' target=_blank style='color:#2F92EE;'>#呼吸困难#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39633, encryptionId=21753963364, topicName=呼吸困难)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=365d170, createdName=chenwq08, createdTime=Thu Nov 16 16:45:00 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1486425, encodeId=b46914864257d, content=<a href='/topic/show?id=76291384571' target=_blank style='color:#2F92EE;'>#PCI术后#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13845, encryptionId=76291384571, topicName=PCI术后)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=4ea78134582, createdName=12499e01m49暂无昵称, createdTime=Thu Nov 16 16:45:00 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261601, encodeId=ec0c26160194, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Thu Nov 16 05:30:25 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261379, encodeId=fc602613e91a, content=非常棒.认真学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo61WAV0ROeLAoicPxPKoKaogwLWLL8STv86qplbdOibN2YR4KxkJicqNectCXGR8gPJhGLc7yYLSdnpx4kaVXndTfu/0, createdBy=a6962042337, createdName=1391e9f2a7m, createdTime=Wed Nov 15 06:46:55 CST 2017, time=2017-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261375, encodeId=14ab2613e56e, content=谢谢分享.阅读, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2017/04/21/72142930668371951a41ef4ea4b233e6.jpg, createdBy=dcbc1715228, createdName=刘煜, createdTime=Wed Nov 15 06:41:20 CST 2017, time=2017-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261369, encodeId=457a261369a5, content=好好好好好好好好就, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Wed Nov 15 05:27:58 CST 2017, time=2017-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261367, encodeId=77da26136ec6, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/21/9461f3b3c9f14e1d844256cdd08f2cf3.jpg, createdBy=a30f1426910, createdName=swfzhanggui, createdTime=Wed Nov 15 02:26:55 CST 2017, time=2017-11-15, status=1, ipAttribution=)]
  5. [GetPortalCommentsPageByObjectIdResponse(id=1633831, encodeId=1c39163383129, content=<a href='/topic/show?id=578d13843ad' target=_blank style='color:#2F92EE;'>#PCI术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13843, encryptionId=578d13843ad, topicName=PCI术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ea4322051797, createdName=zxl736, createdTime=Mon Jul 23 15:45:00 CST 2018, time=2018-07-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1281857, encodeId=9281128185e23, content=<a href='/topic/show?id=21753963364' target=_blank style='color:#2F92EE;'>#呼吸困难#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39633, encryptionId=21753963364, topicName=呼吸困难)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=365d170, createdName=chenwq08, createdTime=Thu Nov 16 16:45:00 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1486425, encodeId=b46914864257d, content=<a href='/topic/show?id=76291384571' target=_blank style='color:#2F92EE;'>#PCI术后#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13845, encryptionId=76291384571, topicName=PCI术后)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=4ea78134582, createdName=12499e01m49暂无昵称, createdTime=Thu Nov 16 16:45:00 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261601, encodeId=ec0c26160194, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Thu Nov 16 05:30:25 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261379, encodeId=fc602613e91a, content=非常棒.认真学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo61WAV0ROeLAoicPxPKoKaogwLWLL8STv86qplbdOibN2YR4KxkJicqNectCXGR8gPJhGLc7yYLSdnpx4kaVXndTfu/0, createdBy=a6962042337, createdName=1391e9f2a7m, createdTime=Wed Nov 15 06:46:55 CST 2017, time=2017-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261375, encodeId=14ab2613e56e, content=谢谢分享.阅读, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2017/04/21/72142930668371951a41ef4ea4b233e6.jpg, createdBy=dcbc1715228, createdName=刘煜, createdTime=Wed Nov 15 06:41:20 CST 2017, time=2017-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261369, encodeId=457a261369a5, content=好好好好好好好好就, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Wed Nov 15 05:27:58 CST 2017, time=2017-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261367, encodeId=77da26136ec6, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/21/9461f3b3c9f14e1d844256cdd08f2cf3.jpg, createdBy=a30f1426910, createdName=swfzhanggui, createdTime=Wed Nov 15 02:26:55 CST 2017, time=2017-11-15, status=1, ipAttribution=)]
    2017-11-15 1391e9f2a7m

    非常棒.认真学习

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1633831, encodeId=1c39163383129, content=<a href='/topic/show?id=578d13843ad' target=_blank style='color:#2F92EE;'>#PCI术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13843, encryptionId=578d13843ad, topicName=PCI术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ea4322051797, createdName=zxl736, createdTime=Mon Jul 23 15:45:00 CST 2018, time=2018-07-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1281857, encodeId=9281128185e23, content=<a href='/topic/show?id=21753963364' target=_blank style='color:#2F92EE;'>#呼吸困难#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39633, encryptionId=21753963364, topicName=呼吸困难)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=365d170, createdName=chenwq08, createdTime=Thu Nov 16 16:45:00 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1486425, encodeId=b46914864257d, content=<a href='/topic/show?id=76291384571' target=_blank style='color:#2F92EE;'>#PCI术后#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13845, encryptionId=76291384571, topicName=PCI术后)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=4ea78134582, createdName=12499e01m49暂无昵称, createdTime=Thu Nov 16 16:45:00 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261601, encodeId=ec0c26160194, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Thu Nov 16 05:30:25 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261379, encodeId=fc602613e91a, content=非常棒.认真学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo61WAV0ROeLAoicPxPKoKaogwLWLL8STv86qplbdOibN2YR4KxkJicqNectCXGR8gPJhGLc7yYLSdnpx4kaVXndTfu/0, createdBy=a6962042337, createdName=1391e9f2a7m, createdTime=Wed Nov 15 06:46:55 CST 2017, time=2017-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261375, encodeId=14ab2613e56e, content=谢谢分享.阅读, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2017/04/21/72142930668371951a41ef4ea4b233e6.jpg, createdBy=dcbc1715228, createdName=刘煜, createdTime=Wed Nov 15 06:41:20 CST 2017, time=2017-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261369, encodeId=457a261369a5, content=好好好好好好好好就, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Wed Nov 15 05:27:58 CST 2017, time=2017-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261367, encodeId=77da26136ec6, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/21/9461f3b3c9f14e1d844256cdd08f2cf3.jpg, createdBy=a30f1426910, createdName=swfzhanggui, createdTime=Wed Nov 15 02:26:55 CST 2017, time=2017-11-15, status=1, ipAttribution=)]
    2017-11-15 刘煜

    谢谢分享.阅读

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=1633831, encodeId=1c39163383129, content=<a href='/topic/show?id=578d13843ad' target=_blank style='color:#2F92EE;'>#PCI术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13843, encryptionId=578d13843ad, topicName=PCI术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ea4322051797, createdName=zxl736, createdTime=Mon Jul 23 15:45:00 CST 2018, time=2018-07-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1281857, encodeId=9281128185e23, content=<a href='/topic/show?id=21753963364' target=_blank style='color:#2F92EE;'>#呼吸困难#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39633, encryptionId=21753963364, topicName=呼吸困难)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=365d170, createdName=chenwq08, createdTime=Thu Nov 16 16:45:00 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1486425, encodeId=b46914864257d, content=<a href='/topic/show?id=76291384571' target=_blank style='color:#2F92EE;'>#PCI术后#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13845, encryptionId=76291384571, topicName=PCI术后)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=4ea78134582, createdName=12499e01m49暂无昵称, createdTime=Thu Nov 16 16:45:00 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261601, encodeId=ec0c26160194, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Thu Nov 16 05:30:25 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261379, encodeId=fc602613e91a, content=非常棒.认真学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo61WAV0ROeLAoicPxPKoKaogwLWLL8STv86qplbdOibN2YR4KxkJicqNectCXGR8gPJhGLc7yYLSdnpx4kaVXndTfu/0, createdBy=a6962042337, createdName=1391e9f2a7m, createdTime=Wed Nov 15 06:46:55 CST 2017, time=2017-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261375, encodeId=14ab2613e56e, content=谢谢分享.阅读, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2017/04/21/72142930668371951a41ef4ea4b233e6.jpg, createdBy=dcbc1715228, createdName=刘煜, createdTime=Wed Nov 15 06:41:20 CST 2017, time=2017-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261369, encodeId=457a261369a5, content=好好好好好好好好就, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Wed Nov 15 05:27:58 CST 2017, time=2017-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261367, encodeId=77da26136ec6, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/21/9461f3b3c9f14e1d844256cdd08f2cf3.jpg, createdBy=a30f1426910, createdName=swfzhanggui, createdTime=Wed Nov 15 02:26:55 CST 2017, time=2017-11-15, status=1, ipAttribution=)]
    2017-11-15 yjs木玉

    好好好好好好好好就

    0

  8. [GetPortalCommentsPageByObjectIdResponse(id=1633831, encodeId=1c39163383129, content=<a href='/topic/show?id=578d13843ad' target=_blank style='color:#2F92EE;'>#PCI术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13843, encryptionId=578d13843ad, topicName=PCI术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ea4322051797, createdName=zxl736, createdTime=Mon Jul 23 15:45:00 CST 2018, time=2018-07-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1281857, encodeId=9281128185e23, content=<a href='/topic/show?id=21753963364' target=_blank style='color:#2F92EE;'>#呼吸困难#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39633, encryptionId=21753963364, topicName=呼吸困难)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=365d170, createdName=chenwq08, createdTime=Thu Nov 16 16:45:00 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1486425, encodeId=b46914864257d, content=<a href='/topic/show?id=76291384571' target=_blank style='color:#2F92EE;'>#PCI术后#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13845, encryptionId=76291384571, topicName=PCI术后)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=4ea78134582, createdName=12499e01m49暂无昵称, createdTime=Thu Nov 16 16:45:00 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261601, encodeId=ec0c26160194, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Thu Nov 16 05:30:25 CST 2017, time=2017-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261379, encodeId=fc602613e91a, content=非常棒.认真学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo61WAV0ROeLAoicPxPKoKaogwLWLL8STv86qplbdOibN2YR4KxkJicqNectCXGR8gPJhGLc7yYLSdnpx4kaVXndTfu/0, createdBy=a6962042337, createdName=1391e9f2a7m, createdTime=Wed Nov 15 06:46:55 CST 2017, time=2017-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261375, encodeId=14ab2613e56e, content=谢谢分享.阅读, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2017/04/21/72142930668371951a41ef4ea4b233e6.jpg, createdBy=dcbc1715228, createdName=刘煜, createdTime=Wed Nov 15 06:41:20 CST 2017, time=2017-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261369, encodeId=457a261369a5, content=好好好好好好好好就, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Wed Nov 15 05:27:58 CST 2017, time=2017-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=261367, encodeId=77da26136ec6, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/21/9461f3b3c9f14e1d844256cdd08f2cf3.jpg, createdBy=a30f1426910, createdName=swfzhanggui, createdTime=Wed Nov 15 02:26:55 CST 2017, time=2017-11-15, status=1, ipAttribution=)]
    2017-11-15 swfzhanggui

    学习了.谢谢分享

    0

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