Global biventricular dysfunction in patients with asymptomatic coronary artery disease may be caused by myocarditis
Global biventricular dysfunction in patients with asymptomatic coronary artery disease may be caused by myocarditis
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DOI：
10.1161/01.cir.99.10.1295
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发表时间：
1999-03-16
期刊：
影响因子：
37.8
通讯作者：
Maseri, A
中科院分区：
文献类型：
--
作者：
Frustaci, A;Chimenti, C;Maseri, A
方法和结果：291名年龄40岁的患者接受了无创(二维超声心动图)和有创(导管术、冠状动脉造影术和双室心内膜心肌活检)的心脏研究，每名患者因进行性心力衰竭(纽约心脏协会功能III级或IV级)而进行心脏研究，其中7名患者(2.4%；7名男性；平均年龄49±6.9岁)有严重冠状动脉病变(4例3支，1例2支，左前降支近端闭塞2例)。二维超声心动图显示左心室舒张末内径和射血分数分别为73±10.5 mm和23+/-6.5%，右室舒张末内径和射血分数分别为39+/-7 mm和29+/-7.2%。活检标本显示，所有患者(5例有纤维性心肌炎，2例无纤维性心肌炎)均有广泛的淋巴细胞浸润，局部肌溶解符合Dallas心肌炎诊断标准。用间接免疫荧光法检测了2例活动期心肌炎患者血清中的心脏自身抗体。2例活动期炎症患者在常规心力衰竭药物治疗的基础上加用泼尼松(1 mg·kg(-1)·d(-1))治疗4周，随后给予0.33 mg·kg(-1)·d(-1)治疗5个月)和硫唑嘌呤(2 mg·kg(-1)·d(-1)治疗5个月)。在8个月的总体随访中，免疫抑制患者的心脏容量和功能显著改善，而常规治疗的患者心脏容量和功能保持不变，其中我死亡。结论-严重无症状冠状动脉疾病患者的整体双室功能障碍可能是由心肌炎引起的，以前没有心肌梗死的证据。组织学结果可能会影响治疗。
Background-The causal role of asymptomatic critical coronary artery obstruction in patients presenting with severe global biventricular dysfunction but no evidence of myocardial infarction is uncertain.Methods and Results-Among 291 patients aged >40 years undergoing a noninvasive (2-dimensional echocardiography) and invasive (catheterization, coronary angiography, and biventricular endomyocardial biopsy, 6 to 8 samples/patient) cardiac study because of progressive heart failure (New York Heart Association functional class III or IV) with global biventricular dysfunction and no history of myocardial ischemic events, 7 patients (2.4%; 7 men; mean age, 49+/-6.9 years) had severe coronary artery disease (3 vessels in 4 patients; 2 vessels in 1 patient, proximal occlusion of left anterior descending coronary artery in 2 patients). Left ventricular end-diastolic diameter and ejection fraction by 2-dimensional echocardiography were 73+/-10.5 mm and 23+/-6.5%, respectively, and right ventricular end-diastolic diameter and ejection fraction were 39+/-7 mm and 29+/-7.2%, respectively. Biopsy specimens showed extensive lymphocytic infiltrates with focal myocytolysis meeting the Dallas criteria for myocarditis in all patients (in 5 patients with and 2 patients without fibrosis). Cardiac autoantibodies were detected with indirect immunofluorescence in the serum of 2 patients with active myocarditis. The 2 patients with active inflammation received prednisone (1 mg.kg(-1).d(-1) for 4 weeks followed by 0.33 mg.kg(-1).d(-1) for 5 months) and azathioprine (2 mg.kg(-1).d(-1) for 5 months) in addition to conventional drug therapy for heart failure. At 8-month overall follow-up, cardiac volume and function improved considerably in immunosuppressed patients but remained unchanged in conventionally treated patients, of whom I died.Conclusions-Global biventricular dysfunction in patients with severe asymptomatic coronary artery disease and no evidence of previous myocardial infarction may be caused by myocarditis. Histologic findings may influence the treatment.