中青年不典型急性心肌梗死七例误诊分析

张少利，李 燕，王学惠，陈志刚

中青年不典型急性心肌梗死七例误诊分析

张少利，李 燕，王学惠，陈志刚

目的 探讨中青年急性心肌梗死(acute myocardial infarction， AMI)的不典型表现及误诊原因，降低误诊率。方法 回顾性分析2015年5月—2016年2月我院收治的7例中青年不典型AMI误诊病例资料。结果 本组年龄24～44岁。2例因上腹疼痛、恶心、呕吐、呃逆、腹泻等消化道症状误诊为急性胃肠炎；1例因咳嗽、咳痰、气促，X线胸片示肺纹理增粗误诊为支气管炎；1例因单纯胸痛误诊为肋间神经炎；1例因心悸、乏力、心电图ST段压低误诊为心脏神经症；1例因头昏、双上肢无力及腔隙性脑梗死病史误诊为脑梗死；1例因低血压、体位改变后晕厥误诊为体位性晕厥。本组平均误诊时间(4.56±1.26)d，按误诊疾病治疗效果不佳，后行心电图检查发现动态改变，查心肌酶谱异常，确诊为AMI。确诊后予再灌注治疗，病情稳定后出院。结论 复杂多样化及不典型的临床表现极易导致中青年AMI误诊，临床医师应提高对中青年AMI的警惕性，减少误诊误治。

心肌梗死；中青年；误诊；胃肠炎；支气管炎

急性心肌梗死(acute myocardial infarction， AMI)好发于中老年人群，典型临床表现为心前区或胸骨后持续性、压榨性、窒息性疼痛不适，且伴有出汗及心音低钝[1-5]。但中青年AMI患者多数无心绞痛发作史，临床表现复杂多样，极易误漏诊[6]，延误诊治可导致严重后果。2015年5月—2016年2月我院收治56例中青年AMI，占我院同期收治AMI总患者数的19.0%，其中7例误诊，误诊率12.5%，现回顾分析误诊病例资料如下。

1 临床资料

1.1 一般资料 本组7例，男6例，女1例；年龄24～44岁。病程6～48 h。有慢性胃肠炎、腔隙性脑梗死病史各1例。所有患者均符合2015年世界卫生组织AMI诊断标准[7]。首诊科室:神经内科、消化内科及心内科各2例，呼吸内科1例。

1.2 临床表现及误诊误治情况 1例因上腹疼痛、恶心、呕吐伴呃逆、腹泻2 d就诊，查血白细胞14.5×109/L，根据慢性胃肠炎病史，初步诊断为急性胃肠炎，予抗感染、补液等对症处理。1例因重体力劳动后出现胸闷、腹痛伴冷汗、恶心、呕吐8 h入院，腹部X线平片示胃黏膜皱襞改变，查血白细胞13.8×109/L，初诊为急性胃炎，予抗感染、补液、抑酸等对症处理。1例因咳嗽伴少量咳痰，气促、不能平卧3 d就诊，X线胸片示肺纹理增粗增多，初诊为急性支气管炎，予止咳化痰等对症治疗。1例无明显诱因出现胸痛12 h，查心电图无明显异常，初诊为肋间神经炎，予抗炎、镇痛等治疗。1例无诱因出现心悸、乏力36 h，无胸痛、胸闷等，查心电图示ST段压低，初诊为心脏神经症，予相关对症治疗。1例有腔隙性脑梗死病史，此次因头昏伴双上肢无力麻木3 d，伴短暂意识障碍入院，头颅CT检查示多发腔隙性脑梗死，初诊为脑梗死，予活血化淤等对症处理。1例因日晨起床后突发性晕厥伴面色苍白、全身不适6 h就诊，测血压90/58 mmHg，心电图未见明显异常，诊断为体位性晕厥，予升压等对症处理。

1.3 确诊经过及预后 本组均按初诊疾病治疗2～4 d后症状无改善，且病情加重，逐步出现胸闷、呼吸困难等，进一步行心电图检查发现典型心肌梗死动态改变，心肌标志物异常：心肌型肌酸激酶同工酶42.3～50.2 U/L，肌钙蛋白I 0.8～1.2 μg/L，确诊为AMI，其中下壁并前侧壁、前壁、广泛前侧壁心肌梗死各1例，前壁、高侧壁心肌梗死各2例，误诊时间(4.56±1.26)d。确诊后均给予积极扩张冠状动脉、溶栓、经皮冠状动脉介入术等再灌注治疗，病情逐步稳定，无AMI相关并发症及死亡事件发生。

2 讨论

2.1 发病特点 AMI为老年人多见，中青年AMI患者发病特点与大多数老年患者有所不同，男性发病率较女性高，发病常有诱因存在，吸烟为最常见诱因，胸痛为较典型临床表现，大多数以冠状动脉单支病变为主[8-12]。目前认为引发中青年AMI的高危因素有：高血压病、高脂血症、糖尿病等遗传因素；吸烟、酗酒等不健康生活方式；长期紧张、抑郁等不良心理状态[8-12]。

2.2 误诊原因分析 ①临床表现不典型：本组大多数入院时以AMI不典型症状就诊，且入院首次心电图检查无明显异常，使接诊医生忽略该病诊断；②对中青年AMI缺乏警惕性：本组患者首诊科室多为非心内科，非心内科医生对AMI缺乏认识，不熟知AMI复杂多样的临床表现，导致误诊；③病史了解不全面：首诊医生接诊患者时未详细询问病史、仔细了解病情，亦未进行全面的体格及医技检查，导致许多关键信息无法获得，从而发生误诊；④患者因素：患者自身对AMI的危险性缺乏认识，不配合心电图、心肌酶等检查，导致不能及时获得诊断依据。

2.3 防范误诊措施 ①提高对中青年AMI的警惕性：各专科医生均应认识到AMI年轻化的趋势，全面了解AMI不典型临床表现，提高警惕性。②详尽了解病史及仔细查体：详细询问患者病情变化，仔细查体，及早明确诊断。③了解该病医技检查特点：心肌标志物和心电图表现在AMI发病各期均有一定的动态改变。部分AMI患者尤其是非ST段抬高型AMI患者心电图早期改变不典型。因此，对高度可疑AMI者不能满足于单次心电图检查无异常，应反复多次检查以避免延误诊断，造成严重不良后果。

综上所述，临床医生应全面提高对该病的认识，不能仅限于局部表现，应拓展诊断思维，合理利用各种医技检查手段，早期明确诊断，降低误诊率，提高诊治水平。

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Analysis of Misdiagnosed 7 Young and Middle-aged Patients with Atypical Acute Myocardial Infarction

ZHANG Shao-li， LI Yan， WANG Xue-hui， CHEN Zhi-gang

( The Third Department of Cardiology, the First Affiliated Hospital of Xinxiang Medical College, Weihui, Henan 453100, China)

Objective To investigate atypical manifestations and misdiagnosed causes of young and middle-aged patients with atypical acute myocardial infarction (AMI) in order to reduce misdiagnosis rate. Methods Clinical data of 7 young and middle-aged patients with atypical AMI admitted during May 2015 and February 2016 was retrospectively analyzed. Results The range of patients were from 24 to 44 years old. A total of 2 patients were misdiagnosed as having acute gastroenteritis due to gastrointestinal symptoms such as abdominal pain, nausea, vomiting, hiccups, diarrhea; 1 patient was misdiagnosed as having bronchitis due to cough, expectoration, shortness of breath and thickening lung markings by chest X-ray; 1 patient was misdiagnosed as having intercostal neuritis due to simple chest pain; 1 patient was misdiagnosed as having cardiac neuropathy due to palpitations, fatigue and ST segment depression by electrocardiogram (ECG); 1 patient was misdiagnosed as having cerebral infarction due to dizziness, both upper extremities powerless and lacunar infarction history; 1 patient was misdiagnosed as having postural syncope due to hypotension and syncope. The average time of misdiagnosis was (4.56±1.26)d. The effects of symptomatic treatment for misdiagnosed diseases were poor, and dynamic changes were found after ECG examination, and then AMI was confirmed after finding abnormal result of myocardial enzyme examination. Reperfusion therapy was given after confirming AMI, and patients were discharged after having stable conditions. Conclusion Complex and atypical manifestations can easily lead to misdiagnosis for young and middle-aged patients with AMI, so clinicians should improve the vigilance of young and middle-aged patients with AMI so as to avoid misdiagnosis and mistreatment.

Myocardial infarction; Young and middle-aged; Misdiagnosis; Gastroenteritis; Bronchitis

453100 河南 卫辉，新乡医学院第一附属医院心内三科

陈志刚，电话：13837397691;E-mail：zsl19781127@sina.com

R542.22

A

1002-3429(2017)04-0050-02

10.3969/j.issn.1002-3429.2017.04.017

2016-09-13 修回时间：2017-01-24)