自发性冠状动脉夹层一例诊治分析并文献复习

doi:10.12114/j.issn.1007-9572.2018.00.361

摘要/Abstract

摘要： 目的　提高对自发性冠状动脉夹层的发病机制、临床特征、诊断和治疗的认识。方法　2017-11-29 1例胸痛患者入住浙江省人民医院，诊断为自发性冠状动脉夹层，分析患者的诊治过程并进行相关文献复习。结果　1例45岁女性患者，因“一次跳跃动作后胸痛10 h”入院，肌钙蛋白I阳性，心电图示V1~V5导联ST段抬高，冠状动脉造影示左前降支远段鼠尾征，诊断为自发性冠状动脉夹层。经皮冠状动脉介入术（PCI）后予抗血小板、抗凝、降脂稳定斑块、抑制心肌重塑、营养心肌改善微循环等对症支持治疗，患者胸痛症状逐渐改善。随访半年时间内胸痛症状未再发。结论　自发性冠状动脉夹层与冠状动脉粥样硬化性心脏病引起急性冠状动脉综合征临床表现相似，鉴别困难，而治疗和预后相距甚远。复习相关文献，提高对自发性冠状动脉夹层的认识，利于鉴别诊断。

关键词: 动脉瘤, 夹层；自发性冠状动脉夹层；胸痛；病例报告；历史文献

Abstract: Objective　To improve the understanding of pathogenesis，clinical features，diagnosis and treatment of spontaneous coronary artery dissection.Methods　One patient with chest pain was admitted to Zhejiang Provincial People's Hospital in 29 November 2017，diagnosed with spontaneous coronary artery dissection.The diagnosis and treatment process of the patient were analyzed and related literature was reviewed.Results　 A 45-year-old female patient was admitted to the hospital because of chest pain for 10 hours after a jump.Troponin I was positive，electrocardiogram （ECG）showed V1-V5 lead ST segment elevation.Coronary arteriongraphy showed rat tail sign in the anterior descending artery，and she was diagnosed as spontaneous coronary artery dissection.After percutaneous coronary intervention （PCI），antiplatelet，anticoagulation，lipid-lowering and plaque stabilization，inhibition of myocardial remodeling，nutritional myocardium for microcirculation were given in symptomatic supportive treatment.The symptom of chest pain was gradually improved.Chest pain did not recur in half a year after follow-up.Conclusion　 It is difficult to distinguish spontaneous coronary artery dissection with acute coronary syndrome due to coronary atherosclerotic heart disease，but the treatment and prognosis of them are so different.Reviewing relevant literature can improve the understanding of spontaneous coronary artery dissection，and facilitate differential diagnosis.

Key words: Aneurysm, dissecting；Spontaneous coronary artery dissection；Chest pain；Case reports；Historical article

倪飞华,屈百鸣,陈曦,等. 自发性冠状动脉夹层一例诊治分析并文献复习[J]. 中国全科医学, 2019, 22(14): 1746-1750. DOI: 10.12114/j.issn.1007-9572.2018.00.361.
NI Feihua,QU Baiming,CHEN Xi, et al. Spontaneous Coronary Artery Dissection：One Case Report and Literature Review　[J]. Chinese General Practice, 2019, 22(14): 1746-1750. DOI: 10.12114/j.issn.1007-9572.2018.00.361.

参考文献

［1］ADLAM D，ALFONSO F，MAAS A，et al．European Society of Cardiology，acut cardiovascular care association，SCAD study group：a position paper on spontaneous coronary artery dissection［J］.Eur Heart J，2018，39（36）：3353-3368.
［2］SABATINE M S，JAFFER F A，STAATS P N，et al．Case records of the Massachusetts General Hospital.Case 28-1010.A 32-year-old woman，3 weeks post partum，with substernal chest pain［J］.N Engl J Med，2010，363（12）：1164-1173.
［3］SAW J，MANCINI G B J，HUMPHRIES K H.Contemporary review on spontaneous coronary artery dissection［J］.J Am Coll Cardiol，2016，68（3）：297-312.DOI：10.1016/j.jacc.2016.05.034.
［4］NISHIGUCHI T，TANAKA A，OZAKI Y，et al．Prevalence of spontaneous coronary artery dissection in patients with acute coronary syndrome［J］.Eur Heart J Acute Cardiovasc Care，2016，5（3）：263-270.DOI：10.1177/2048872613504310.
［5］VANZETTO G，BERGER-COZ E，BARONE-ROCHETTE G，et al．Prevalence，therapeutic management and medium-term prognosis of spontaneous coronary artery dissection：results from a database of 11，605 patients［J］.Eur J Cardiothorac Surg，2009，35（2）：250-254.DOI：10.1016/j.ejcts.2008.10.023.
［6］NAKASHIMA T，NOGUCHI T，HARUTA S，et al．Prognostic impact of spontaneous coronary artery dissection in young female patients with acute myocardial infarction：a report from the Angina Pectoris-Myocardial Infarction Multicenter Investigators in Japan［J］.Int J Cardiol，2016，207：341-348.
［7］SAW J，RICCI D，STAROVOYTOV A，et al．Spontaneous coronary artery dissection：prevalence of predisposing conditions including fibromuscular dysplasia in a tertiary center cohort［J］.JACC Cardiovasc Interv，2013，6（1）：44-52.
［8］SAW J，AYMONG E，SEDLAK T，et al．Spontaneous coronary artery dissection：association with predisposing arteriopathies and precipitating stressors and cardiovascular outcomes［J］.Circ Cardiovasc Interv，2014，7（5）：645-655.
［9］ROGOWSKI S，MAEDER M T，WEILENMANN D，et al．Spontaneous coronary artery dissection：angiographic follow-up and long-term clinical outcome in a predominantly medically treated population［J］.Catheter Cardiovasc Interv，2017，89（1）：59-68.DOI：10.1002/ccd.26383.
［10］ELKAYAM U，JALNAPURKAR S，BARAKKAT M N，et al．Pregnancy-associated acute myocardial infarction：a review of contemporary experience in 150 cases between 2006 and 2011［J］.Circulation，2014，129（16）：1695-1702.
［11］FAHMY P，PRAKASH R，STAROVOYTOV A，et al．Pre-disposing and precipitating factors in men with spontaneous coronary artery dissection［J］.JACC Cardiovasc Interv，2016，9（8）：866-868.DOI：10.1016/j.jcin.2016.02.024.
［12］TWEET M S，HAYES S N，CODSI E，et al．Spontaneous coronary artery dissection associated with pregnancy［J］.J Am Coll Cardiol，2017，70（4）：426-435.
［13］CODSI E，TWEET M S，ROSE C H，et al．Spontaneous coronary artery dissection in pregnancy：what every obstetrician should know［J］.Obstet Gynecol，2016，128（4）：731-738.
［14］HAVAKUK O，GOLAND S，MEHRA A，et al．Pregnancy and the risk of spontaneous coronary artery dissection：an analysis of 120 contemporary cases［J］.Circ Cardiovasc Interv，2017，10（3）：e004941.DOI：10.1161/CIRCINTERVENTIONS.117.004941.
［15］PERSU A，GIAVARINI A，TOUZE E，et al．European consensus on the diagnosis and management of fibromuscular dysplasia［J］.J Hypertens，2014，32（7）：1367-1378.
［16］PERSU A，VAN DER NIEPEN P，TOUZE E，et al．Revisiting fibromuscular dysplasia：rationale of the European fibromuscular dysplasia initiative［J］.Hypertension，2016，68（4）：832-839.DOI：10.1161/HYPERTENSIONAHA.116.07543.
［17］ELEID M F，G UDDETI R R，TWEET M S，et al．Coronary artery tortuosity in spontaneous coronary artery dissection：angiographic characteristics and clinical implications［J］.Circ Cardiovasc Interv，2014，7（5）：656-662.
［18］PRASAD M，TWEET M S，HAYES S N，et al．Prevalence of extracoronary vascular abnormalities and fibromuscular dysplasia in patients with spontaneous coronary artery dissection［J］.Am J Cardiol，2015，115（12）：1672-1677.
［19］LYISOY A，AGAC M T，CELIK T，et al．Spontaneous dissection of left main coronary artery associated with hypertensive crisis：a probable fatal complication detected by intravascular ultrasound［J］.Int J Cardiol，2010，139（1）：e5-7.
［20］BALAKRISHNAN K，SCOTT P，OLIVER L.A confluence of circumstances：a case of IVF，extreme exercise and spontaneous coronary artery dissection［J］.Int J Cardiol，2016，203：76-77.
［21］HENKIN S，NEGROTTO S M，TWEET M S，et al．Spontaneous coronary artery dissection and its association with heritable connective tissue disorders［J］.Heart，2016，102（11）：876-881.DOI：10.1136/heartjnl-2015-308645.
［22］GOEL K，TWEET M，OLSON T M，et al．Familial spontaneous coronary artery dissection：evidence for genetic susceptibility［J］.JAMA Intern Med，2015，175（5）：821-826.
［23］TWEET M S，GULATI R，WILLIAMSON E E，et al．Multimodality imaging for spontaneous coronary artery dissection in women［J］.JACC Cardiovasc Imaging，2016，9（4）：436-450.
［24］SAW J，MANCINI G B，HUMPHRIES K，et al．Angiographic appearance of spontaneous coronary artery dissection with intramural hematoma proven on intracoronary imaging［J］.Catheter Cardiovasc Interv，2016，87（2）：E54-61.DOI：10.1002/ccd.26022.
［25］JOVIC Z，OBRADOVIC S，DJENIC N，et al．Does thrombolytic therapy harm or help in ST elevation myocardial infarction （STEMI） caused by the spontaneous coronary dissection?［J］.Vojnosanit Pregl，2015，72（6）：536-540.
［26］ZUPAN I，NOC M，TRINKAUS D，et al．Double vessel extension of spontaneous left main coronary artery dissection in young women treated with thrombolytics［J］.Catheter Cardiovasc Interv，2001，52（2）：226-230.
［27］GOH A C，LUNDSTRON R J.Spontaneous coronary artery dissection with cardic tamponade［J］.Tex Heart Inst J，2015，42：479-482.DOI：10.14503/THIJ-14-4260.
［28］IBANEZ B，JAMES S，AGEWALL S，et al．2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation［J］.Rev Esp Cardiol（Engl Ed），2017，70（12）：1082.DOI：10.1016/j.rec.2017.11.010.
［29］SAW J，HUMPHRIES K，AYMONG E，et al．Spontaneous coronary artery dissection：clinical outcomes and risk of recurrence［J］.J Am Coll Cardiol，2017，70（9）：1148-1158.
［30］TWEET M S，HAYES S N，PITTA S R，et al．Clinical features，management，and prognosis of spontaneous coronary artery dissection［J］.Circulation，2012，126（5）：579-588.
［31］AL-HUSSAINI A，ADLAM D.Spontaneous coronary artery dissection［J］.Heart，2017，103（13）：1043-1051.
［32］GUO L Q，WASFY M M，HEDGIRE S，et al．Multimodality imaging of spontaneous coronary artery dissection：case studies of the Massachusetts General Hospital［J］.Coron Artery Dis，2016，27（1）：70-71.DOI：10.1097/MCA.0000000000000320.

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