突发情绪应激所致心肌顿抑的神经体液特征

Neurohumoral features of myocardial stunning due to sudden emotional stress.

作者信息

Wittstein Ilan S, Thiemann David R, Lima Joao A C, Baughman Kenneth L, Schulman Steven P, Gerstenblith Gary, Wu Katherine C, Rade Jeffrey J, Bivalacqua Trinity J, Champion Hunter C

机构信息

Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.

出版信息

N Engl J Med. 2005 Feb 10;352(6):539-48. doi: 10.1056/NEJMoa043046.

DOI:10.1056/NEJMoa043046

PMID:15703419

Abstract

BACKGROUND

Reversible left ventricular dysfunction precipitated by emotional stress has been reported, but the mechanism remains unknown.

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.

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).

CONCLUSIONS

Emotional stress can precipitate severe, reversible left ventricular dysfunction in patients without coronary disease. Exaggerated sympathetic stimulation is probably central to the cause of this syndrome.

摘要

背景

已有报道称情绪应激可引发可逆性左心室功能障碍，但其机制仍不明。

方法

我们评估了19例在突发情绪应激后出现左心室功能障碍的患者。所有患者均接受了冠状动脉造影和系列超声心动图检查；5例接受了心内膜心肌活检。将13例与应激相关的心肌功能障碍患者的血浆儿茶酚胺水平与7例Killip III级心肌梗死患者的血浆儿茶酚胺水平进行比较。

结果

应激性心肌病患者的中位年龄为63岁，95%为女性。临床表现包括胸痛、肺水肿和心源性休克。大多数患者出现弥漫性T波倒置和QT间期延长。17例患者血清肌钙蛋白I水平轻度升高，但19例中只有1例有冠状动脉造影显示临床显著冠心病的证据。入院时存在严重左心室功能障碍（中位射血分数为0.20；四分位间距为0.15至0.30），所有患者均迅速恢复（2至4周时射血分数为0.60；四分位间距为0.55至0.65；P<0.001）。心内膜心肌活检显示单核细胞浸润和收缩带坏死。应激性心肌病患者就诊时的血浆儿茶酚胺水平显著高于Killip III级心肌梗死患者（中位肾上腺素水平，每毫升1264 pg [四分位间距为916至1374] 对比每毫升376 pg [四分位间距为275至476]；去甲肾上腺素水平，每毫升2284 pg [四分位间距为1709至2910] 对比每毫升1100 pg [四分位间距为914至1320]；多巴胺水平，每毫升111 pg [四分位间距为106至146] 对比每毫升61 pg [四分位间距为46至77]；所有比较P<0.005）。