Poor R wave progression in the transition zone

Introduction Poor R wave in the transition zone: amyloidosis affects coronary arteries can cause angina. About 80% of patients have a pathological Q wave in the chest lead or a poor R wave in the transition zone. Amyloidosis is a myocardial disease caused by the deposition and infiltration of amyloid in the heart. The pathogenesis of cardiacyloidosis is unknown, but it is currently considered to be a protein conformational disease. The folding error of extracellular proteins plays an important role, resulting in insoluble, toxic proteins in the tissue of the -sheet fiber. Protein deposition, which is related to immune, genetic, and inflammation factors. Myocardial amyloidosis may be associated with mutations in aspartate-18 glutamate of the thyroxine transporter.

Cause

Clinically, it is generally divided into primary and secondary: it occurs in tuberculous rheumatoid arthritis, ulcerative colitis, chronic osteomyelitis, chronic suppurative and wasting disease, etc., or occurs in multiple myeloma. Amyloidosis; if there is no above cause, it is a primary amyloidosis, and more genetically related amyloidosis is a pathological noun. It refers to the accumulation of a large amount of fibrous substances with glycoprotein properties in the tissue. The main protein component is immune. The light chain protein (AC) non-immune amyloid (AA) calcitonin protein (AEI) and senile amyloid plasma pre-protein (SA) and other four species.

1. AC-induced amyloidosis is the most common amyloidosis in clinical practice, and it is often caused by defects in primary or systemic amyloidosis immunoglobulin degradation or synthetic defects. Such amyloids are secreted by abnormally cloned beta cells; mainly involving the heart, the gastrointestinal tract, muscles, tendons and skin. In addition, the liver, spleen and kidney, adrenal gland and thyroid gland can also be affected.

2. AA-induced amyloidosis is called secondary amyloidosis, often caused by chronic infectious diseases such as tuberculosis, rheumatoid arthritis ulcerative colitis, chronic osteomyelitis chronic suppurative disease, or multiple myeloma. The inflammatory response of macrophages phagocytose and decompose the serum AA protein mainly affects the kidney, liver spleen and adrenal gland and other tissues are also related to atrial myxoma formation.

3. AEI-induced amyloidosis is more common in medullary thyroid carcinoma.

4.SA-induced amyloidosis of the heart and pancreas The prostate and brain are the main affected parts, especially in the elderly, so it is often called senile systemic amyloidosis.

an examination

Related inspection

M-mode echocardiography (ME) Doppler echocardiogram electrocardiogram

The following medical history is an important clue to the early detection of this disease: 1 ventricular cavity is not accompanied by progressive refractory heart failure; 2 left ventricular hypertrophy with ECG low voltage; 3 left ventricular wall uniform hypertrophy with diffuse wall activity; 4 previous high blood pressure with progressive hypotension and similar old myocardial infarction; 5 tongue wide and hypertrophy. Diagnosis is diagnosed by endocardial biopsy and histochemical staining.

Differential diagnosis

Need to be identified are: constrictive pericarditis, idiopathic restrictive cardiomyopathy, idiopathic hypertrophic cardiomyopathy, coronary atherosclerotic heart disease, senile degenerative heart disease.

Hypothyroidism can result in multiple serous effusions and lower extremity edema, but the patient's thyroid function is basically normal, temporarily not supported. Patients with chest tightness, shortness of breath, edema as the first performance, repeated symptoms, progressively worse, lower body blood pressure, decreased pulse pressure, jugular vein engorgement, bilateral pleural effusion, ascites, lower extremity edema, clinical manifestations Diastolic heart failure, cardiogenic diseases should be considered.

a. constrictive pericarditis: the most common cause of diastolic heart failure, mostly caused by tuberculous pericarditis, suppurative pericarditis, chest radiograph or CT visible pericardial calcification, thickening, cardiac two-dimensional ultrasound can be clearly diagnosed, but The patient had no corresponding medical history. The 5D negative PPD test did not support tuberculosis infection. The heart two-dimensional ultrasound had no pericardial thickening calcification, only a small amount of pericardial effusion, and the diagnosis was not supported.

b. Cardiomyopathy manifested as diastolic dysfunction: patients with ventricular septum and left ventricular posterior wall hypertrophy, normal EF values, hypertrophy for symmetry, not typical hypertrophic cardiomyopathy, and surface electrocardiogram suggesting limb lead low voltage, Does not support hypertrophic cardiomyopathy; representative disease of amyloidosis cardiomyopathy is endocardial myocardial fibrosis, clinical manifestations of systemic obstructive congestion, electrocardiogram can have low voltage or atrioventricular hypertrophy, echocardiographic findings of affected heart chamber Narrow, endocardial ultrasound enhanced and calcified reflective points, normal or slightly increased ventricular septum and left ventricular posterior wall thickness. Endocardial biopsy in many parts of the affected heart cavity is of great significance. The ventricular septum and posterior wall of the left ventricle are thickened significantly, and there is no typical endocardial tissue thickening and calcification. If necessary, endocardial myocardial biopsy can be considered. The typical disease characterized by restrictive cardiomyopathy in amyloidosis is cardiac amyloidosis, often with myocardial symmetric hypertrophy and enhanced myocardial echo under ultrasound (granular-like scintillation). This example does not have this performance and protein electrophoresis and immunoglobulin. Electrophoresis showed no increase in monoclonal increase, but the surface electrocardiogram low voltage was more consistent with cardiac amyloidosis, and it was feasible to make oral or intestinal mucosal or abdominal fat biopsy and Congo red staining;

c. Pulmonary heart disease: patients with lower extremity edema, clinical manifestations of right heart failure, to consider deep vein thrombosis caused by chronic thromboembolic pulmonary hypertension, amyloidosis cardiomyopathy, if necessary, can do deep veins and vena cava Doppler ultrasound and pulmonary CTA were clear.

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