Hoffman J I
Prog Cardiovasc Dis. 1987 May-Jun;29(6):429-64. doi: 10.1016/0033-0620(87)90016-8.
The predilection for subendocardial underperfusion and ischemia is great and must be considered in the management of any patient, especially if there is coronary artery disease or ventricular hypertrophy. Although the mechanisms of subendocardial ischemia remain to be fully defined, they are clearly associated with the transmural distribution of intramyocardial systolic pressures. Even though almost all the myocardium is perfused in diastole, a reduction of diastolic perfusion pressure or duration will result in subendocardial ischemia. The factors that produce subendocardial ischemia are all associated with a reduction or loss of coronary flow reserve, and as our ability to measure flow reserve in humans improves, it is likely that we will be able to select medical or surgical therapy that will minimize or abolish subendocardial ischemia. For example, it will someday become possible to choose a time for valve replacement in an asymptomatic patient to obtain maximal protection of the myocardium or to select the right combination of therapies for the immediate post-operative period so that as much myocardium as possible will be spared. The more we learn to understand the mechanisms of subendocardial ischemia, the sooner will we be able to achieve these desired ends.
心内膜下灌注不足和缺血的倾向很大，在任何患者的治疗中都必须予以考虑，尤其是存在冠状动脉疾病或心室肥厚的患者。尽管心内膜下缺血的机制仍有待充分明确，但它们显然与心肌收缩压的跨壁分布有关。即使几乎所有心肌在舒张期都能得到灌注，但舒张期灌注压或持续时间的降低仍会导致心内膜下缺血。产生心内膜下缺血的因素均与冠状动脉血流储备的减少或丧失有关，随着我们测量人体血流储备能力的提高，我们很可能能够选择将心内膜下缺血降至最低或消除的药物或手术治疗方法。例如，有朝一日有可能为无症状患者选择进行瓣膜置换的时机，以最大程度地保护心肌，或者为术后即刻选择合适的治疗组合，从而尽可能多地保留心肌。我们对心内膜下缺血机制了解得越多，就越能早日实现这些预期目标。
