不典型急性心肌梗死漏误诊研究.doc

不典型急性心肌梗死漏误诊研究[摘要] 目的：探讨急性心肌梗死（AMI）的临床特点。方法：回顾分析8年间217例AMI住院患者的临床资料。结果：36例被漏误诊的AMI患者起病时多无典型心绞痛，首发表现为呼吸困难、胸闷、面色苍白、出汗、乏力、胃肠道反应、意识障碍等症状，多数患者心电图不典型。结论：询问病史、临床症状及动态观察心电图可减少误诊漏诊。 [关键词] 急性心肌梗死；误诊 [中图分类号]R542.2 [文献标识码]B [文章编号]1673-7210（2008）08（b）-139-02 Analysis of the misdiagnosis and missed diagnosis of atypical acute myocardial infarction ZHONG Jian-bing, YANG Yan-qiu, SONG Zong-ren (Guanlan People′s Hospital, Shenzhen 518110, China) [Abstract] Objective: To discuss the clinical characteristics of acute myocardial infarction(AMI). Methods: Retrospectively analyzed the clinical data of 217 inpatients with AMI in 8 years. Results: 36 patients with AMI who were misdiagnosed and missed diagnosed had no typical angina pectoris at the onset of disease, and the first manifestations were dyspnea, chest distress, pallor, perspiration, hypodynamia, gastrointestinal reaction, disturbance of consciousness etc, and the electrocardiograms of most patients were untypical. Conclusion: Misdiagnosis and missed diagnosis could be decreased by asking medical history, clinical symptoms as well as observing dynamic electrocardiogram motion. [Key words] Acute myocardial infarction; Misdiagnosis 急性心肌梗死(AMI)是内科急危重症之一，来势凶猛,临床表现多种多样，若不及时诊治，其病死率很高[1，2]。AMI典型者一般不难诊断，症状、体征或心电图不典型易造成误诊漏诊，现将我院近8年来217例AMI住院患者中误诊漏诊的36例加以分析。 1 临床资料 本组36例中男性22例，女性14例，年龄40～83岁，平均（61±3.7）岁。其中病变涉及广泛前壁者7例，前间壁者12例，前间壁合并下壁者3例，前壁者3例，下壁者6例，高侧壁者3例，右心室、无Q波心肌梗死各1例。36例中≥60岁者19例，40～60岁者13例，40岁以下（包括40岁）者4例。起病时有典型心绞痛者6例，占16.7%；不典型心绞痛者30例，占83.3%。首发临床表现为胸闷、呼吸困难者16例，占44.4%；面色苍白、出汗、乏力者4例，占11.1%；腹痛、恶心、呕吐等胃肠道反应者6例，占16.6%；晕厥、黑?、头昏等神经系统症状者7例，占19.4%；以头痛、颈项疼痛及上肢痛等为首发表现者3例，占8.3%。典型心电图改变者13例，不典型心电图改变者23例。 2 典型病例 2.1 经心电图诊断AMI的经验不足 例1，男，63岁，因心前区疼痛、恶心6 h入院，做心电图（EKG）检查，发现Ⅲ呈W形，ST段弓背向上抬高2 mm，电轴左偏34°，值班医生诊断为心绞痛，给予硝酸甘油含化，疼痛未缓解。做心肌酶检查，示明显增高，诊断为急性下壁心肌梗死，给予尿激酶溶栓等治疗，治愈出院。 2.2 以意识障碍为主要表现 例2，女，农民，65岁，从事家务劳动时突然头昏、不省人事3 h入院。无恶心、呕吐及外伤史。查体：血压13/8 kPa，脉搏90次/min，颈软，两肺（-），心音低钝，病理反射未引出，血糖6.2 mmol/L。给予复方丹参及含镁极化液静滴，半小时后意识清醒，后因患