Cordioli E, Tondini C, Pizzi C, Massarelli G
Dipartimento di Medicine Interna, Cardioangiologia, Epatologia, Università degli Studi, Bologna.
Cardiologia. 1997 Jun;42(6):635-8.
A 48-year-old woman with no cardiovascular risk factors was admitted to the hospital because of acute dyspnea. At 27-year-old, she developed Hodgkin's disease, that was successfully treated with splenectomy, combined chemotherapy (nitrogen mustard, vincristine, procarbazine, prednisone-MOPP regimen) and radiotherapy (4500 rads). At 43-year-old the lymphoma relapsed and she had further chemotherapy with doxorubicin, bleomycin, vinblastina and dacarbazine. After this treatment, she had an episode of pulmonary edema, attributed to doxorubicin acute cardiotoxicity. She responded to digitalis and diuretics and was discharged with an electrocardiogram (ECG) showing left bundle branch block and a normal echocardiogram. The patient enjoyed good health for several years and 4 months before the present admission the ECG and echocardiogram were unchanged. On this admission there were signs of left ventricular failure with acute pulmonary edema, and a new soft apical murmur (3-4 Levine). The patient required endotracheal intubation and high doses of diuretics, digitalis and vasodilators. The cardiac enzymes were negative, the serial ECGs confirmed left bundle branch block, while the echocardiogram showed moderate to severe mitral regurgitation, akinesia of the interventricular septum and inferior wall with dilation of the left ventricle. A previous silent myocardial infarction was suspected. After recovery, she underwent cardiac catheterization confirming akinesia of the interventricular septum and inferior wall with moderate mitral regurgitation, while coronary angiography showed a critical ostial stenosis of the right coronary artery. In view of a dipyridamole-thallium scan negative for myocardial viability, reperfusion was not attempted. With changes in radiotherapeutic techniques, the incidence of radiation-induced heart disease (pericarditis, myocarditis, conduction abnormalities and, rarely, occlusive coronary artery disease) is declining. Nevertheless, after irradiation of the chest and mediastinum a longterm cardiological follow-up is useful in selecting patients at higher risk of radiation-induced coronary artery disease, who will eventually require coronary angiography and reperfusion intervention.
一名无心血管危险因素的48岁女性因急性呼吸困难入院。27岁时，她患上霍奇金病，通过脾切除术、联合化疗（氮芥、长春新碱、丙卡巴肼、泼尼松——MOPP方案）及放疗（4500拉德）成功治愈。43岁时淋巴瘤复发，她接受了多柔比星、博来霉素、长春碱和达卡巴嗪的进一步化疗。此次治疗后，她出现了一次肺水肿，归因于多柔比星急性心脏毒性。她对洋地黄和利尿剂有反应，出院时心电图显示左束支传导阻滞，超声心动图正常。患者数年来健康状况良好，此次入院前4个月，心电图和超声心动图无变化。此次入院时，有左心室衰竭伴急性肺水肿的体征，以及新出现的柔和的心尖部杂音（3至4级，莱文分级）。患者需要气管插管及大剂量利尿剂、洋地黄和血管扩张剂。心肌酶检查为阴性，系列心电图证实存在左束支传导阻滞，而超声心动图显示中度至重度二尖瓣反流、室间隔和下壁运动减弱以及左心室扩张。怀疑此前有隐匿性心肌梗死。康复后，她接受了心导管检查，证实室间隔和下壁运动减弱伴中度二尖瓣反流，而冠状动脉造影显示右冠状动脉开口处严重狭窄。鉴于双嘧达莫——铊扫描显示心肌无活力，未尝试进行再灌注治疗。随着放射治疗技术的改变，放射性心脏病（心包炎、心肌炎、传导异常以及罕见的闭塞性冠状动脉疾病）的发病率正在下降。然而，胸部和纵隔放疗后，长期心脏随访对于选择放射性冠状动脉疾病高危患者很有用，这些患者最终可能需要冠状动脉造影和再灌注干预。
