Resnekov L
Am J Med. 1985 Sep 13;79(3A):30-4. doi: 10.1016/0002-9343(85)90491-7.
Current concepts concerning the pathophysiology of acute myocardial ischemia are reviewed. The importance of intermittent, dynamic shifts in the diameter of the coronary artery lumen is emphasized. Traditionally, it has been thought that angina pectoris is the common clinical hallmark of myocardial ischemia. It is now apparent that asymptomatic episodes of myocardial ischemia may be occurring far more frequently than symptomatic episodes. Although the natural history of asymptomatic myocardial ischemia is still unknown, ischemia, even in an asymptomatic form, can have serious consequences. This suggests the need for a careful assessment of patients in whom ischemia has been detected. In truly asymptomatic patients, detection is usually fortuitous; in patients with known coronary arterial disease, asymptomatic episodes should be sought as part of a noninvasive cardiac investigation, using multiple-stage exercise treadmill testing and 24-hour ambulatory electrocardiographic monitoring. Suggestions are made for the management of asymptomatic myocardial ischemia in relation to three patient groups: (1) asymptomatic ischemia in patients known to have symptomatic ischemia as well, (2) asymptomatic ischemia in patients without symptoms at any time, and (3) asymptomatic ischemia in patients who have had myocardial infarction. Medical management includes the use of calcium channel blocking drugs, beta-adrenergic blocking drugs, and nitrates. Documentation of an inadequate coronary artery reserve or evidence of associated left main coronary artery disease indicates the need for either aortocoronary bypass graft surgery or percutaneous transluminal coronary angioplasty, depending on the condition of the coronary anatomy and the degree of ventricular function. Whatever mode of treatment is used, documentation of its effectiveness should always be determined by appropriate follow-up studies. Clinical studies of the natural history of asymptomatic myocardial ischemia and its management are urgently needed.
本文综述了当前关于急性心肌缺血病理生理学的概念。强调了冠状动脉管腔直径间歇性、动态变化的重要性。传统上，人们认为心绞痛是心肌缺血常见的临床标志。现在很明显，无症状性心肌缺血发作可能比有症状发作更为频繁。虽然无症状性心肌缺血的自然病程仍不清楚，但即使是无症状形式的缺血也可能产生严重后果。这表明需要对已检测到缺血的患者进行仔细评估。在真正无症状的患者中，检测通常是偶然的；在已知患有冠状动脉疾病的患者中，应将无症状发作作为无创心脏检查的一部分进行查找，采用多级运动平板试验和24小时动态心电图监测。针对三组患者的无症状性心肌缺血管理提出了建议：（1）已知也有症状性缺血的患者中的无症状缺血；（2）任何时候都无症状的患者中的无症状缺血；（3）曾发生心肌梗死的患者中的无症状缺血。药物治疗包括使用钙通道阻滞剂、β肾上腺素能阻滞剂和硝酸盐类药物。冠状动脉储备不足的记录或相关左主干冠状动脉疾病的证据表明，根据冠状动脉解剖情况和心室功能程度，需要进行主动脉冠状动脉搭桥手术或经皮腔内冠状动脉成形术。无论采用何种治疗方式，其有效性的记录都应始终通过适当的随访研究来确定。迫切需要对无症状性心肌缺血的自然病程及其管理进行临床研究。
