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一、公共神經(jīng)內(nèi)科的概念與特征
背景
研究人員已報告了由情感應激所引起的可逆性左心室功能障礙，但對其機制尚不了解。
BACKGROUND Reversible left ventricular
dysfunction precipitated by emotional stress has
been reported, but the mechanism remains unknown.
方法
我們對情感應激后有左心室功能障礙表現(xiàn)的19例病人進行評估。所有病人均接受冠狀動脈造影和(定期)連續(xù)的超聲心動圖檢查，5例接受心內(nèi)膜心肌活檢。檢測了13例應激相關的心肌功能不全病人血漿兒茶酚胺水平，并將其與7例Killip分級Ⅲ級的心肌梗死病人進行比較。
METHODS We evaluated 19 patients who presented
with left ventricular dysfunction after sudden
emotional stress. All patients underwent coronary
angiography and serial echocardiography; five
underwent endomyocardial biopsy. Plasma
catecholamine levels in 13 patients with
stress-related myocardial dysfunction were compared
with those in 7 patients with Killip class Ⅲ
myocardial infarction.
結果
應激引起的心肌病病人的中位年齡為63歲，95%為女性。臨床表現(xiàn)包括胸痛、肺水腫和心源性休克等。大多數(shù)病人有廣泛性T波倒置和QT間期延長。17例病人有血清肌鈣蛋白Ⅰ輕度升高，但19例病人中僅1例存在有臨床意義的冠心病血管造影檢查證據(jù)。所有病人入院時有嚴重的左心室功能障礙(射血分數(shù)的中位值為
0.20，四分位數(shù)間距為0.15～0.30)，但均迅速緩解(2～4周時的射血分數(shù)中位值為0.60，四分位數(shù)間距為0.55～0.65，P<
0.001)。心內(nèi)膜活檢有單個核細胞浸潤與收縮帶壞死的表現(xiàn)，應激導致的心肌病病人就診時血漿兒茶酚胺水平顯著高于Killip分級Ⅲ級的心肌梗死病人
[腎上腺素水平的中位值為1264 pg/ml(四分位間距范圍為916～1374
pg/ml)對376 pg/ml (四分位間距范圍為275～476
pg/ml)，去甲腎上腺素水平的中位值為2284
pg/ml(四分位間距范圍為1709～2910 pg/ml)對1100
pg/ml(四分位間距范圍為914～1320 pg/ml)，多巴胺水平的中位值為111
pg/ml(四分位間距范圍為106～146 pg/ml)對61
pg/ml(四分位間距范圍為46～77 pg/ml)，所有的比較P值均<0.005]
RESULTS The median age of patients with
stress-induced cardiomyopathy was 63 years, and 95
percent were women. Clinical presentations included
chest pain, pulmonary edema, and cardiogenic shock.
Diffuse T-wave inversion and a prolonged QT interval
occurred in most patients. Seventeen patients had
mildly elevated serum troponin I levels, but only 1
of 19 had angiographic evidence of clinically
significant coronary disease. Severe left
ventricular dysfunction was present on admission
(median ejection fraction, 0.20; interquartile
range, 0.15 to 0.30) and rapidly resolved in all
patients (ejection fraction at two to four weeks,
0.60; interquartile range, 0.55 to 0.65;
P<0.001). Endomyocardial biopsy showed
mononuclear infiltrates and contraction-band
necrosis. Plasma catecholamine levels at
presentation were markedly higher among patients
with stress induced cardiomyopathy than among those
with Killip class III myocardial infarction (median
epinephrine level, 1264 pg per milliliter [interquartile
range, 916 to 1374] vs. 376 pg per milliliter [interquartile
range, 275 to 476]; norepinephrine level, 2284 pg
per milliliter [interquartile range, 1709 to 2910]
vs. 1100 pg per milliliter [interquartile range, 914
to 1320]; and dopamine level, 111 pg per milliliter
[interquartile range, 106 to 146] vs. 61 pg per
milliliter [interquartile range, 46 to 77];
P<0.005 for all comparisons).
結論
情感應激可導致無冠心病的病人發(fā)生嚴重的、可逆的左心室功能障礙。對于該綜合征的發(fā)生原因，夸張的交感神經(jīng)刺激可能十分重要。
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