【作者】 张长城；

【导师】 赵利华；

【作者基本信息】 吉林大学 ， 内科学， 2004， 硕士

【摘要】 选择性冠状动脉造影术被认为冠心病诊断的金标准，对于冠状动脉造影正常者，基本可排除冠心病的诊断，临床上发现有一部分冠状动脉造影正常的病人有胸痛症状、心电图变化以及心电图运动试验阳性等，给冠心病的诊断带来困难。本文对在本院冠状动脉造影正常而有胸痛、胸闷或/和心电图有ST-T改变的256例病人进行分析。结果：高血压78例，占所有病例的30.46%，其中左心室肥厚者54例，占21.09%。植物神经功能紊乱76例，占29.68%。心肌梗死11例，占4.3%。心肌病8例，占3.11%。颈、椎-基底动脉供血不足29例，占11.33%。颈椎病16例，占6.25%。过早复极综合症12例，占4.69%。心脏瓣膜病8例，占3.12%。此外，所有病例中高脂血症10例，占3.90%。糖尿病8例，占3.13%。 高血压及左心室肥厚劳损的患者出现心电图ST-T改变及临床症状机制可能是心电图变化可能与心肌肥厚，心肌排列紊乱致心肌除极与复极方向发生变化有关，交感神经活动紊乱也可引起心肌除极复极变化。由于随着高血压病情的发展，左心室重量增加，逐渐出现心肌肥厚劳损，而冠状动脉并不出现相应的增粗或增粗与肥厚程度不成比例。造成单位体积心肌供血减少，引起心肌相对缺血，而出现心肌缺血症状或心电图改变。因而与冠状动脉狭窄造成的心肌缺血不同。高血压患者出现胸痛症状，多表现为劳累性，也说明是心肌相对缺血引起。此外心肌肥厚的心脏的冠状动脉血流储备下降，其结果是基础状态下心肌供血良好，而在运动状态下心肌需血量增加的情况下，单位重量心肌供血量低于正<WP=34>常。冠状动脉血流储备能反映各种生理和病理状态下冠脉循环的功能，若冠脉无明显狭窄，而冠脉血流储备降低，可提示冠状动脉微血管病变。 心肌梗死后冠状动脉造影正常可能的机制是，原来罪犯血管没有病变，但由于一些诱因，使冠脉内皮受损，激活血小板系统以及大量血管活性物质的释放，诱发血管痉挛，一旦闭塞时间长，则形成心肌梗死。以后血栓自溶或治疗后血栓消退，或冠状动脉病变发生在很小的血管，造影无法显示。 颈动脉及椎-基底动脉供血不足，使延髓内心血管调节中枢缺血，使冠状动脉供血不足、心律失常，传导系统紊乱，引起心电图变化，心前区疼痛等症状。颈椎病引起胸痛、胸闷及心电图改变与支配心脏的神经解剖有关。 肥厚型心肌病可出现心肌缺血，其机制是心肌壁内纤维化区小冠状动脉内膜和中层增生引起管壁增厚和管腔狭窄，冠状动脉舒张期储备能力下降。心肌显著肥厚引起毛细血管密度减低，由于左室流出道出现梗阻，运动是更为明显，使室壁经张力增加，引起心肌耗氧量过度增加。心肌收缩压迫大血管，可引起冠状动脉阻力增加引起心肌缺血。有时临床上不易和冠心病鉴别也应行冠状动脉造影检查，以排除冠心病 。扩张型心肌病出现胸闷症状，实际是心功能下降的早期表现。 早期复极综合症易误诊为急性心肌梗死，但冠状动脉造影无动脉狭窄，其心电图改变的机制可能与心室部分心肌提早复极，迷走神经张力增高有关。 血脂异常及糖尿病是引起冠状动脉粥样硬化的重要原因，在<WP=35>本研究中高脂血症和糖尿病占比例较低，是冠状动脉造影正常的原因之一。植物神经功能紊乱患者在本研究中占比例较高，因此对于有不典型胸痛和心电图有变化的较年轻患者，应行冠状动脉造影，避免误诊及盲目治疗。结论：有胸痛、胸闷及心电图改变而冠状动脉造影正常可有多种原因引起，其中高血压左心室肥厚和植物神经功能紊乱是最常见原因。此外，颈、椎基底动脉供血不足也应引起重视。其他少见原因有：心肌病、心脏瓣膜病、过早复极综合症、颈椎病等。此类病人血脂、血糖多数正常。更多还原

【Abstract】 The selectivity coronary angiogrphy are generally accepted for the golden standard of coronary heart disease. To those patients with normal angiogram, the diagnosis of the coronary heart disease are basic expelled, but some patients with normal angiogram are found with angina pectoris symptom, electrocardiogram change and positive electrocardiogram exercises test. This text analyse the clinical characteristics in 256 patients with normal angiogram, chest -pain or/and electrocardiogram change. Result: 78 cases have hypertension, occupying for 30.46% of all cases, and among them, 54 cases have left ventricular hypertrophy, occupying for 21.091%; 76 cases have plant nerve function mess, occupying for 29.68% of all the cases; 7 cases with acute cardiac infarction, occupying for 2.73%;8 case with cardiomypathies, occupying for 3.11%; 29 cases with vertebrobasilar insufficency, occupying 11.33%; 16 cases with cervical vertebra disease, occupying for 6.25%; 10 cases with dyslipidemia, occupying for 3.90%; 8 cases with diabetes, occupying for 3.13%; 12 cases with early repolarization sydrome, occupying for 4.69%.8 cases with heart valve disease, occupying for 3.13%. The principle that hypertension and left ventricular hypertrophy cause chest pain and electrocardiogram change maybe is that along with the development of the hypertension, the left ventricular weight increase which gradually leads left ventricular hypertrophy, but <WP=37>coronary artery do not increase congruously or increase disproportionate with thick degree. Resulting in the blood supply of unit volume myocardial decrease, and which cause the opposite blood lacking in myocardial. All these lead blood lacking of myocardial symptom or electrocardiograms changes. So it is different from blood lacking that caused by coronary narrow. When hypertensive patients have the angina pectoris symptom, most of them appear tired angina pectoris. Which also suggest it is caused by opposite blood lacking cause of myocardial. In addition the coronary flow reserve decrease after ventricular hypertrophy, its result is the blood supply is good in basic situation, but under the situation of exercising, the needs of blood of the myocardial increase, the blood supply of the unit weight myocardial is lower than normal. The coronary flow reserve can the coronary function of physiological and pathologic circulation, if coronary artery has no obvious narrow, but the coronary flow reserve is low, can clue to the coronary artery capillaries pathological changes. The principle of normal coronary angiography after myocardial infarction is the original criminal coronary artery having no pathological changes, but because some inducement cause the coronary endothelium damaged. Which activate blood platelets system and large quantity blood vessels active material release. All this lead the coronary convulse. Once time is long enough, the cardiac infarction may occur. The thrombus maybe autolyze later or is melted after therapy. It also probably that the coronary artery pathological <WP=38>changes take place in the pimping blood vessel, the artery can’t be show. The shortage of blood supply of carotid artery and vertebrobasilar insufficiency make the spinal heart blood vessel regulate centrum the axis lack the blood, which lead the blood supply of coronary artery lacking, cardiac arrhythmia, the electrocardiogram change and chest-paint. The cervical vertebra disease also can causes the chest-pain and the electrocardiogram changes. Which is related to the anatomise that control cardiac nerve. Dyslipidemia and diabeteses are important reasons to cause coronary atherosclerotic heart disease. In this study the ratio of dyslipidemia and diabetes is lower, which is a reasons that coronary angiogrphy is normal. The ratio of plant nerve function mess is higher in this study, therefore to the young patients with no typical model chest-pain and electrocardiogram change, coronary angiogrphy should be made, avoiding the misdiagnosis and blindnesses treatment. Hypertrophic card更多还原