依伐布雷定用于急性心肌梗死非血运重建1例

A Case of Application of Ivabradine in Acute Myocardial Infarction with Non Revascularization

摘要: 一名47岁的男性患者有高血压病史，无明显诱因突发胸闷、憋喘，心电图提示广泛的前壁导联ST段抬高，后复查肌钙蛋白水平升高，复查心电图提示前壁、下壁导联ST段抬高。急诊冠脉造影提示冠状动脉血管多支严重病变合并前降支开口后完全闭塞，建议冠状动脉搭桥术(coronary artery bypass surgery, CABG)治疗，患者暂拒绝CABG后予以药物保守治疗。术后患者出现心衰(heart failure, HF)症状，予以沙库巴曲缬沙坦、美托洛尔缓释片、地高辛、新活素等抗HF、改善心室率治疗。但症状改善不明显，同时伴有血压下降、心率增快。考虑患者对于美托洛尔等降心率药物不耐受，故加用依伐布雷定口服降心率，心率稳定于70~80次/分伴HF症状明显改善。后复查心电图及血液指标均得到改善，患者症状缓解后选择CABG治疗，预后良好。依伐布雷定在药物说明及相关治疗建议中不提倡用于急性心肌梗死(acute myocardial infarction, AMI)病人，这次我们报告了一例AMI后未进行冠状动脉血运重建病人，适量使用依伐布雷定可有效改善患者症状。有关此类病例的临床经验确实相当有限，本病例在相关文献的背景下进行了回顾，为临床用药提供了参考。

Abstract: A 47-year-old male patient with hypertension, experienced sudden chest tightness and dyspnoea without obvious inducement. The ECG indicated that there’s extensive anterior ST-Segment Eleva-tion. In further check-up, this male patient marked increases in troponin, the ECG indicated that the elevation of anterior and inferior ST-segment .Emergency coronary angiography indicates severe lesions in multiple coronary arteries with complete occlusion of the anterior descending branch opening. It is recommended to undergo coronary artery bypass surgery (CABG), but the patient has temporarily refused the CABG to conservative medication treatment. The patient developed symp-toms of heart failure (HF) and was treated with sacubitril/valsartan, metoprolol sustained-release tablets, digoxin, and recombinant human brain natriuretic peptide to improve ventricular rate. However, the improvement in symptoms was not significant, accompanied by blood pressure de-cline and elevation of heart rate. Considering that the patient is intolerant to heart rate lowering drugs such as metoprolol, oral administration of ivabradine was added to lower heart rate. The heart rate was remaining stably at 70-80 beats per minute with significant improvement in HF symptoms. The follow-up ECG and blood indicators have improved. After the patient’s symptoms improved, they chose to undergo CABG, and the prognosis was good. Evabradine is not recom-mended for use in patients with AMI in drug instructions and related treatment recommendations. This time, we reported a case of a patient with AMI who did not undergo coronary artery revascu-larization. Moderate use of ivabradine can effectively improve the patient’s symptoms. The clinical experience regarding such cases is indeed quite limited. This case was reviewed in the context of relevant literature, providing a reference for clinical medication.