VIRAL MYOCARDITIS MIMICKING ACUTE MYOCARDIAL-INFARCTION
VIRAL MYOCARDITIS MIMICKING ACUTE MYOCARDIAL-INFARCTION
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DOI：
10.1016/0735-1097(92)90141-9
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发表时间：
1992-07-01
影响因子：
24
通讯作者：
PALACIOS, I
中科院分区：
文献类型：
--
作者：
DEC, GW;WALDMAN, H;PALACIOS, I
坊间报道显示，心肌炎可以模仿急性心肌梗死，伴有胸痛、心电图异常、血清肌酸激酶升高和血流动力学不稳定。对34例临床症状和体征符合急性心肌梗死的患者，在冠状动脉造影确认正常解剖后的6.5年间，行右室心肌膜活检。34例患者中有11例经组织学检查发现心肌炎。3例（27%）心肌炎患者在入院后6小时内发生需要主动脉内球囊支持的心源性休克。心肌炎组平均年龄42±5岁。6例患者（54%）既往有病毒性疾病。心电图异常多种多样，包括ST段抬高（n = 6）、T波反转（n = 3）、ST段下降（n = 2）和病理性Q波（n = 2）。心电图异常主要见于前心前导联，但在3例患者中弥漫性明显。6例患者左心室功能正常，其余5例患者左心室功能整体下降，其射血分数从14%到45%不等。10例诊断为淋巴细胞性心肌炎，其余患者诊断为巨细胞性心肌炎。4例左心室功能受损的患者接受了强的松和硫唑嘌呤（n = 2）或环孢素（n = 2）的免疫抑制治疗。入院时左心室功能正常的6例患者均按功能1级存活。在5例收缩功能受损的患者中，4例接受免疫抑制治疗的患者中有3例在治疗3个月内射血分数恢复正常，1例仅接受支持治疗的患者射血分数恢复正常。所有需要主动脉内球囊泵支持的患者存活至出院。一例巨细胞心肌炎患者在18个月时因进行性心力衰竭而死亡。缺血性胸痛综合征患者应在临床上怀疑心肌炎，特别是当心电图异常超出单一血管分布，缺乏节段性壁运动异常或心室造影显示整体左室运动不足时。冠状动脉解剖正常后，应考虑右心室心肌内膜活检，因为这些心肌炎患者长期预后良好，不需要抗缺血治疗。
Anecdotal reports have shown that myocarditis can mimic acute myocardial infarction with chest pain, electrocardiographic (ECG) abnormalities, serum creatine kinase elevation and hemodynamic instability. Thirty-four patients with clinical signs and symptoms consistent with acute myocardial infarction underwent right ventricular endomyocardial biopsy during a 6.5-year period after angiographic identification of normal coronary anatomy. Myocarditis was found on histologic study in 11 of these 34 patients. Cardiogenic shock requiring intraaortic balloon support developed within 6 h of admission in three (27 %) of the patients with myocarditis.The mean age of the group with myocarditis was 42 +/- 5 years. A preceding viral illness had been present in six patients (54 %). The ECG abnormalities were varied and included ST segment elevation (n = 6), T wave inversions (n = 3), ST segment depression (n = 2) and pathologic Q waves (n = 2). The ECG abnormalities were typically seen in the anterior precordial leads but were diffusely evident in three patients. Left ventricular function was normal in six patients and globally decreased in the remaining five patients, whose ejection fraction ranged from 14 % to 45 %. Lymphocytic myocarditis was diagnosed in 10 patients, and giant cell myocarditis was detected in the remaining patient. Four patients with impaired left ventricular function received immunosuppressive therapy with prednisone and either azathioprine (n = 2) or cyclosporine (n = 2).All six patients whose left ventricular function was normal on admission remain alive in functional class 1. Of the five patients with impaired systolic function, ejection fraction normalized in three of the four patients who received immunosuppressive therapy within 3 months of treatment and in the one patient who received only supportive therapy. All patients who required intraaortic balloon pump support survived to discharge. One death, due to progressive heart failure, occurred at 18 months in the patient with giant cell myocarditis.Myocarditis should be clinically suspected in patients with an ischemic chest pain syndrome, particularly when ECG abnormalities are present beyond a single vascular distribution, segmental wall motion abnormalities are lacking or global left ventricular hypokinesia is present on ventriculography. The subsequent demonstration of normal coronary anatomy should prompt consideration of right ventricular endomyocardial biopsy, because those patients with myocarditis have an excellent long-term prognosis and do not require anti-ischemic therapy.