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ACM

Advances in Clinical Medicine

2161-8712

Scientific Research Publishing

10.12677/ACM.2022.12121751

ACM-59924

ACM20221200000_94511919.pdf

医药卫生

替格瑞洛致心动过缓合并应激性心肌病误诊1例 A Case of Misdiagnosis of Ticagrelor-Induced Bradycardia Combined with Stress Cardiomyopathy

张

灿

¹ ² 冷

一平

³ ¹ 叶

国红

³ ¹ 邓

平

³ ¹

长沙市中心医院，湖南长沙

null

湖南中医药大学，湖南长沙

05 12 2022

12 12 12159 12165

2014

This work is licensed under the Creative Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/

目的：我们通过描述一例应激性心肌病误诊为急性心肌梗死的案例，介绍应激性心肌病与急性心肌梗死的鉴别要点以及应激性心肌病的诊断标准、治疗方案，以及在治疗过程中因误诊为急性心肌梗死而使用负荷剂量替格瑞洛致患者出现窦性心动过缓这一副反应报道较少。方法：我们将汇报该病例的临床表现、实验室检查、影像学特点、治疗方案。结论：应激性心肌病与急性心肌梗死表现酷似，临床过程中应注意在心电图、心肌酶、肌钙蛋白、冠脉造影等方面鉴别。患者不明原因出现窦性心动过缓时在排除器质性疾病后可考虑药物因素。 We describe the case of stress cardiomyopathy misdiagnosed as acute myocardial infarction. We introduce the distinguishing points of stress cardiomyopathy and acute myocardial infarction and the diagnosis criteria and treatment plan of stress cardiomyopathy. The patient due to misdiagnosis of acute myocardial infarction is used the loading dose of ticagrelor which is rarely reported. Meth-ods: We will report the clinical presentation, laboratory examination, imaging characteristics, and treatment plan of the case. Conclusion: Stress cardiomyopathy is similar to acute myocardial infarc-tion, especially in electrocardiogram, myocardial enzymes, troponin, and coronary angiography. Drug factors can be considered after excluding organic disease.

应激性心肌病，急性心肌梗死，替格瑞洛，窦性心动过缓, Stress Cardiomyopathy Acute Myocardial Infarction Ticagrelor Sinus Bradycardia

摘要

关键词

应激性心肌病，急性心肌梗死，替格瑞洛，窦性心动过缓

A Case of Misdiagnosis of Ticagrelor-Induced Bradycardia Combined with Stress Cardiomyopathy<sup> </sup>

Can Zhang^1*, Yiping Leng², Guohong Ye², Ping Deng^2#

¹Hunan University of Chinese Medicine, Changsha Hunan

²Changsha Central Hospital, Changsha Hunan

Received: Nov. 26^th, 2022; accepted: Dec. 23^rd, 2022; published: Dec. 30^th, 2022

ABSTRACT

We describe the case of stress cardiomyopathy misdiagnosed as acute myocardial infarction. We introduce the distinguishing points of stress cardiomyopathy and acute myocardial infarction and the diagnosis criteria and treatment plan of stress cardiomyopathy. The patient due to misdiagnosis of acute myocardial infarction is used the loading dose of ticagrelor which is rarely reported. Methods: We will report the clinical presentation, laboratory examination, imaging characteristics, and treatment plan of the case. Conclusion: Stress cardiomyopathy is similar to acute myocardial infarction, especially in electrocardiogram, myocardial enzymes, troponin, and coronary angiography. Drug factors can be considered after excluding organic disease.

Keywords:Stress Cardiomyopathy, Acute Myocardial Infarction, Ticagrelor, Sinus Bradycardia

This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).

http://creativecommons.org/licenses/by/4.0/

1. 前言

应激性心肌病是一种急性短暂性左心室收缩功能障碍为特征的心肌病，又称为Takotsubo综合征、心尖球形综合征、章鱼壶心肌病、心碎综合征、应激诱导性心肌病、圣瓶综合征 [ 1 ]。临床上应激性心肌病常与急性心肌梗死难以区分。替格瑞洛(Ticagrelor)是一种选择性P2Y12受体拮抗剂，通过抑制新血凝块的形成，帮助患者降低动脉粥样化血栓形成事件的发生 [ 2 ]。P2Y12受体存在于血小板表面以及内皮细胞、白细胞、血管平滑肌细胞等细胞，是P2Y12受体拮抗剂抗血小板机制的基础 [ 3 ]。研究证实替格瑞洛通过抑制血小板聚集抑制剂(主要是血小板糖蛋白IIb/IIIa受体)活化、纤维蛋白原连接、血小板释放促凝物质血小板源性细胞外囊泡形成、血栓素B2代谢途径等形成广谱的抗血小板聚集效应 [ 4 ]。本病例是应激性心肌病患者误诊为急性心肌梗死，并在短时间内予以替格瑞洛联负荷剂量，导致应激性心肌病患者出现窦性心动过缓。

2. 病例描述

患者女，73岁，以“胸痛6小时”为主诉入院。患者家属代诉因患者配偶去世悲伤过度突发胸痛，为心前区针刺样痛，伴背部放射痛、头痛，入院查体：血压125/75 mmHg (1 mmHg = 0.133 kPa)，急性痛苦面容，双肺呼吸音清，无啰音，心界不大，心率77次/min，律齐，未闻及心脏杂音，双下肢无水肿。本次纳入患者基线资料包括：年龄、性别、BMI、既往心脑血管疾病史、入院时血压、胸痛时间、发病诱因(见表1)。

Table 1 There are the patient of age, gender, BMI, past history of previous cardiovascular and cerebrovascular diseases, blood pressure at admission, time of chest pain, and the cause of the cas

年龄	性别	BMI	既往心脑血管疾病史	入院时血压	胸痛时间	发病诱因
73	女	22	心肌桥和腔隙性脑梗死	125/75 mmhg	6小时	配偶去世

表1. 本病例的年龄、性别、BMI、既往心脑血管疾病史、入院时血压、胸痛时间、发病诱因

3. 诊断性评估

表2显示了患者入院时血常规、肝肾功能、电解质、凝血功能、空腹血糖、血脂。患者血糖、血脂正常，考虑患者暂无急性心肌梗死的危险因素。肝肾功能、血常规、电解质、凝血功能的正常代表暂未合并除心脏外其他器官的损伤。图1显示了入院时造影和心脏彩超情况。急诊冠状动脉造影提示：左前降支中段见收缩期狭窄约20%~30%，前向血流TIMI3级；余各段及其分支未见明显斑块、狭窄(图1(a)、图1(b))。左室造影：呈“章鱼壶样”改变，符合应激性心肌病(图1(c))。超声心动图示：主动脉瓣返流(轻度)，二尖瓣返流(轻度)，左室舒张功能减退，收缩功能正常(图1(d))。术后继续予以替格瑞洛抗血小板聚集、普伐他汀调脂。图2显示了患者入院第1天至第7天心电图变化。入院心电图示II、avF、V2-3、V5-6导联ST段抬高，avR导联ST段下移，左前分支阻滞。考虑急性ST段抬高性心肌梗死，遂给予阿司匹林肠溶片(300 mg, st) + 替格瑞洛片(180 mg, st) + 阿托伐他汀钙片(20 mg, st)口服。患者入院后心率较慢，第2天至4天、第6天至7天心电图均示窦性心动过缓，最慢心率为52次/分，分析患者当前用药，考虑替格瑞洛引起心动过缓可能性大。图3显示了患者住院期间及出院后6月时心肌酶(图3(a)、图3(b))、肌钙蛋白动态变化(图3(c))。表明患者心肌酶高峰提前。

图1. (a)、(b)：冠状动脉造影(2022-01-16)示前降支近端狭窄约20%~30%，回旋支及右冠脉未见斑块及狭窄。(c)：左室造影(2022-01-16)显示呈“章鱼壶样”改变。(d)：心脏彩超(2022-01-18)未见室壁运动异常

Table 2 There are the patients of blood routine, liver and renal function, electrolyte, coagulation function, fasting blood glucose and blood lipid at admissio

血常规	肝功能	肾功能	凝血功能	空腹血糖	血脂
正常	正常	正常	正常	正常	正常

表2. 本病例入院时血常规、肝肾功能、电解质、凝血功能、空腹血糖、血脂

图2. 入院第1天至第7天心电图变化

图3. 显示了患者住院期间及出院后6月时心肌酶 (a)、(b)、肌钙蛋白动态变化 (c)

4. 案例治疗分析 4.1. 应激性心肌病误诊原因

应激性心肌病是一种急性短暂性左心室收缩功能障碍为特征的心肌病，又称为Takotsubo综合征。本例患者因胸痛入院，表现难以与急性心肌梗死区分。初诊心电图示II、avF、V2-3、V5-6导联ST段抬高，avR导联ST段下移，左前分支阻滞，美国心脏病协会制定的一项区分心肌梗死与应激性心肌病的心电图标准 [ 5 ]：当比较STEMI和STE-TTC时，STE-TTC的特征是aVR导联中ST段下移，敏感和特异性分别为43%和95%，阳性预测值(PPV)为91%，阴性预测值(NPV)为62%% (P < 0.001)；当aVR导联中ST段下移伴有下壁导联ST段升高时，敏感性和特异性分别为14%和98% (PPV为89%，NPV为52%) (P = 0.001)。STEMI的特征是aVR导联ST段升高(敏感性和特异性分布为31%和95% P < 0.001，PPV 85%和NPV 59%)和V2-V3-V4的ST段降低(敏感性和特异性分布为24%和100% P < 0.001，PPV 100%和NPV 76%)。根据ST段的改变，本病例心电图符合应激性心肌病改变。研究表明大约15%的Takotsubo综合征患者同时存在冠状动脉疾病，一旦行侵入性冠状动脉造影显示冠状动脉疾病正常或非阻塞性，通常可诊断Takotsubo综合征 [ 6 ]。该患者心电图示左前分支阻滞，研究发现左前分支阻滞若见于50岁以上的老年人，常提示冠心病 [ 7 ]。因此该病例暂不排除应激性心肌病合并急性心肌梗死的可能，行急诊冠脉造影考虑左前降支狭窄所致。研究表明Takotsubo综合征的住院死亡率与急性ST段抬高型心肌梗死相当 [ 8 ]。目前没有明确的证据表明β受体阻滞剂治疗可以改善长期生存获益 [ 8 ] [ 9 ]。Templin等人做的一项纳入1750名患者的回顾性研究表明无论应激性心肌病患者是否接受β-阻滞剂治疗，1年后的死亡率都相当 [ 10 ]。Singh等人的一项荟萃分析表明β-阻滞剂不能防止Takotsubo综合征复发 [ 11 ]。同样，关于血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂治疗的证据不足 [ 8 ] [ 9 ]。故治疗应针对个别患者量身定制。

该病例以胸痛为主要临床表现，经历了重大丧亲之痛，且伴有心电图、心肌酶学和左室造影的异常，冠脉造影示左前降支狭窄20%~30%，因此应激性心肌病诊断明确。出院6月后随访病人未诉特殊不适，复查心肌酶、肌钙蛋白、心电图均为正常。

4.2. 替格瑞洛致心动过缓的关联性评价、作用机制及处置

该病例窦性心动过缓唯一相关的用药史为替格瑞洛。入院时心电图是正常窦性心律，患者出现窦性心动过缓是在使用替格瑞洛后出现的，入院后连续3天均为窦性心动过缓。众所周知，下壁心肌梗死时表现为窦性心动过缓，而该患者已排除急性心肌梗死。故该病例的窦性心动过缓最有可能与替格瑞洛有关联。替格瑞洛与心动过缓的发生机制有待进一步明确。现有研究认为替格瑞洛通过降低心脏的自律性、传导性以及刺激迷走神经引起心动过缓 [ 12 ] [ 13 ]。替格瑞洛与心动过缓的相关联系专家共识建议 [ 14 ]：① 使用替格瑞洛前评估患者发生心动过缓的风险，若为高危人群应慎用；② 替格瑞洛与其他心动过缓药物合用目前无禁忌症；③ 替格瑞洛相关的心动过缓停药后可恢复患者基础心率。

文章引用

张灿,冷一平,叶国红,邓平. 替格瑞洛致心动过缓合并应激性心肌病误诊1例A Case of Misdiagnosis of Ticagrelor-Induced Bradycardia Combined with Stress Cardiomyopathy[J]. 临床医学进展, 2022, 12(12): 12159-12165. https://doi.org/10.12677/ACM.2022.12121751

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