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急性心肌梗死的心理社会因素

Author
Geoffrey H Tofler, MD
Section Editor
Jonathan M Silver, MD
Deputy Editor
David Solomon, MD
Translators
毛雪琴, 副主任医师，副教授

引言

虽然人们一直怀疑急慢性应激是心肌梗死(myocardial infarction, MI)和心脏性猝死的危险因素，但因果关系的存在受到怀疑。然而，尽管机制仍不明确，但越来越多证据支持有因果关系。近期观察结果为研究开辟了急性风险这一广阔领域，突显了心理社会因素对心梗急性发病和心梗后预后的潜在作用。例如，现今认为ST段抬高型(Q波)心肌梗死继发于冠状动脉血栓形成，而后者继而引起斑块裂[1,2]。斑块裂和血栓形成常发生在先前轻微狭窄部位，提示急剧发生斑块从稳定变为不稳定的转化(诊断流程 1)[3]。 (参见“易损斑块在急性冠脉综合征中的作用”)

昼夜变化

心肌梗死、心脏性猝死及心肌缺血发生频率的昼夜变化特征为晨间高发。一项meta分析纳入66,635例急性心肌梗死患者和19,390例猝死患者，报道称与一日中其余时间相比，早晨6点至中午12点发生了更多的心肌梗死(RR 1.38)和猝死(RR 1.29)(图 1A-B)[4]。

事件发生频率的昼夜变化提示，心脏事件可能由外在活动触发，特别是激活交感神经系统的活动[5]。一项纳入1225例患者的研究支持该观点，报道称糖尿病患者没有此类昼夜变化，特别是存在心脏自主神经病变证据且无心率变异性的患者[6]，以及因心肌梗死住院期间使用β受体阻滞剂或阿司匹林的患者[7]。 (参见“糖尿病自主神经病变”)

促成心肌梗死晨间高发的另一因素可能是纤溶能力的昼夜变化。在稳定型冠状动脉性心脏病患者中，纤溶酶原激活物抑制因子-1的活性高峰见于晨间早时，而此时组织纤溶酶原激活物活性最低；采用一种β受体阻滞剂治疗可以改善这种相对促血栓形成的状态[8]。 (参见“纤溶标志物和心血管风险”)

急性心肌梗死的触发

限制梗死面积的多中心研究(Multicenter Investigation of the Limitation of Infarct Size, MILIS)数据表明，在849例急性心肌梗死患者中，48%的患者描述了一种或多种可能的触发因素，其中最常见的是情绪烦乱(14%)[9]。其他研究也发现多达10%的患者中可能的触发因素[10-12]。

                     

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Literature review current through: 2017-06 . | This topic last updated: 2017-03-17.
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