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摘要: 免疫检查点抑制剂(immune checkpoint inhibitor，ICI)是肿瘤治疗的一大突破，在临床应用日益广泛。ICI相关心肌炎是ICI药物的罕见不良反应之一，病死率较高。尽管国内外均报道了该不良反应的治疗经验和指南，但部分医生在临床工作中仍存在认知不足、监管评估方案缺乏等问题。故本文对ICI相关心肌炎发病机制、诊断、治疗策略进行综述，以提高肿瘤科及心脏科医师的认识。Abstract: Immune checkpoint inhibitors (ICI) are a major breakthrough in oncology treatment and are increasingly used in clinical practice. ICI-associated myocarditis is one of the rare adverse reactions to ICI drugs, with a high mortality rate. Guidelines for treating this adverse reaction have been written both domestically and internationally at home and abroad. However, there is still a lack of awareness and reliable regulatory assessment protocols in clinical work. Therefore, this article reviews the pathogenesis, diagnosis, and treatment strategies of ICI-associated myocarditis in order to raise the awareness of oncologists and cardiologists.
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Key words:
- myocarditis /
- immune checkpoint inhibitor
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表 1 ICI相关心肌炎分级及治疗
Table 1. Grading and treatment of ICI-associated myocarditis
项目 1级 2级 3级 4级 症状 亚临床心肌损伤 轻微症状 明显的心血管症状 明显的心血管症状或危及生命 辅助检查 心脏损伤标志物轻度升高，心电图异常 心肌标志物水平升高，心电图异常 心脏彩超提示LVEF＜50%或室壁局部节段运动异常，CRB确诊或疑似诊断为心肌炎 如心电图提示室性心动过速，心脏彩超提示严重的心功能下降等危及生命的检查 重启免疫 病情稳定后可重启免疫治疗 病情稳定后可重启免疫治疗 有3级心肌炎、肺炎、肾炎、肝炎和严重神经系统毒性者永久停用ICI；若患者心肌炎病情稳定后评估后续免疫治疗获益较大，则可重启免疫治疗 永不重启免疫治疗 多学科会诊 心血管科会诊 心血管科会诊，积极处置基础疾病 多学科会诊 多学科会诊 治疗 甲泼尼龙1~4 mg/kg/d持续3~5 d，后逐渐减量，心脏损伤指标恢复基线水平后继续激素治疗2~4周 甲泼尼龙1~4 mg/kg/d持续3~5 d，后逐渐减量，心脏损伤指标恢复基线水平后继续激素治疗2~4周 甲泼尼龙500~1 000 mg/d，持续3~5 d，后逐渐减量，心脏损伤指标恢复基线水平后继续激素治疗4周 大剂量激素脉冲治疗24 h无效考虑加用ATG/英夫利西单抗(重度心力衰竭患者禁用) 
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