Dande Amit S, Pandit Amrita S
Department of Cardiology, Jacobi Medical Center, 1400 Pelham Pkwy S, Building 1, 5 West, Bronx, NY, 10461, USA,
Curr Treat Options Cardiovasc Med. 2013 Jun;15(3):265-75. doi: 10.1007/s11936-013-0235-8.
The diagnosis of stress cardiomyopathy is often made during coronary angiography. At this point hemodynamic parameters should be assessed; a right heart catheterization with measurement of cardiac output by Fick and thermodilution methods is helpful. Patients with acute neurologic pathology who develop left ventricular dysfunction (neurogenic stunned myocardium) may not be candidates for coronary angiography and in such cases real-time myocardial contrast echocardiography or nuclear perfusion scan can be used to exclude obstructive coronary disease. Hypotension and shock can be due to low output state or left ventricular outflow tract obstruction. Low output state can be managed with diuretics and vasopressor support. Refractory shock and/or severe mitral regurgitation may require an intra-aortic balloon pump for temporary support. In patients with intraventricular gradient intravenous beta-blockers have been used safely. Hemodynamically unstable patients should be managed in a critical care unit and stable patients should be monitored on a telemetry unit as arrhythmias may occur. An echocardiogram should be performed to look for intraventricular gradient, mitral regurgitation, or left ventricular thrombus. If left ventricular thrombus is seen or suspected anticoagulation with warfarin or low molecular weight heparin is generally advised until recovery of myocardial function and resolution of thrombus occurs. In patients with subarachnoid hemorrhage the use of vasopressors to reduce cerebral vasospasm may worsen left ventricular outflow tract gradient. In hemodynamically stable patients, a beta-blocker or combined alpha/beta blocker should be initiated. Myocardial function generally recovers within days to weeks with supportive treatment in most patients. The use of a standard heart failure regimen including an angiotensin-converting enzyme inhibitor or aldosterone receptor antagonist, beta-blocker titrated to maximal dose, diuretics, and aspirin is common until complete recovery of myocardial function occurs. Chronic therapy with a beta-blocker may be advisable. The underlying diagnosis that precipitated stress cardiomyopathy such as critical illness, neurologic injury, or medication exposure should be identified and treated.
应激性心肌病的诊断通常在冠状动脉造影期间作出。此时应评估血流动力学参数；采用Fick法和热稀释法测量心输出量的右心导管检查很有帮助。发生左心室功能障碍（神经源性心肌顿抑）的急性神经病理学患者可能不适合进行冠状动脉造影，在这种情况下，可使用实时心肌对比超声心动图或核灌注扫描来排除阻塞性冠状动脉疾病。低血压和休克可能是由于低输出状态或左心室流出道梗阻。低输出状态可用利尿剂和血管升压药支持治疗。难治性休克和/或严重二尖瓣反流可能需要主动脉内球囊泵进行临时支持。对于存在心室内压差的患者，已安全使用静脉β受体阻滞剂。血流动力学不稳定的患者应在重症监护病房进行治疗，稳定的患者应在遥测病房进行监测，因为可能会发生心律失常。应进行超声心动图检查以寻找心室内压差、二尖瓣反流或左心室血栓。如果发现或怀疑有左心室血栓，一般建议使用华法林或低分子量肝素进行抗凝，直至心肌功能恢复且血栓溶解。在蛛网膜下腔出血患者中，使用血管升压药减轻脑血管痉挛可能会加重左心室流出道压差。对于血流动力学稳定的患者，应开始使用β受体阻滞剂或联合α/β受体阻滞剂。在大多数患者中，通过支持治疗，心肌功能通常在数天至数周内恢复。在心肌功能完全恢复之前，通常会使用标准的心力衰竭治疗方案，包括血管紧张素转换酶抑制剂或醛固酮受体拮抗剂、滴定至最大剂量的β受体阻滞剂、利尿剂和阿司匹林。可能建议长期使用β受体阻滞剂治疗。应识别并治疗引发应激性心肌病的潜在诊断，如危重病、神经损伤或药物暴露。
