討論: 急性心肌梗塞的典型症狀有胸骨後或心前區壓榨樣疼痛，病人以胸痛就醫常可得到及時診治，但老年人症狀多不典型可無明顯胸痛，則可能發生上腹痛等胃腸症狀，易被誤診。本例系急性前間壁心肌梗塞，在發病時首先出現上腹痛、噁心、嘔血、黑便等症狀，由於明顯的失血徵掩蓋了其它症狀，被簡單地診斷爲急性胃出血，忽視了心臟情況而誤診、耽誤治療。本例若能在初診時，注意詢問有關病史，作好心臟查體和鑑別診斷，儘早檢查心電圖，誤診是可以避免的。
筆者認爲須注意以下幾點：1、上腹痛的病人，除考慮腹腔臟器病變外，特別對老年人要考慮有無心肌梗塞的可能，有不少心肌梗塞病人以往可無心絞痛發作史；2、飽餐除可誘發胃炎、膽囊炎、胰腺炎等病外，亦可在冠心病患者中誘發心絞痛甚至心肌梗塞；3、噁心、嘔吐是心肌梗塞的常見症狀之一，故不要片面地認爲噁心、嘔吐就是胃腸疾病，應注意鑑別；4、在上腹疼痛時很快又出現休克徵象，除考慮出血、穿孔外，不要忘記排除心肌梗塞；據報道特發性胃出血被認爲是急性心肌梗塞的併發症之一，這種胃出血的原因是由於心肌梗塞後血循環障礙，引起胃肌肉緊張度減弱和胃粘膜缺氧所致；從本例先後兩次發生胃出血情況來看是符合的。(張君戎)
Atypical initial symptoms of acute myocardial infarction
Medical record: male, aged 67, case No. 2137. June 14, 1981 hospitalization. Continue to the history of hypertension, due to 6 hours before eating 10 peaches (about 2 Jin), epigastric pain after eating Jiangan, nausea, followed by dizziness, weakness, sweating, vomiting, stomach contents of coffee samples 500 ml, the solution tarry stool. Acute blood pressure 90/60mmHg, pulse 110 beats / min, hemoglobin 9 g%, fecal occult blood (++++), diagnosed as acute bleeding. 立Infusion and immediate treatment to stop bleeding, a day after the symptoms have not reduced, and chest tightness, palpitations, irritability, blood pressure dropped to 80/50 mmHg, heart rate 75 beats / min, arrhythmias, weak heart sounds; for acute anteroseptal myocardial electrocardiogram found infarction, frequent ventricular premature beats; erythrocyte sedimentation rate 40 mm / h; serum aspartate aminotransferase of 120 units. By acute myocardial infarction treatment, intravenous infusion of GIK, Salvia and other drugs, the condition does not work, patients with recurrence of gastric bleeding, concurrent ventricular bigeminy and shock after death.
Discussion: The typical symptoms of acute myocardial infarction chest or precordial crushing like pain, chest pain patients to get timely medical treatment often, but older people are not typical symptoms can be no more chest pain, abdominal pain may occur and other gastrointestinal symptoms , easily misdiagnosed. Department of the patients with acute anteroseptal myocardial infarction, when the disease first appeared in the upper abdominal pain, nausea, vomiting, melena and other symptoms, due to significant blood loss signs masked other symptoms, was diagnosed as acute bleeding simply ignored the heart of the case misdiagnosis, delayed treatment. If the first visit in this case, note asked about the history, preparation and differential diagnosis of cardiac examination, ECG check as soon as possible, misdiagnosis can be avoided.
I think that we should note the following points: 1, upper abdominal pain patients, in addition to considering abdominal organ diseases, but especially for the elderly may have to consider whether the heart attack, many patients with previous myocardial infarction, angina pectoris may be no history; 2, except meal can induce gastritis, cholecystitis, pancreatitis and other diseases, it can also induce angina pectoris in patients with coronary artery disease or myocardial infarction; 3, nausea and vomiting are common symptoms of myocardial infarction, it is not one-sided that nausea and vomiting is a gastrointestinal disease, should pay attention to identification; 4, abdominal pain, shock soon sign, in addition to considering bleeding, perforation, but do not forget to rule out myocardial infarction; It is reported that idiopathic bleeding was considered complication of acute myocardial infarction, this bleeding is due to blood circulation disorder following myocardial infarction, reduced muscle tone caused by the stomach and the gastric mucosal hypoxia; from bleeding occurred twice in this case is the situation comply. (Zhang Junrong)