病例分享:心梗可不止会胸闷痛,这种情况你想到没?

2018-03-22 作者:王加伟 单位:惠州市第一人民医院 循环界

73岁男性,反复头痛6个月,劳累或受凉后诱发,休息后头痛通常会迅速缓解。6周前头痛再发加重,频率增加,较低水平活动可发生。同时运动中出现轻微胸痛,然而头痛更明显。既往有2型糖尿病病史10年,无周围神经病变或视网膜病变,仅有轻度肾损害(eGFR 50 mL/min/1.73 m2)。有创伤性硬膜下出血手术史6年,术后2年经磁共振明确诊断为脑梗死。

73岁男性,反复头痛6个月,劳累或受凉后诱发,休息后头痛通常会迅速缓解。6周前头痛再发加重,频率增加,较低水平活动可发生。同时运动中出现轻微胸痛,然而头痛更明显。既往有2型糖尿病病史10年,无周围神经病变或视网膜病变,仅有轻度肾损害(eGFR 50 mL/min/1.73 m2)。有创伤性硬膜下出血手术史6年,术后2年经磁共振明确诊断为脑梗死。

首先考虑脑部疾病,入院后行头部CT检查提示正常。颈部多普勒超声显示双侧颈内动脉50%狭窄。静息心电图正常。考虑到患者头痛跟活动有关,同时出现胸痛,结合患者有高龄、糖尿病及脑梗死等冠心病危险因素,还是要考虑冠心病。于是做了运动平板试验,患者在5分钟内因其典型的运动性头痛而终止,期间患者心电图可见下壁导联进行性水平型ST压低(图1),随后头痛缓慢消退。因此安排了冠状动脉造影检查,结果显示严重血管病变(图2)。

目前诊断为心源性头痛明确,并且患者在住院期间出现急性ST段抬高型心肌梗死,并伴有明显头痛,立即给予冠状动脉旁路移植手术,术后患者便一直没有头痛发作。



图1 运动平板试验,患者5分钟后心电图出现下壁导联ST段压低



图2 冠脉造影提示严重冠脉病变
 
劳力性心绞痛的典型症状为活动后出现的心前区压榨样胸闷痛,可向其他部位放射,休息后缓解。而严重的出现急性心梗,休息时也可以出现胸闷痛,并且程度更严重。冠心病的其他症状还包括呼吸困难、心悸、出汗、乏力,甚至晕厥等不典型症状,个别并无症状。这些都会使诊断变得困难。虽说国内外偶有报道以头痛为首要症状的冠心病病例,但总体而言还是比较少见。

心肌缺血缺氧时,尚未坏死的心肌细胞产生炎性介质以及肌苷、乳酸等疼痛因子刺激心脏交感神经末梢,经交感神经末梢传入椎旁交感神经节,再上行入丘脑,最后传到大脑皮层而产生疼痛。而此病例患者头痛的原因可能是心脏的刺激传到颈交感神经节,并经丘脑传至大脑皮层,而中枢误认为是头部传入所致。同时,患者为老年患者合并有糖尿病多年,对胸闷痛不如年轻人敏感。

本病例提示我们,非典型冠心病症状可能会延误诊断,如出现不能由脑源性解释的头痛症状,结合患者高龄、有糖尿病病史等危险因素,需警惕冠心病,应进行动态心电图、冠脉造影等检查以排除冠心病,以免延误诊治。

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  1. [GetPortalCommentsPageByObjectIdResponse(id=1341003, encodeId=15e61341003d2, content=<a href='/topic/show?id=27b98424ea9' target=_blank style='color:#2F92EE;'>#胸闷#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84247, encryptionId=27b98424ea9, topicName=胸闷)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=838d2500169, createdName=12498cb5m13暂无昵称, createdTime=Sat Mar 24 11:24:00 CST 2018, time=2018-03-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=299176, encodeId=90b12991e64f, content=很好的文章.好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Sat Mar 24 07:11:14 CST 2018, time=2018-03-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=298978, encodeId=82d52989e805, content=非常精彩的病历.获益匪浅.谢谢!, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c09d1605573, createdName=aa6081, createdTime=Fri Mar 23 16:03:18 CST 2018, time=2018-03-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=298717, encodeId=d132298e17f3, content=了解一下.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Thu Mar 22 21:57:21 CST 2018, time=2018-03-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=298699, encodeId=aee629869929, content=阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Thu Mar 22 21:08:19 CST 2018, time=2018-03-22, status=1, ipAttribution=)]
  2. [GetPortalCommentsPageByObjectIdResponse(id=1341003, encodeId=15e61341003d2, content=<a href='/topic/show?id=27b98424ea9' target=_blank style='color:#2F92EE;'>#胸闷#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84247, encryptionId=27b98424ea9, topicName=胸闷)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=838d2500169, createdName=12498cb5m13暂无昵称, createdTime=Sat Mar 24 11:24:00 CST 2018, time=2018-03-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=299176, encodeId=90b12991e64f, content=很好的文章.好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Sat Mar 24 07:11:14 CST 2018, time=2018-03-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=298978, encodeId=82d52989e805, content=非常精彩的病历.获益匪浅.谢谢!, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c09d1605573, createdName=aa6081, createdTime=Fri Mar 23 16:03:18 CST 2018, time=2018-03-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=298717, encodeId=d132298e17f3, content=了解一下.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Thu Mar 22 21:57:21 CST 2018, time=2018-03-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=298699, encodeId=aee629869929, content=阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Thu Mar 22 21:08:19 CST 2018, time=2018-03-22, status=1, ipAttribution=)]
    2018-03-24 张新亮1853311252142e2fm

    很好的文章.好好学习

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1341003, encodeId=15e61341003d2, content=<a href='/topic/show?id=27b98424ea9' target=_blank style='color:#2F92EE;'>#胸闷#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84247, encryptionId=27b98424ea9, topicName=胸闷)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=838d2500169, createdName=12498cb5m13暂无昵称, createdTime=Sat Mar 24 11:24:00 CST 2018, time=2018-03-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=299176, encodeId=90b12991e64f, content=很好的文章.好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Sat Mar 24 07:11:14 CST 2018, time=2018-03-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=298978, encodeId=82d52989e805, content=非常精彩的病历.获益匪浅.谢谢!, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c09d1605573, createdName=aa6081, createdTime=Fri Mar 23 16:03:18 CST 2018, time=2018-03-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=298717, encodeId=d132298e17f3, content=了解一下.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Thu Mar 22 21:57:21 CST 2018, time=2018-03-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=298699, encodeId=aee629869929, content=阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Thu Mar 22 21:08:19 CST 2018, time=2018-03-22, status=1, ipAttribution=)]
    2018-03-23 aa6081

    非常精彩的病历.获益匪浅.谢谢!

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1341003, encodeId=15e61341003d2, content=<a href='/topic/show?id=27b98424ea9' target=_blank style='color:#2F92EE;'>#胸闷#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84247, encryptionId=27b98424ea9, topicName=胸闷)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=838d2500169, createdName=12498cb5m13暂无昵称, createdTime=Sat Mar 24 11:24:00 CST 2018, time=2018-03-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=299176, encodeId=90b12991e64f, content=很好的文章.好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Sat Mar 24 07:11:14 CST 2018, time=2018-03-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=298978, encodeId=82d52989e805, content=非常精彩的病历.获益匪浅.谢谢!, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c09d1605573, createdName=aa6081, createdTime=Fri Mar 23 16:03:18 CST 2018, time=2018-03-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=298717, encodeId=d132298e17f3, content=了解一下.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Thu Mar 22 21:57:21 CST 2018, time=2018-03-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=298699, encodeId=aee629869929, content=阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Thu Mar 22 21:08:19 CST 2018, time=2018-03-22, status=1, ipAttribution=)]
    2018-03-22 天地飞扬

    了解一下.谢谢分享!

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1341003, encodeId=15e61341003d2, content=<a href='/topic/show?id=27b98424ea9' target=_blank style='color:#2F92EE;'>#胸闷#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84247, encryptionId=27b98424ea9, topicName=胸闷)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=838d2500169, createdName=12498cb5m13暂无昵称, createdTime=Sat Mar 24 11:24:00 CST 2018, time=2018-03-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=299176, encodeId=90b12991e64f, content=很好的文章.好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Sat Mar 24 07:11:14 CST 2018, time=2018-03-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=298978, encodeId=82d52989e805, content=非常精彩的病历.获益匪浅.谢谢!, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c09d1605573, createdName=aa6081, createdTime=Fri Mar 23 16:03:18 CST 2018, time=2018-03-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=298717, encodeId=d132298e17f3, content=了解一下.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Thu Mar 22 21:57:21 CST 2018, time=2018-03-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=298699, encodeId=aee629869929, content=阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Thu Mar 22 21:08:19 CST 2018, time=2018-03-22, status=1, ipAttribution=)]
    2018-03-22 神功盖世

    0

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