Roxas Czarina J, Weekes Anthony J
University of Massachusetts Memorial Medical Center, Department of Emergency Medicine, Worcester, Massachusetts 01605, USA.
J Emerg Med. 2011 May;40(5):509-14. doi: 10.1016/j.jemermed.2007.12.041. Epub 2008 Oct 23.
Identifying an acute myocardial infarction caused by a non-atherosclerotic process can have consequences on the short- and long-term management of the disease.
In the first case reported, a 39-year-old woman with a history of hypertension, diabetes, end-stage renal disease, deep vein thrombosis, and a recent hospitalization for staphylococcal bacteremia presented to the Emergency Department (ED) with acute onset of chest pain and shortness of breath. Her electrocardiogram (ECG) showed findings of an ST-segement elevation lateral wall acute myocardial infarction (AMI). The patient's condition worsened in the ED, and thrombolytic therapy was initiated. The patient subsequently had a coronary catheterization that illustrated an irregular mitral valve and abrupt occlusions in the left anterior descending artery, suggestive of coronary embolism from a mitral valve source. This patient was later treated with intravenous antibiotics and mitral valve replacement. In the second case reported, a 56-year-old man with a history of hypertension, diabetes, and end-stage renal disease presented to the ED with shortness of breath, fever, and chest pain. His ECG was significant for ST-segment elevation in the lateral leads, suggestive of an AMI. This patient had a history of positive blood cultures in a previous admission as well as an echocardiogram revealing an aortic valve vegetation. Given the high suspicion for an infective endocarditis causing an embolic event that in turn led to the myocardial infarction, thrombolytics were withheld in the ED and the patient was transported for coronary catheterization. The coronary angiogram demonstrated abrupt cutoffs at the distal left anterior descending artery and distal left posterior descending artery suggestive of an embolic occlusion of these vessels. He was subsequently treated with intravenous antibiotics and aortic valve replacement.
These two cases illustrate the importance of broadening our differential in the causes of AMI. In these cases, the recognition of an embolic event from infective endocarditis as the cause of the acute coronary syndrome allowed physicians to direct their interventions to optimize the appropriate care for each patient.
识别由非动脉粥样硬化过程引起的急性心肌梗死可能会对该疾病的短期和长期管理产生影响。
在第一例报告的病例中，一名39岁女性，有高血压、糖尿病、终末期肾病、深静脉血栓形成病史，近期因葡萄球菌菌血症住院，现因胸痛和呼吸急促急性发作就诊于急诊科（ED）。她的心电图（ECG）显示ST段抬高型侧壁急性心肌梗死（AMI）表现。患者在急诊科病情恶化，随后启动了溶栓治疗。该患者随后接受了冠状动脉造影，显示二尖瓣不规则以及左前降支动脉突然闭塞，提示二尖瓣来源的冠状动脉栓塞。该患者后来接受了静脉抗生素治疗和二尖瓣置换术。在第二例报告的病例中，一名56岁男性，有高血压、糖尿病和终末期肾病病史，因呼吸急促、发热和胸痛就诊于急诊科。他的心电图显示侧壁导联ST段抬高明显，提示AMI。该患者既往住院时血培养阳性，超声心动图显示主动脉瓣赘生物。鉴于高度怀疑感染性心内膜炎导致栓塞事件进而引起心肌梗死，急诊科未给予溶栓治疗，患者被转运接受冠状动脉造影。冠状动脉造影显示左前降支动脉远端和左后降支动脉远端突然截断，提示这些血管发生栓塞性闭塞。他随后接受了静脉抗生素治疗和主动脉瓣置换术。
这两个病例说明了拓宽我们对AMI病因鉴别诊断范围的重要性。在这些病例中，认识到感染性心内膜炎引起的栓塞事件是急性冠状动脉综合征的病因，使医生能够指导其干预措施，以优化对每个患者的适当治疗。
