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摘要: 目的:探讨急性心肌梗死合并左室游离壁破裂的早期预警症状及有效的检查方法,为急性心肌梗死合并游离壁破裂的早期识别提供临床参考。方法:回顾性分析2015年1月-2021年1月于武汉协和医院心内科CCU确诊为急性心肌梗死合并左室游离壁破裂的患者56例,并同时随机选取急性心肌梗死无左室游离壁破裂的患者60例作为对照组。分析两组间症状、体征、生化指标及胸部CT的心包积液CT值来判断左室游离壁破裂的早期预警症状及最佳诊断指标。结果:左室游离壁破裂患者中Ⅰ型破裂共22例(39.3%),其中前壁心肌梗死16例(72.7%),下后壁和(或)侧壁心肌梗死6例(27.3%),存活率仅为4.5%;Ⅱ型破裂共34例(60.7%),其中前壁心肌梗死4例(11.8%),下后壁和(或)侧壁心肌梗死30例(88.2%),存活率为82.3%。在诸多游离壁破裂的相关因素中,既往心绞痛病史和急诊PCI患者发生游离壁破裂的风险分别降低58%和47%;而合并再次胸痛、晕厥、烦躁等症状时提示急性心肌梗死患者发生游离壁破裂的风险分别增加2.03倍、1.72倍和1.48倍;同时,血压下降、中心静脉压、高敏C反应蛋白(hs-CRP)以及动脉血乳酸水平增高时发生左室游离壁破裂的风险均增高;心包积液CT值增高时发生游离壁破裂的风险增加3.45倍,其截点值为27时,诊断左室游离壁破裂具有最高的诊断价值,诊断敏感性为88.2%,特异性为92%,约登指数为0.802。结论:早期识别再次胸痛、晕厥、烦躁等症状以及血压下降、中心静脉压增高等体征,以及监测hs-CRP及动脉血乳酸水平,并通过胸部CT评估心包积液CT值对于预警心脏破裂具有重要价值。Abstract: Objective: To explore the early warning symptoms and practical examination of acute myocardial infarction complicated with left ventricular free wall rupture(FWR) and provide a reference for clinic practice.Methods: Fifty-six patients with acute myocardial infarction complicated with FWR diagnosed by CCU of Wuhan Union Hospital from January 2015 to January 2021 were analyzed retrospectively, and 60 patients with acute myocardial infarction without FWR were randomly selected as the control group. The symptoms, signs, biochemical indexes, and CT values of pericardial effusion on chest CT were analyzed to judge the early warning symptoms and the best diagnostic indexes of FWR.Results: There were 22 cases(39.3%) with type Ⅰ FWR, including 16 cases(72.7%) of the anterior wall myocardial infarction, 6 cases(27.3%) of the inferior posterior wall and/or lateral wall myocardial infarction, and the survival rate was only 4.5%. There were 34 cases(60.7%) of type Ⅱ rupture, including 4 cases(11.8%) of anterior wall myocardial infarction, and 30 cases(88.2%) of inferior posterior wall and/or lateral wall, and the survival rate was 82.3%. Among the related factors of FWR, patients with a previous history of angina pectoris and emergency PCI had a reduced risk of FWR by 58% and 47%, respectively. Patients with recurrent chest pain, syncope, and irritability had increased risk of FWR by 2.03, 1.72, and 1.48 times, respectively. Meanwhile, when patients with decreased blood pressure, increased central venous pressure, high sensitivity C-reactive protein(hs-CRP), and arterial blood lactate level, the risk of FWR increased. The risk of FWR increased 3.45 times when the CT value of pericardial effusion increased. When the cut-off value of chest CT of pericardial effusion was 27, it had the highest diagnostic value for the FWR with Youden's index of 0.802, the sensitivity was 88.2% and specificity was 92%.Conclusion: Early recognition of symptoms such as recurrent chest pain, syncope and irritability, as well as signs such as decreased blood pressure and increased central venous pressure, hs-CRP and arterial blood lactate level, and the CT value of pericardial effusion through chest CT have great value for the diagnosis of cardiac rupture.
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Key words:
- acute myocardial infarction /
- free wall rupture /
- mechanical complication /
- CT value
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