主动脉综合征诊断研究进展

Advances in the Diagnosis of Aortic Syndrome

摘要: 目的：急性主动脉综合征(ASs)是累及胸主动脉的致命心血管急症。AS是一种相对罕见的疾病，具有非特异性的体征和症状(包括躯干疼痛、晕厥、神经功能缺损和肢体缺血)，需要胸腹对比增强断层扫描血管造影(CTA)进行最终诊断和后续治疗计划。在急诊科(ED)，大多数有AS潜在体征或症状的患者最终被发现受到其他替代诊断的影响。因此，误诊和延迟诊断是AS的主要问题。方法：对于危重患者，通常可以直接决定是否进行CTA，因为检查的好处大于风险。在心电图显示st段抬高的患者、疑似原发性缺血性中风的患者和病情稳定的患者(代表最常见的ED场景)中，由于存在误诊和过度检测的风险，需要进行CTA的患者的正确筛查是很麻烦的。结果：现有研究支持了一种综合了临床概率评估、床边超声心动图和d-二聚体(如果临床概率不高)的算法。治疗管理包括对所有患者进行药物治疗，包括阿片类药物和抗冲动药物(一种受体阻滞剂和一种血管扩张剂)，目标是心率为每分钟60次，收缩压为100~120毫米汞柱。累及升主动脉的AS患者可能需要紧急手术，而复杂的B型AS (严重的主动脉扩张、即将发生或直接破裂、器官灌注不良、难愈性疼痛、严重高血压)需要评估是否需要紧急血管内治疗。

Abstract: Objective: Acute aortic syndrome (AS) is a fatal cardiovascular emergency involving the thoracic aorta. AS is a relatively rare disorder with non-specific signs and symptoms (including trunk pain, syncope, neurological deficits, and limb ischemia) that requires chest and abdominal con-trast-enhanced tomography angiography (CTA) for final diagnosis and subsequent treatment plan-ning. In the emergency department (ED), most patients with potential signs or symptoms of AS are eventually found to be affected by other alternative diagnoses. Therefore, misdiagnosis and delayed diagnosis are the main problems of AS. Methods: In critically ill patients, the decision to have a CTA is often straightforward, as the benefits of testing outweigh the risks. Proper screening of patients requiring CTA is troublesome due to the risk of misdiagnosis and overtesting in patients whose ECG shows ST-segment elevation, patients with suspected primary ischemic stroke, and patients with stable disease (representing the most common ED scenario). Results: Available studies support an algorithm that combines clinical probability assessment, bedside echocardiography, and D-dimer (if clinical probability is not high). Treatment management includes medication for all patients, in-cluding opioids and anti-impulse drugs (a beta-blocker and a vasodilator), with a target heart rate of 60 beats per minute and systolic blood pressure of 100~120 MMHG. Patients with AS involving the ascending aorta may require emergency surgery, while complex type B AS (severe aortic dila-tion, imminent or immediate rupture, poor organ perfusion, intractable pain, severe hypertension) requires evaluation for emergency endovascular treatment.