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目的:探讨急性严重胸痛伴主动脉瓣区舒张期杂音的心血管急危重症患者的病因诊断、临床特点和预后判断。方法:收集急性严重胸痛伴主动脉瓣区舒张期杂音病例66例,分析其疾病诊断,观察其临床指标,记录有无首诊误诊以及严重临床事件、住院期间死亡终点事件。结果:66例患者以急性主动脉夹层Stanford A型(32例,占48.5%)、急性心肌梗死(AMI)伴主动脉瓣关闭不全(28例,占42.4%)多见,少数为急性主动脉窦瘤破裂(6例,占9.1%)。stanford A型急性主动脉夹层组白细胞计数、D-二聚体、C-反应蛋白明显升高的占比较高;AMI伴主动脉瓣关闭不全组多有糖尿病史,以心电图ST-T改变、肌钙蛋白I(TnI)升高及左室射血分数下降的比例较高;急性主动脉窦瘤破裂组以年轻患者突发严重心力衰竭及显著BNP升高的更常见。急性主动脉窦瘤破裂组首诊误诊率明显高于急性主动脉夹层Stanford A型及AMI伴主动脉瓣关闭不全组。急性主动脉窦瘤破裂组病死率明显低于急性主动脉夹层Stanford A型及AMI伴主动脉瓣关闭不全组。结论:临床上急性严重胸痛诊断时应高度关注主动脉瓣区舒张期杂音,警惕少见疾病,避免误诊,正确判断预后;尤其是D二聚体或CRP显著升高的患者,需注意非AMI的可能。
Objective: To investigate the etiological diagnosis, clinical features and prognosis of acute severe chest pain with diastolic murmur of aortic valve area. Methods: A total of 66 cases of acute severe chest pain with diastolic murmur in aortic valve area were collected. The diagnosis of the disease was analyzed. The clinical indexes were observed. The first and second misdiagnosis and serious clinical events were recorded. The death end point during hospitalization was recorded. Results: A total of 66 patients were diagnosed as having acute aortic dissection Stanford Type A (32 cases, 48.5%), acute myocardial infarction (AMI) with aortic insufficiency (28 cases, 42.4%), Sinus rupture (6 cases, 9.1%). Stanford type A acute aortic dissection group, white blood cell count, D-dimer, C-reactive protein increased significantly higher; AMI with aortic valve insufficiency group more than the history of diabetes, ST-T ECG changes, muscle A higher proportion of elevated TnI and decreased left ventricular ejection fraction; acute rupture of the sinus aneurysm was more common in young patients with severe heart failure and elevated BNP. The first misdiagnosis rate of acute sinus aneurysm rupture group was significantly higher than that of acute aortic dissection Stanford A type and AMI with aortic valve insufficiency. The mortality rate in ruptured acute sinus aneurysm group was significantly lower than that in acute aortic dissection Stanford type A and AMI with aortic valve insufficiency. Conclusions: In clinical diagnosis of acute severe chest pain, aortic valve area diastolic murmur should be paid great attention to, vigilant rare diseases, misdiagnosis and prognosis correctly. Especially in patients with significantly increased D dimer or CRP, attention should be paid to non AMI may.