張少利，李 燕，王學(xué)惠，陳志剛

中青年不典型急性心肌梗死七例誤診分析

張少利，李 燕，王學(xué)惠，陳志剛

目的 探討中青年急性心肌梗死(acute myocardial infarction， AMI)的不典型表現(xiàn)及誤診原因，降低誤診率。方法 回顧性分析2015年5月—2016年2月我院收治的7例中青年不典型AMI誤診病例資料。結(jié)果 本組年齡24～44歲。2例因上腹疼痛、惡心、嘔吐、呃逆、腹瀉等消化道癥狀誤診為急性胃腸炎；1例因咳嗽、咳痰、氣促，X線胸片示肺紋理增粗誤診為支氣管炎；1例因單純胸痛誤診為肋間神經(jīng)炎；1例因心悸、乏力、心電圖ST段壓低誤診為心臟神經(jīng)癥；1例因頭昏、雙上肢無力及腔隙性腦梗死病史誤診為腦梗死；1例因低血壓、體位改變后暈厥誤診為體位性暈厥。本組平均誤診時間(4.56±1.26)d，按誤診疾病治療效果不佳，后行心電圖檢查發(fā)現(xiàn)動態(tài)改變，查心肌酶譜異常，確診為AMI。確診后予再灌注治療，病情穩(wěn)定后出院。結(jié)論 復(fù)雜多樣化及不典型的臨床表現(xiàn)極易導(dǎo)致中青年AMI誤診，臨床醫(yī)師應(yīng)提高對中青年AMI的警惕性，減少誤診誤治。

心肌梗死；中青年；誤診；胃腸炎；支氣管炎

急性心肌梗死(acute myocardial infarction， AMI)好發(fā)于中老年人群，典型臨床表現(xiàn)為心前區(qū)或胸骨后持續(xù)性、壓榨性、窒息性疼痛不適，且伴有出汗及心音低鈍[1-5]。但中青年AMI患者多數(shù)無心絞痛發(fā)作史，臨床表現(xiàn)復(fù)雜多樣，極易誤漏診[6]，延誤診治可導(dǎo)致嚴(yán)重后果。2015年5月—2016年2月我院收治56例中青年AMI，占我院同期收治AMI總患者數(shù)的19.0%，其中7例誤診，誤診率12.5%，現(xiàn)回顧分析誤診病例資料如下。

1 臨床資料

1.1 一般資料 本組7例，男6例，女1例；年齡24～44歲。病程6～48 h。有慢性胃腸炎、腔隙性腦梗死病史各1例。所有患者均符合2015年世界衛(wèi)生組織AMI診斷標(biāo)準(zhǔn)[7]。首診科室:神經(jīng)內(nèi)科、消化內(nèi)科及心內(nèi)科各2例，呼吸內(nèi)科1例。

1.2 臨床表現(xiàn)及誤診誤治情況 1例因上腹疼痛、惡心、嘔吐伴呃逆、腹瀉2 d就診，查血白細(xì)胞14.5×109/L，根據(jù)慢性胃腸炎病史，初步診斷為急性胃腸炎，予抗感染、補(bǔ)液等對癥處理。1例因重體力勞動后出現(xiàn)胸悶、腹痛伴冷汗、惡心、嘔吐8 h入院，腹部X線平片示胃黏膜皺襞改變，查血白細(xì)胞13.8×109/L，初診為急性胃炎，予抗感染、補(bǔ)液、抑酸等對癥處理。1例因咳嗽伴少量咳痰，氣促、不能平臥3 d就診，X線胸片示肺紋理增粗增多，初診為急性支氣管炎，予止咳化痰等對癥治療。1例無明顯誘因出現(xiàn)胸痛12 h，查心電圖無明顯異常，初診為肋間神經(jīng)炎，予抗炎、鎮(zhèn)痛等治療。1例無誘因出現(xiàn)心悸、乏力36 h，無胸痛、胸悶等，查心電圖示ST段壓低，初診為心臟神經(jīng)癥，予相關(guān)對癥治療。1例有腔隙性腦梗死病史，此次因頭昏伴雙上肢無力麻木3 d，伴短暫意識障礙入院，頭顱CT檢查示多發(fā)腔隙性腦梗死，初診為腦梗死，予活血化淤等對癥處理。1例因日晨起床后突發(fā)性暈厥伴面色蒼白、全身不適6 h就診，測血壓90/58 mmHg，心電圖未見明顯異常，診斷為體位性暈厥，予升壓等對癥處理。

1.3 確診經(jīng)過及預(yù)后 本組均按初診疾病治療2～4 d后癥狀無改善，且病情加重，逐步出現(xiàn)胸悶、呼吸困難等，進(jìn)一步行心電圖檢查發(fā)現(xiàn)典型心肌梗死動態(tài)改變，心肌標(biāo)志物異常：心肌型肌酸激酶同工酶42.3～50.2 U/L，肌鈣蛋白I 0.8～1.2 μg/L，確診為AMI，其中下壁并前側(cè)壁、前壁、廣泛前側(cè)壁心肌梗死各1例，前壁、高側(cè)壁心肌梗死各2例，誤診時間(4.56±1.26)d。確診后均給予積極擴(kuò)張冠狀動脈、溶栓、經(jīng)皮冠狀動脈介入術(shù)等再灌注治療，病情逐步穩(wěn)定，無AMI相關(guān)并發(fā)癥及死亡事件發(fā)生。

2 討論

2.1 發(fā)病特點(diǎn) AMI為老年人多見，中青年AMI患者發(fā)病特點(diǎn)與大多數(shù)老年患者有所不同，男性發(fā)病率較女性高，發(fā)病常有誘因存在，吸煙為最常見誘因，胸痛為較典型臨床表現(xiàn)，大多數(shù)以冠狀動脈單支病變?yōu)橹鱗8-12]。目前認(rèn)為引發(fā)中青年AMI的高危因素有：高血壓病、高脂血癥、糖尿病等遺傳因素；吸煙、酗酒等不健康生活方式；長期緊張、抑郁等不良心理狀態(tài)[8-12]。

2.2 誤診原因分析 ①臨床表現(xiàn)不典型：本組大多數(shù)入院時以AMI不典型癥狀就診，且入院首次心電圖檢查無明顯異常，使接診醫(yī)生忽略該病診斷；②對中青年AMI缺乏警惕性：本組患者首診科室多為非心內(nèi)科，非心內(nèi)科醫(yī)生對AMI缺乏認(rèn)識，不熟知AMI復(fù)雜多樣的臨床表現(xiàn)，導(dǎo)致誤診；③病史了解不全面：首診醫(yī)生接診患者時未詳細(xì)詢問病史、仔細(xì)了解病情，亦未進(jìn)行全面的體格及醫(yī)技檢查，導(dǎo)致許多關(guān)鍵信息無法獲得，從而發(fā)生誤診；④患者因素：患者自身對AMI的危險性缺乏認(rèn)識，不配合心電圖、心肌酶等檢查，導(dǎo)致不能及時獲得診斷依據(jù)。

2.3 防范誤診措施 ①提高對中青年AMI的警惕性：各?？漆t(yī)生均應(yīng)認(rèn)識到AMI年輕化的趨勢，全面了解AMI不典型臨床表現(xiàn)，提高警惕性。②詳盡了解病史及仔細(xì)查體：詳細(xì)詢問患者病情變化，仔細(xì)查體，及早明確診斷。③了解該病醫(yī)技檢查特點(diǎn)：心肌標(biāo)志物和心電圖表現(xiàn)在AMI發(fā)病各期均有一定的動態(tài)改變。部分AMI患者尤其是非ST段抬高型AMI患者心電圖早期改變不典型。因此，對高度可疑AMI者不能滿足于單次心電圖檢查無異常，應(yīng)反復(fù)多次檢查以避免延誤診斷，造成嚴(yán)重不良后果。

綜上所述，臨床醫(yī)生應(yīng)全面提高對該病的認(rèn)識，不能僅限于局部表現(xiàn)，應(yīng)拓展診斷思維，合理利用各種醫(yī)技檢查手段，早期明確診斷，降低誤診率，提高診治水平。

[1] Rudnick S, Shepple B, Keeley E,etal. 376 Prevalence and Mortality of Acute Myocardial Infarction in Cirrhotic Patients[J].Gastroenterology, 2014,146(5):909.

[2] 唐藝加.糖耐量水平對冠心病患者冠狀動脈病變程度及血小板參數(shù)的影響[J].解放軍醫(yī)藥雜志,2016,27(2):52-54.

[3] 竇存芳.以腹痛為首發(fā)表現(xiàn)的老年急性心肌梗死八例誤診報告[J].臨床誤診誤治,2015,30(11):10-12.

[4] 曹丹陽,張健,裴志勇,等.老年急性心肌梗死患者臨床特點(diǎn)以及住院死亡的危險因素[J].中國循證心血管醫(yī)學(xué)雜志,2015,7(4):472-474.

[5] 蔣桔泉,丁世芳,陳志楠,等.年輕人急性心肌梗死36例臨床分析[J].華南國防醫(yī)學(xué)雜志,2007,21(1):42-43.

[6] 曹茂榮,劉衛(wèi)星,董濱,等.急性心肌梗死216例診斷分析[J].武警醫(yī)學(xué)院學(xué)報,2008,17(5):407-408,411.

[7] 李春慧,云虹渝,何森,等.心臟增強(qiáng)MRI在冠狀動脈造影基本正常急性心肌梗死一例中的應(yīng)用及文獻(xiàn)分析[J].華西醫(yī)學(xué),2014,28(10):1891-1894.

[8] 趙祥淘,楊松,陳燕春,等.青年人急性心肌梗死危險因素及冠脈病變特點(diǎn)[J].山東醫(yī)藥,2014,54(7):45-47.

[9] 劉碩,李玉子.microRNAs與急性心肌梗死的研究進(jìn)展[J].吉林醫(yī)學(xué),2015,57(11):2345-2346.

[10]Echeverría P, Domingo P, Llibre J M,etal. Prevalence of ischemic heart disease and management of coronary risk in daily clinical practice: results from a Mediterranean cohort of HIV-infected patients[J].Biomed Res Int, 2014,2014(2014):823058.

[11]史云桃,蔣廷波.急性ST段抬高心肌梗死患者合并心力衰竭的危險因素分析[J].中華老年心腦血管病雜志,2014,16(2):151-154.

[12]周滿臻,譚春紅,張忠明,等.主動脈夾層誤診為急性心肌梗死一例分析[J].臨床誤診誤治,2015,28(8):6-7.

Analysis of Misdiagnosed 7 Young and Middle-aged Patients with Atypical Acute Myocardial Infarction

ZHANG Shao-li， LI Yan， WANG Xue-hui， CHEN Zhi-gang

( The Third Department of Cardiology, the First Affiliated Hospital of Xinxiang Medical College, Weihui, Henan 453100, China)

Objective To investigate atypical manifestations and misdiagnosed causes of young and middle-aged patients with atypical acute myocardial infarction (AMI) in order to reduce misdiagnosis rate. Methods Clinical data of 7 young and middle-aged patients with atypical AMI admitted during May 2015 and February 2016 was retrospectively analyzed. Results The range of patients were from 24 to 44 years old. A total of 2 patients were misdiagnosed as having acute gastroenteritis due to gastrointestinal symptoms such as abdominal pain, nausea, vomiting, hiccups, diarrhea; 1 patient was misdiagnosed as having bronchitis due to cough, expectoration, shortness of breath and thickening lung markings by chest X-ray; 1 patient was misdiagnosed as having intercostal neuritis due to simple chest pain; 1 patient was misdiagnosed as having cardiac neuropathy due to palpitations, fatigue and ST segment depression by electrocardiogram (ECG); 1 patient was misdiagnosed as having cerebral infarction due to dizziness, both upper extremities powerless and lacunar infarction history; 1 patient was misdiagnosed as having postural syncope due to hypotension and syncope. The average time of misdiagnosis was (4.56±1.26)d. The effects of symptomatic treatment for misdiagnosed diseases were poor, and dynamic changes were found after ECG examination, and then AMI was confirmed after finding abnormal result of myocardial enzyme examination. Reperfusion therapy was given after confirming AMI, and patients were discharged after having stable conditions. Conclusion Complex and atypical manifestations can easily lead to misdiagnosis for young and middle-aged patients with AMI, so clinicians should improve the vigilance of young and middle-aged patients with AMI so as to avoid misdiagnosis and mistreatment.

Myocardial infarction; Young and middle-aged; Misdiagnosis; Gastroenteritis; Bronchitis

453100 河南 衛(wèi)輝，新鄉(xiāng)醫(yī)學(xué)院第一附屬醫(yī)院心內(nèi)三科

陳志剛，電話：13837397691;E-mail：zsl19781127@sina.com

R542.22

A

1002-3429(2017)04-0050-02

10.3969/j.issn.1002-3429.2017.04.017

2016-09-13 修回時間：2017-01-24)