光学相干断层成像指导治疗变异型心绞痛1例并文献复习

doi:10.3969/j.issn.1004-583X.2023.10.010

摘要/Abstract

摘要： 目的探讨变异型心绞痛的临床特点,以期提高对该病的诊疗与认识。方法回顾性分析1例由光学相干断层成像指导治疗的变异型心绞痛患者临床资料,并以“变异型心绞痛”以及“光学相干断层成像”等关键词,通过检索中国知网、PubMed及万方数据库,筛选公开发表的中英文文献,以分析变异型心绞痛的临床特点。结果本例患者老年男性,因间断胸闷2年余,加重10余天就诊,发作时心电图检查提示Ⅱ、Ⅲ、aVF导联ST段抬高,其余导联ST段显著压低,症状缓解后ST段回落,于光学相关断层成像指导下行冠状动脉造影结果示右冠状动脉近中段狭窄20%~30%,中段第二转折狭窄70%,远段可见支架影,右冠状动脉行麦角新碱激发试验,可见弥漫痉挛,给予硝酸甘油及硝普钠后痉挛解除,考虑患者胸闷症状反复发作,药物控制欠佳,且术中冠脉痉挛明显,遂给予右冠状动脉支架置入,经治疗患者胸闷症状未再发作,治疗效果良好。结论变异型心绞痛疾病特点及治疗方法与冠状动脉粥样硬化不同,临床易误诊误治,因此提高对其的警惕性及认识,及早行腔内影像学检查及激发试验可明确诊断,有助于选择合适的治疗方案并改善患者预后。

关键词: 光学相干断层成像, 变异型心绞痛, 冠状动脉介入治疗

Abstract: Objective To explore the clinical characteristics of variant angina pectoris, thus improving its diagnosis and treatment. Methods The clinical data of a patient with variant angina pectoris who was treated under the guidance of optical coherence tomography (OCT) were retrospectively analyzed. The clinical features of variant angina pectoris were analyzed by searching relevant articles in the CNKI, PubMed and Wanfang database with key words of “variant angina pectoris” and “OCT”. Results The male older patient presented with intermittent chest for more than 2 years and aggravated for more than 10 days was admitted. Electrocardiography on attack showed ST elevations in leads of II, III and arteriovenous fistula (AVF), and downwards of the remaining leads. The ST segment fell back after symptoms were relieved. The results of coronary angiography under the guidance of OCT showed a stenosis of 20%-30% in the proximal and middle segments of the right coronary artery, a stenosis of 70% in the second turn of the middle segment, and a stent shadow in the distal segment. Ergonovine stimulation test in the right coronary artery showed diffuse spasm, which was relieved after the treatment of nitroglycerin and sodium nitroprusside. Considering the repeated attacks of chest tightness, poor response to medication andintraoperative coronary spasm, the patient was managed by stent implantationin the right coronary artery.After stent implantation, symptoms of chest tightness disappeared with a good efficacy. Conclusion Disease characteristics and treatment of variant angina differ from those of coronary atherosclerosis, presenting a high rate of misdiagnosis. It is necessary to improve the vigilance and understanding of the disease. Timelyintracavitary imaging examination and provocation test contribute to a precise diagnosis and favor the selection of the optimal treatment and improvement of the prognosis.

Key words: optical coherence tomography, variant angina pectoris, coronary intervention

中图分类号:

R541.4

王家琦, 谢悦陶, 高曼, 宋学莲, 张飞飞, 党懿, 齐晓勇. 光学相干断层成像指导治疗变异型心绞痛1例并文献复习[J]. 临床荟萃, 2023, 38(10): 917-921.

Wang Jiaqi, Xie Yuetao, Gao Man, Song Xuelian, Zhang Feifei, Dang Yi, Qi Xiaoyong. Treatment of variant angina pectoris guided by the optical coherence tomography: A case report and literature review[J]. Clinical Focus, 2023, 38(10): 917-921.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2023.10.010

https://huicui.hebmu.edu.cn/CN/Y2023/V38/I10/917

图/表 2

图1 a.胸闷发作时心电图(可见Ⅱ、Ⅲ、aVF导联ST段抬高,其余导联ST段显著压低);b.无胸闷症状时心电图

Fig. 1 a. Electrocardiography on attack (it showed ST elevations in leads of Ⅱ, Ⅲ and AVF and the downwards of the remaining leads; b. Electrocardiogram in cases of without the symptom of chest tightness

图2 a.麦角新碱激发试验右侧冠脉痉挛时OCT图像;b.支架置入后OCT图像;c.麦角新碱激发试验造影图像;d.支架置入后造影图像

Fig. 2 a. Representative OCT image of right coronary artery spasm during provocation test using ergometrine; b. Representative OCT image after stent placement; c. Representative radiologic image of provocation test using ergometrine; d. Representative radiologic image after stent placement

参考文献 16

[1]	Prinzmetal M, Kennamer R, Merliss R. Angina pectoris. I. A variant form of angina pectoris; preliminary report[J]. Am J Med, 1959, 27:375-388. doi: 10.1016/0002-9343(59)90003-8 URL
[2]	丁娣, 王齐兵. 冠脉痉挛及其诊治的研究进展[J]. 上海医药, 2021, 42(13):39-42.
[3]	向定成, 曾定尹, 霍勇. 冠状动脉痉挛综合征诊断与治疗中国专家共识[J]. 中国介入心脏病学杂志, 2015, 23(4):181-186.
[4]	徐成胜, 李火平. 变异型心绞痛发病机制及治疗进展[J]. 中华实用诊断与治疗杂志, 2013, 27(5):419-421.
[5]	Ozdemir D, Kishor J, Hall JM, et al. A rare case of vasospastic angina presenting with inferior lead ST-segment elevation and ventricular fibrillation in the absence of coronary obstruction: A case report[J]. Cureus, 2019, 11(12):e6332.
[6]	Picard F, Sayah N, Spagnoli V, et al. Vasospastic angina: A literature review of current evidence[J]. Arch Cardiovasc Dis, 2019, 112(1):44-55. doi: S1875-2136(18)30132-3 pmid: 30197243
[7]	Seitz A, Ong P. Coexisting microvascular dysfunction in patients with diffuse epicardial coronary spasm: A novel piece of the coronary vasomotor disorder puzzle[J]. Int J Cardiol, 2021, 331:12-13. doi: 10.1016/j.ijcard.2021.01.018 pmid: 33535076
[8]	Shimokawa H. 2014 Williams Harvey Lecture: importance of coronary vasomotion abnormalities-from bench to bedside[J]. Eur Heart J, 2014, 35(45):3180-3193. doi: 10.1093/eurheartj/ehu427 pmid: 25354517
[9]	Chahin M, Zoltowska DM, Al-Turk B, et al. Vasospastic angina on coronary angiography[J]. BMJ Case Rep, 2020, 13(9):e237753. doi: 10.1136/bcr-2020-237753 URL
[10]	Masumoto A, Mohri M, Takeshita A. Three-year follow-up of the Japanese patients with microvascular angina attributable to coronary microvascular spasm[J]. Int J Cardiol, 2001, 81(2-3):151-156. pmid: 11744131
[11]	Patel KH, Doodnauth AV, Dunkley JC, et al. Aborted sudden cardiac death from vasospastic-induced ventricular fibrillation with normal coronary angiography: A case report and review of the literature[J]. Am J Med Case Rep, 2022, 1:78-82.
[12]	Cho SS, Jo SH, Han SH, et al. Clopidogrel plus aspirin use is associated with worse long-term outcomes, but aspirin use alone is safe in patients with vasospastic angina: Results from the VA-Korea registry, a prospective multi-center cohort[J]. Sci Rep, 2019, 9(1):17783. doi: 10.1038/s41598-019-54390-w
[13]	Park JY, Rha SW, Poddar KL, et al. Impact of low-dose aspirin on coronary artery spasm as assessed by intracoronary acetylcholine provocation test in Korean patients[J]. J Cardiol, 2012, 60(3):187-191. doi: 10.1016/j.jjcc.2012.02.007 pmid: 22770476
[14]	Kim MC, Ahn Y, Park KH, et al. Clinical outcomes of low-dose aspirin administration in patients with variant angina pectoris[J]. Int J Cardiol, 2013, 167(5):2333-2334. doi: 10.1016/j.ijcard.2012.11.010 pmid: 23182000
[15]	Sugisawa J, Matsumoto Y, Takeuchi M, et al. Beneficial effects of exercise training on physical performance in patients with vasospastic angina[J]. Int J Cardiol, 2021, 328:14-21. doi: 10.1016/j.ijcard.2020.12.003 pmid: 33309635
[16]	童亚良, 贺玉泉, 杨萍. 光学相干断层成像联合麦角新碱激发试验诊治典型冠状动脉痉挛综合征1例[J]. 中国介入心脏病学杂志, 2019, 27(5):298-300.