ST段神奇回落,这是哪路心梗?要立即置入支架么?

2019-02-18 武德崴 医学界心血管频道

你是否曾在值班时遇到这样的情况,患者因胸痛入院,ST段抬高,心肌酶阳性,诊断ST段抬高型心梗(STEMI)确切无疑。但是在急诊经皮冠脉介入治疗(PCI)的准备过程中,患者ST段奇迹般回落,胸痛症状也基本消失,下一步这个患者到底做不做急诊PCI?

你是否曾在值班时遇到这样的情况,患者因胸痛入院,ST段抬高,心肌酶阳性,诊断ST段抬高型心梗(STEMI)确切无疑。但是在急诊经皮冠脉介入治疗(PCI)的准备过程中,患者ST段奇迹般回落,胸痛症状也基本消失,下一步这个患者到底做不做急诊PCI?

血运重建前ST段神奇回落,这是哪路心梗?

ST段在血运重建前完全回落,这种情况称为短暂ST抬高型心肌梗死(Transient STEMI,TSTEMI)。TSTEMI并不罕见,据既往的观察性研究,4%-24%的STEMI患者表现为TSTEMI。在临床中,我们也经常遇到这样的患者。

然而,指南从未对TSTEMI患者的治疗做过推荐。到底应该依照STEMI进行即刻血运重建,还是参考非ST段抬高型心梗(NSTEMI),根据GRACE评分进行延迟血运重建,很多时候,我们仅能依靠术者的经验和精力做出决定,缺乏可靠的循证医学证据。

近期在《欧洲心脏杂志(European Heart Journal)》发表的TRANSIENT研究对这一问题进行了探讨。

即刻PCI vs 延迟PCI,孰优孰劣?

TRANSIENT研究是一项多中心随机对照试验,入选患者符合以下条件:

入院前出现急性心肌梗死临床症状,同时伴有心电图2个以上相邻导联的ST段抬高;

无论院前是否接受过治疗(溶栓除外),入院时症状已完全缓解,ST段完全回落。

研究共入选142例患者,随机分为即刻干预组和延迟干预组,即刻干预组即刻接受造影检查(中位时间0.3h),延迟干预组根据GRACE评分进行延迟造影检查(>140分24小时内进行,≤140分72小时内进行,中位时间22.7h)。

研究的首要终点是发病第4天心脏磁共振检查测量的梗死面积,次要终点是肌酸激酶同工酶(CK-MB)或肌钙蛋白I(TnI)的曲线下面积以及心脏磁共振测量的左室射血分数,同时评估了两种治疗方式下30天的主要不良血管事件(MACE)发生率。

结果表明,两组患者的平均梗死面积无显着差异(即刻组vs延迟组,1.3%vs 1.5%,P=0.48),30天的MACE无显着差异(即刻组vs延迟组,2.9%vs2.8%,P=1.00)。

不过,延迟组中有4例患者因出现胸痛复发而接受了即刻PCI术。该研究表明,TSTEMI患者即刻PCI治疗和延迟PCI治疗相比,在梗死面积和短期预后方面并未见到显着差异。

陌生不要紧,记住这3个要点!

TRANSIENT研究是第一项评估TSTEMI患者治疗时机的随机对照试验。既往有过类似主题的研究,如ELISA-3试验的事后分析和一些观察性研究也提示类似的结论。这些研究让我们对TSTEMI有了更加深入的认识。

1.TSTEMI是一种相对低危的心肌梗死

在ST段持续抬高的心肌梗死患者中,心脏MR测定的梗死面积多在10%左右,而TSTEMI的梗死范围仅有1%左右;30天3%左右的MACE事件发生率也低于常规的STEMI患者(10%左右)。

因此,大多数TSTEMI的缺血风险远低于常规的STEMI患者。不过,仍有患者在症状缓解,ST段回落后出现症状复发,ST段再次抬高,此时应考虑再梗死的可能性,虽然并无正式的研究数据评估这类患者的预后,但是根据临床经验还是应当将这中情况归为高危患者,在本研究中同样有4例延迟PCI组患者因ST段的再次抬高而接受了即刻PCI治疗。

2.血流是否再通是PCI时机的重要参考

即刻PCI治疗对于缺血高危患者可以迅速开通闭塞血管,挽救梗死心肌。同时也存在诸多风险,急性期患者血栓负荷较重,早期的机械干预可能会导致微血栓堵塞微血管,造成无复流;同时,机械刺激也可能导致新发斑块破裂和新的血栓事件。

延迟PCI可以通过前期的药物治疗稳定破裂斑块,减轻血栓负荷,降低PCI过程中无复流的发生率。因此,对于血流再通的STEMI患者,可以考虑进行延迟PCI治疗。

3.通过症状缓解和ST段回落判断血管是否再通

在所有入选患者中,除1例即刻PCI组患者以及2例ST段再次抬高的患者外,其他所有患者均达到TIMI2级以上血流,并有超过90%的患者达到TIMI3级血流。同时,出现ST段再次抬高是血管再次闭塞的重要体现,4例患者中有2例出现了TIMI0-1级血流。因此,对于STEMI患者,心电图的动态观察和症状的评估对指导其预后非常重要。

结语

TRANSIENT研究可以为TSTEMI患者的治疗提供重要的参考:对于ST段完全回落,症状完全缓解的患者,可以依照NSTEMI的处理方式决定治疗时机,行延迟造影检查,同时加强抗栓治疗和稳定斑块治疗。若等待过程中出现ST段再次抬高或胸痛再发,则应参照STEMI,行即刻PCI治疗。

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    2019-02-19 hyf035
  2. [GetPortalCommentsPageByObjectIdResponse(id=1624406, encodeId=8da71624406c6, content=<a href='/topic/show?id=f27b16862d9' target=_blank style='color:#2F92EE;'>#ST段#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=16862, encryptionId=f27b16862d9, topicName=ST段)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=676820671866, createdName=hyf035, createdTime=Tue Feb 19 16:04:00 CST 2019, time=2019-02-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=360935, encodeId=002b3609357f, content=好文章,点赞啦!认真学习,谢谢分享给广大同好!, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRuUXgacXpPeW0x8Z3Qr9c3I2kTic4ZIpR29iaftYgkjRcbv982icYMtqANBPYBgPnOia6mVtX76qMXuc/0, createdBy=d85d1636106, createdName=lietome2, createdTime=Mon Feb 18 11:36:25 CST 2019, time=2019-02-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=360912, encodeId=b4dc36091285, content=心肌梗塞的诊断, beContent=null, objectType=article, channel=null, level=null, likeNumber=81, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160718/IMG578C993D395567540.jpg, createdBy=59b81918946, createdName=flysky120, createdTime=Mon Feb 18 09:11:33 CST 2019, time=2019-02-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=360908, encodeId=ba5c36090891, content=很好的学习机会, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/04/12/cd30eefc465f70dc4dad89bd57479781.jpg, createdBy=02be2318568, createdName=一天没事干, createdTime=Mon Feb 18 08:44:51 CST 2019, time=2019-02-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=360893, encodeId=8b6c36089361, content=学习学习学习学习, 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/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Mon Feb 18 05:34:02 CST 2019, time=2019-02-18, status=1, ipAttribution=)]
    2019-02-18 lietome2

    好文章,点赞啦!认真学习,谢谢分享给广大同好!

    0

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    2019-02-18 flysky120

    心肌梗塞的诊断

    0

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    2019-02-18 一天没事干

    很好的学习机会

    0

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    2019-02-18 yjs木玉

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心电图 ST 段读图四步法

第一步确定等电位线(基线)我们都知道 ST 段的改变要和心电图上的等电位做比较,那么等电位线在哪里?等电位线其实是一个抽象的定义,有点类似于海平面的概念。当窦房结的冲动传导到心室时,十多亿个心室的心肌细胞在很短的时间,共同除极,它们释放总电流形成高而窄的 QRS 波。然后它们一起开始午休。好比在中午 12 点到 2 点,这十多亿个心肌细胞一起进入动作电位 2 时相的平台期,一起睡午觉,这一段叫 S

病例分享:胸痛+ST段抬高+肌钙蛋白升高,不一定就是心梗!

骑白马的不一定是唐僧,还可能是我们心目中万分期待的王子。因此,当胸痛+ST段抬高+肌钙蛋白(cTn)升高找上门时,其背后的元凶也许并不十分可怕,而是急性心梗的“最善意的模仿者”。

ST段呈动态演变的de Winter综合征1例

患者男性,43岁,因"突发胸痛6 h"于2017年11月23日入院。患者入院6 h前劳累后突感胸痛,持续不可缓解,由急救车送入我院急诊,急救车中行心电图示Ⅱ、aVF、V2~V6导联J点下移,伴ST段上斜型压低,aVR导联ST段轻度抬高(图1)。

满视野ST段抬高,快速定位3步走!

图1来自67岁的老年男性,患者间断胸痛6年,活动时明显,每次于快速步行1000米或登楼梯4层即出现胸骨后闷痛,休息5-10min可自行缓解,本次休息时出现胸骨后压榨性疼痛,持续2小时不能缓解,伴明显大汗、头晕,测血压80/50 mmHg,心率80 次/分,为进一步诊治收入急诊。患者入院心电图可见多导联的ST段抬高(如图1)。

NEJM:活久见! 碰上一个ST段压低36年的“没事人”

心肌缺血的心电图表现会持续数十年吗?