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摘要

主动脉夹层是一种相对少见且可能误诊的疾病，需要早期准确的诊断和治疗，以保证患者的生存。

病例我们报告一名62岁男性，诊断为斯坦福a型急性主动脉夹层，误诊为高血压危象。他被及时转诊手术。根据手术团队的回顾信息，该患者在手术后38天死于呼吸衰竭。

关键词：

急性主动脉夹层，高血压危象，计算机断层，经胸超声心动图，经食管超声心动图

介绍

主动脉夹层(AD)是一种相对罕见的疾病，尽管需要早期和准确的诊断和治疗患者的生存[1]。任何AD最常见的症状是胸痛。然而，急性主动脉夹层的诊断有许多潜在的困难。AD可能与其他更常见的疾病相似，如急性冠状动脉综合征、肺栓塞、心力衰竭、中风和急性腹部疾病，导致误诊的风险[2,3]。在撒哈拉以南非洲，最常见的心血管疾病是高血压、心肌病和心脏瓣膜病。高血压最常见的急性并发症是中风。急性冠状动脉综合征仍然是不常见的[4]和很少知道的频率急性主动脉综合征。我们报告一位62岁的男性，因斯坦福a型急性主动脉夹层被误诊为高血压危象。

病例报告

一名62岁男性，有未经治疗的高血压（HBP）病史和严重吸烟史，在两周内有进行性呼吸困难和疲劳史，被转诊到我们的门诊心脏病诊所。15天前，患者在休息时突然出现剧烈背痛，在10分钟内辐射到手臂和肩膀，但没有辐射到胸部，也没有出现其他症状。当时，他访问了一家地区医院，观察到HBP，其被解释为高血压危象，并开始了与阿司匹林相关的三重降压治疗。由于持续的症状，他被转诊到我们医院。入院时，双臂血压（BP）为150/50 mmHg，脉搏为92 bpm，具有Corrigan脉搏特征。心前区检查显示第一心音正常，第二心音响亮，主动脉区出现3/6级舒张性心脏杂音。心电图正常。实验室检查正常。D二聚体和心脏生物标记物不可用。胸部X线显示轻度至中度纵隔增宽。经胸二维超声心动图（TTE）显示升主动脉（51 mm）扩张，图像显示内膜扑动，多个视图显示急性AD（图1）。左心室大小正常，收缩功能良好，未见壁肥厚或心包积液。多普勒分析显示中度主动脉瓣返流。患者因诊断为急性AD而入住心脏重症监护病房；β受体阻滞剂启动了。经静脉造影增强的计算机断层扫描（CT）显示整个主动脉的AD，从主动脉根部开始延伸至右髂总动脉，证实斯坦福A型主动脉夹层的诊断（图2）。冠状动脉和主动脉上分支从真管腔显露出来。他被转诊做手术。根据手术小组的回顾资料，该患者在手术后38天死于呼吸衰竭。

图1。多普勒分析显示中度主动脉瓣返流。

图2。计算机断层扫描(CT)和静脉造影显示全主动脉AD，从主动脉根部开始，延伸至右侧髂总动脉，证实Stanford A型主动脉夹层的诊断。

讨论

急性AD在一般西方人群中的发病率估计在2,6 - 3,5 / 100,000人/年[5]。20%的AD患者在到达医院前死亡，30%在住院期间死亡。A型AD在发病前24-48小时的死亡率为每小时1.2%，如果不及时治疗，多达50%的患者将在一周内死亡。早期准确诊断AD至关重要。解剖的后果包括体积减少、器官缺血和随后的梗死。AD分为Stanford A型(累及升主动脉)和Stanford B型(只累及降主动脉[7])。夹层动脉瘤的临床表现是突发性“撕裂性”胸痛，辐射至背部，并伴有上肢间脉搏或血压不足和胸部x线异常，只有三分之一的患者出现[2]。我们的病人症状少。AD是一个动态过程，可发生在主动脉的任何部位，患者可根据假腔出现的位置、夹层扩散的程度以及血管来自真腔还是假腔而表现出各种各样的症状。患者发病15天来我院就诊，出现心力衰竭症状和主动脉功能不全的典型征象，结合影像学表现，可能接近急性AD的诊断。 In fact, the typical patient in IRAD registry [2] is a male in his seventh decade with a history of hypertension, who presents with abrupt onset of chest pain [2]. The majority of patients with acute AD had abnormalities in thoracic X-ray. However 10 to 20% of the patients had a normal thoracic X-ray, so a normal thoracic X-ray cannot rule out the diagnosis. For definitive diagnosis of acute AD, imaging such as cardiac CT, magnetic resonance imaging (MRI), p (TEE) or aortography must be performed. CT is the most often used modality to diagnose of AD because of its high specificity and sensitivity and it availability. However CT had limitations since it cannot detect aortic regurgitation. MRI also has high specificity and sensitivity, but the test is time consuming and less available. TEE is usually used for hemodynamically unstable patients since it can be performed at the bedside or in an operating room for emergency. In spite of previously reported moderate specificity and sensitivity of transthoracic echocardiography (TTE) [8], in patient presented herein the TTE was used as the first imaging modality because it was promptly available, the patient had signs and symptoms of aortic regurgitation and a high probability to have an AD; the result confirmed the suspension. The TTE have been described as an useful imaging modality for the diagnosis of classic acute type A AD [9]. In order to establish definitive diagnosis, better characterize the AD and to decide the therapeutic option; we perform a CT, once the patient was hemodynamically stable. According to the guideline of American Heart Association [1] patients with risk score 2 or 3 (abrupt onset back pain, systolic BP differential, murmur of aortic insufficiency) have to undergone immediate aortic imaging evaluation and surgical consultation, as in our case. The initial management of an AD is the same independent of the type. The patient should be kept pain free and their blood pressure controlled using intravenous beta blockers. Patient who have a type A dissection, if they are fit for surgery will require emergency operative repair. Patients who have a type B dissection can be managed medically and monitored for the development of complication which will determine if surgical intervention is required. Our patient had a Stanford type A aortic dissection, so he was promptly referred for surgery. Overall, in-hospital mortality rates in patients with type A AD remains high with nearly 1/3 of patients, as in this case, even in centers that have extensive expertise and interest in the treatment of these high-risk patients [10].

结论

总之，本病例强调了临床怀疑这种潜在生命状况的重要性。尽管采用了最佳的医疗和外科方法，但及时诊断对挽救生命极其重要。医生必须始终意识到HBP存在时的主动脉夹层、突然出现背痛/胸痛的症状，并应进行投资适当检查主动脉夹层的其他征象。

参考文献

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