心筋梗塞の死因，特に心破裂の変遷と治療の関係

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  • A change of the cause of death in myocardial infarction and the beneficial effect of vasodilator therapy on cardiac rupture following myocardial infarction.
  • シンキン コウソク ノ シイン トクニ シン ハレツ ノ ヘンセン ト チリ

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First, the causes of death and the pathological features of myocardial infarction were examined in 574 autopsy cases (292 men 282 women, mean age 79.2 years) for eleven years. Myocardial infarction was observed in 19.3 percent of all autopsy cases and its incidence was unchanged in this period. Cardiac death was found in 94.5 percent of the cases died less than one month after the onset, and 19.1 percent of them were cardiac rupture. The incidence of cardiac rupture including papillary muscle rupture and ventricular septal rupture was 12.2 percent of all cases of acute myocardial infarction (AMI) and the incidence in each year has significantly decreased since 1981. The incidence of cardiac free wall rupture was 9.5 percent, being the most prevalent (50 percent) in large anterior infaction. The majority of cardiac free wall rupture (82 percent) occurred within the first 48 hours after the onset of AMI. Secondly, the influence of the drugs used and hemodynamics in the acute phase of AMI on cardiac rupture was examined in 320 cases (151 men 169 women, mean age 75.3 years) which admitted to our coronary care unit in the same period. The subjects were classified into following three groups; ruptured group comprised 25 cases of the cardiac rupture including papillary muscle rupture (2 cases) and ventricular septal rupture (6 cases). Non-ruptured group comprised remaining 295 cases. All-ruptured group was consisted of 38 cases (19 men 19 women, mean age 78.1 years) in which 13 cases of cardiac rupture admitting to the general wards were added to the ruptured group. The use of vasolilator drugs including calcium antagonist has been increased since 1980, and that of nitrate has tended to increase as well since 1981 when cardiac rupture has decreased. Thus, we compared the main drugs used whithin 7 days after admission, between the all-ruptured group and non-ruptured group. As a result, diuretic (χ2=5.84, p<0.05), nitrate (χ2=9.62, p<0.01) and vasodilator (χ2=7.06, p<0.01) were used more frequently in nonruptured group compared with that in ruptured group. The blood pressure and hemodynamics were not significantly different between ruptured and non-ruptured group, but Killip's I group was observed in 53 percent of cases with cardiac free wall rupture. We concluded that vasodilator therapy was effective on the protection of cardiac rupture due to not only the reduction of after-load but also the reduction of pre-load.

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