Kulka P J, Scheu C, Tryba M, Grünewald R, Wiebalck A, Oberheiden R
Evangelisches Krankenhaus Oberhausen (EKO), Akademisches Lehrkrankenhaus, Universität Essen, Abteilung für Anästhesiologie und Intensivmedizin, Virchowstrasse 20, 46047 Oberhausen.
Anaesthesist. 2001 Apr;50(4):280-4. doi: 10.1007/s001010051003.
Up to now 136 cases of myocardial infarction during pregnancy have been reported, and angiography revealed normal findings in 47%. In these cases coronary spasms have been discussed as the major mechanism of the disease. In isolated cases coronary artery dissection may also present with a normal coronary angiography. The case of a 31-year-old pregnant women who developed myocardial infarction during a caesarean section under spinal anaesthesia gives rise to the assumption that an early stage of coronary artery disease may be the third cause that has to be considered. Probably as a consequence of phases of tachycardia and hypertension during the course of anaesthesia, the patient developed a myocardial infarction that she survived without sequelae. While coronary angiography showed normal coronary vessels, an intravascular ultrasound study (IVUS) demonstrated an atheroma in the left main coronary artery with a ruptured fibrous cap. Laboratory screening for risk factors of coronary artery disease (CAD) showed hypercholesterinemia, increased factor VII activity and hyperfibrinogenemia. Platelet aggregation was not inhibited by acetylsalicylic acid. It was pointed out recently that even in asymptomatic patients, plaques may be present in coronary vessels indicating an early stage of CAD that cannot be diagnosed by angiography. Plaque rupture is often triggered by hypertension and may lead to myocardial infarction, instable angina pectoris, or sudden ischemic death. As IVUS is a new diagnostic tool that allows diagnoses of even early stages of CAD we believe that myocardial infarction during pregnancy is more often caused by plaque rupture than may be expected according to the current literature.
到目前为止，已报道了136例妊娠期心肌梗死病例，血管造影显示47%的病例结果正常。在这些病例中，冠状动脉痉挛被认为是该疾病的主要机制。在个别病例中，冠状动脉夹层也可能表现为冠状动脉造影正常。一名31岁孕妇在腰麻下行剖宫产时发生心肌梗死，这使人们推测冠状动脉疾病的早期阶段可能是第三个需要考虑的病因。可能由于麻醉过程中出现心动过速和高血压阶段，该患者发生了心肌梗死，但幸免于难且无后遗症。冠状动脉造影显示冠状动脉血管正常，但血管内超声检查（IVUS）显示左主干冠状动脉有一个带有破裂纤维帽的动脉粥样硬化斑块。对冠状动脉疾病（CAD）危险因素的实验室筛查显示有高胆固醇血症、因子VII活性增加和高纤维蛋白原血症。血小板聚集未被阿司匹林抑制。最近有人指出，即使在无症状患者中，冠状动脉血管中也可能存在斑块，这表明CAD处于早期阶段，无法通过血管造影诊断。斑块破裂常由高血压引发，可能导致心肌梗死、不稳定型心绞痛或心源性猝死。由于IVUS是一种新的诊断工具，能够诊断CAD的早期阶段，我们认为妊娠期心肌梗死由斑块破裂引起的情况比目前文献预期的更为常见。
