虚血性心疾患にかんする臨床的考察 : とくに中間型に対する批判

概要

論文の詳細を見る
Ischemic cardiac patients with or without pain were divided into three main groups by the modification of Ross' classification with special reference to clinical symptoms, laboratory results, electrocardiographic as well as vectorcardiographic findings, cardiovascular dynamical values and patho-anatomical examinations. On the other hand, this classification was compared with that presented by WHO in 1962. In this paper there was kept account on intermediate types in the sense of WHO (I.T.) which is supposed to be situated between exertional angina pectoris (A.P.) and myocardial infarction (M.I.). These three abbreviations described here are strictly meant by three sorts of the respective ischemic heart diseases (I.H.D.) defined by the WHO recommendation, since baseball without ground rule is quite nonsensical. The significance of I.T. has remained, however, still uncertain and has become a source of contraversy ; accordingly I.T. involves at present a lot of various synonyms depending on different authors' opinions, for example, definition of Vakil or Prinzmetal. 1. In the light of Ross, the ischemic heart diseases complicated with cardiac pains could be also divided into three groups chiefly according to the types of attacks. In the group I, the duration of the attack was usually within five minutes; nitroglycerine was proven effective in favour. In the group III, the duration of the attack was longer than one hour; nitroglycerine was refractory against the attack; in addition, shock of various severity was occasionally complicated. The group II was intermediately situated between the former two groups. 2. In the group II, nitroglycerine was proven also fairly effective nearly in one half of the cases. The rate of occurrence of myocardial necrotic signs suggested from those of changes in serum fermentative reactions, blood sedimentation rate, white cell number and fever etc. was again intermediately observed between those in the group I and III. Consequently as far as the modification of Ross' classification is concerned, the clinical and laboratory findings were usually supposed in parallel with the severity of attacks. Regarding prognosis, the rate of recovery was, without mention, better in the group I than in the group II and III; at least respecting the hospitalized subjects here observed the mortality in the group III did not so strikingly exceed that in the group II. 3. Electrocardiographically there existed the significant difference of αQRS, αT and G/R between the group I and II. Vectorcardiographically there existed also roughly the same tendency as being found electrocardiographically ; that is, as the anginal symptoms became severe, the initial vector of QRS in horizontal plane turned posteriorly and the T vector was displaced dextro-anteriorly. Regarding _SVG, there appeared the decrease in _<SA>T and SG/SR. These changes in Ecg and Vcg were seemed to furnish with useful informations about any sort of classifications of ischemic heart diseases, for example, the two-peaked T in V, without ST-T change in V_<2〜6> occasionally experienced among such patients as belonging to the group II. 4. In ischemic heart patients whose conditions allowed to perform the circulatory analysis, no marked decrease in stroke and minute volumes could be estimated on an average. The prolongation of tension time ASZ and the diminution of ejection time ATZ, that is, the tendency to pressure reaction in the sense of Blumberger displayed more strikingly in the group II and III than in the group I. 5. According to the classification recommended by WHO, most of the patients with A.P. belonged to the above-mentioned group I and 80 per cent of the patients with M.I. to the group III. There existed, however, a minority of patients with M.I. belonging to thegroup I or II. The patients with I.T. defined by WHO could be seen in each of the three sorts of the groups classified by the modification of Ross' method. In the group II there could not be observed any case of A.P., but some patients with I.T. or M.I. in the sense of WHO could be seen, though the cases of M.I. remained only a few. The group III of ischemic heart diseases defined by the modified Ross' method corresponded, for the most part, to M.I. defined by WHO, though the patients in this group did not necessarily show any sign of myocardial necrosis. The recommendation of WHO emphasized that A.P. is of exertional nature ; there could, however, be seen not only eleven per cent of I.T., but also thirty per cent of M.I.; while nitroglycerine was proven refractory in all of M.I., it was found effective in one-third of I.T. As to the hospitalized patients here observed, the mortality was estimated zero per cent in A.P., 16.6 per cent of in I.T. and 15.9 per cent of M.I. respectively. The myocardial necrotic signs in I.T. appeared at the intermediate rate between A.P. and M.I. 6. In I.T., the intrinsicoid deflection showed the intermediate delay between A.P. and M.I.; VG of I.T., however, did nod display any pathognomonic change. There could be observed vectorcardiographically the posterior displacement of the initial vector of QRS and the change in T vector, as mentioned in the group II; these findings could be also assured in I.T. The cardiovascular dynamical values found in each of the subdivisions of I.H.D. according to the classification of WHO showed more or less clear difference from those in normal health on an average, but there existed no characteristic feature of the change in circulatory dynamical values among the subdivisions of I.H.D. 7. The patho-anatomical findings of I.H.D. Respecting the coronary arterial sclerosis, there could not be observed any pathognomonic pattern corresponding to the subdivisions of I.H.D., whereas regarding the changes in myocardium there could be consistently seen the dissemination of small myomalacia with or without microthrombosis and small myocardial fibrosis at the autopsy of the group I and II. Except for one cases (No. 40) in this observation, all of the other patients belonging to the group III showed the typical myocardial infarction. There existed no autopsy of A.P. classified by WHO. Two cases of I.T. showed the coronary arteriosclerosis, the other one the rheumatic occlusive coronaritis as one of the manifestations of the generalized rheumatic angiitis and the last the coronary angiitis in systemic lupus erythematosus, while neither localisation nor severity of the patho-anatomical finding could be assured respecting coronary stenosis found in I.T.; that is, the disseminated myocardial lesions could be observed in each of the patients with I.T. In M.I. according to WHO classification, there could be not rarely seen such cases as showing diffuse disseminated, small changes in myocardium, instead of massive localized infarction. Thus there exist some disagreement between clinical classifications heretofore published and patho-anatomical findings, especially it remains still difficult clinically to grasp the patho-anatomical meaning in I.T. 8. The casuistic reports were described as follows: a.I.T.: i. Prinzmetal's variant form, especially involved in posterior cardiac wall, ii. Prinzmetal's variant form, especially involved in anterior cardiac wall, iii. The myocardial fibrosis, dead of sudden death, complicated with so-called cardio-cerebral symptom-complex, left bundle branch block and congestive heart failure in the course of the recurrent acute coronary failure in the typical sense of Blumgart. iv. The acute coronary failure, complicated severe shock symptoms, missing any gross change in coronary system at autopsy. b. Special cases of M.I.: i. Coronary involvement in the course of Niemann-Pick's lipoidosis complicated with various sorts of neurological symptoms. ii. Diffuse rheumatic occlusive coronaritis and fresh atrial infarction in mitralstenoinsufficiency. iii. The patient with the diffuse disseminated small myocardial scarrs and infarctional cardiac aneurysma found at autopsy, who was suddenly dead of the stenosis of the coronary stem due to luetic aortitis showing the anterior QRS pattern persisting two months long after the first marked attack. c. Sudden death due to the coronary angiitis in systemic lupus erythematosus. d. Among so-called silent or painless I.H.D. according to the classification of WHO, the following casuistic cases were described. i. Temporal, but considerably long-standing left bundle branch block, ii. Old high lateral infarction found in the course of the rheumatic heart disease, iii. Coronary angiitis observed in the panangiitis nodosa suddenly dead of acute haemothorax. iv. Severe myocardial involvement of a patient with Behget's disease, v. Coronary sclerosis complicated systemic amyloidosis with right bundle branch block (sudden death).
千葉大学の論文

著者

板倉純夫
千葉大学医学部(二内)

虚血性心疾患にかんする臨床的考察 : とくに中間型に対する批判

スポンサーリンク

概要

著者

関連論文

スポンサーリンク