Cardiocerebral syndrome in the elderly
Introduction
Introduction to heart and brain syndrome in the elderly This syndrome is caused by a variety of heart diseases caused by decreased cardiac output, systemic blood pressure, resulting in sudden syncope, convulsions, coma, focal neurological signs, mental retardation and other brain symptoms. basic knowledge The proportion of the disease: the incidence rate of the elderly over 60 years old is about 0.3% - 0.4% Susceptible people: the elderly Mode of infection: non-infectious Complications: cerebral infarction
Cause
The cause of heart and brain syndrome in the elderly
Causes:
Common diseases are acute myocardial infarction of coronary heart disease, various types of arrhythmia, rheumatic heart disease, cardiac catheterization, prosthetic valve replacement and other cardiac operations, while the elderly are common in the past.
Pathogenesis:
1. With the advancement of neuroanatomy and physiology and pathology, there is a new understanding of cardiac central nervous system regulation. There are three ways to integrate the cardiac afferent fibers to the spinal cord and the nucleus of the nucleus and the dorsal nucleus of the vagus nerve.
2. The dorsal nucleus of the vagus nerve and the suspected nucleus are parasympathetic efferent systems. In addition to direct contact with the heart, there are still fibers that are transmitted to the middle and outer gray matter areas of the spinal cord.
3. Cortex, diencephalon, hypothalamus to spinal cord levels are still in contact with each other.
Experiments have shown that the left sympathetic innervation mainly affects the heart rhythm; the left vagus nerve is mainly distributed in the atrioventricular node, which can cause atrioventricular block after stimulation, and stimulate the left stellate ganglion to cause ST segment decline, T wave high tip and QT Prolonged, stimulated the right stellate ganglion caused ST segment elevation and T wave depth inversion, the hypothalamus stimulated T wave flat or inverted, U wave is obvious, there may also be high tip T wave, ST segment elevation and P wave, The amplitude of QRS wave group changes, the brain weight of adults only accounts for 2% to 3% of body weight, but the oxygen consumption accounts for 20% of the whole body; the adult brain needs 200-600ml oxygen per minute, and 75-100mg glucose can maintain its normal function. In addition, brain tissue anaerobic and glucose storage capacity, relying on the flow of blood supply, with 133Xe internal carotid artery injection or C15O2 continuous inhalation method, PET can be used to measure the average blood flow of healthy people in a calm state of 50 ~ 60ml / ( 100g brain tissue·min), brain gray matter 7080ml, white matter 2025ml, when the regional cerebral blood flow is reduced by more than 70%, brain CT scan can show low-density ischemic foci, and the degree of cerebral arteriosclerosis is determined by the above method. Relationship between cerebral blood flow, mildly sclerotic whole cerebral blood An amount of 42ml / (100g brain · min), hardened to 35 ml of moderate; Severe only 30ml or less, at this time can cause mental retardation and mental focal symptoms.
Effective perfusion pressure and cerebrovascular resistance are a pair of contradictory contradictions. Cerebral blood flow is positively correlated with effective perfusion pressure and negatively correlated with cerebrovascular resistance. If the blood flow per minute per 100g brain tissue is less than 31ml, it can cause TIA. Below 20ml, the electrical activity of nerve cells is significantly weakened, and death is less than 5ml. Under normal temperature, cerebral hypoxia for 6-30min (different parts) can cause irreversible ischemic changes, experimental carotid atrial rhythm in the middle of carotid blood Flow rate can be reduced by 10% to 48%, frequent pre-contraction can reduce brain blood supply by about 10%, atrial fibrillation can be reduced by 23%, and ventricular paroxysmal tachycardia can be reduced by 40% to 70%. Can lead to a variety of brain symptoms, in addition to hypertension, atherosclerosis, adrenal insufficiency, spinal cord degeneration, autonomic dysfunction, baroreceptor and effector degeneration, etc., senile cerebral perfusion pressure, resulting in orthostatic hypotension , which leads to the occurrence of cerebrovascular disease.
Prevention
Elderly heart and brain syndrome prevention
1, to maintain blood pressure stability, such as hypotension and shock, we must strictly control the concentration of blood pressure drugs and drip rate, so that blood pressure rises to a suitable level, avoid sudden and large fluctuations in blood pressure, if there is high blood pressure need to use When compressing the drug, it is possible to use a intravenous antihypertensive drug which has a quick onset effect and a fast disappearing action, and avoids the use of an antihypertensive drug which is slow in oral administration and has a long effect.
2, keep the stool smooth, avoid forced stool, absolute bed rest in the acute phase, to avoid fatigue or body and activities.
3, the rational application of anticoagulant therapy: in the absence of conditions for thrombolysis or emergency coronary endoscopic surgery, if there is no contraindications to anticoagulation therapy, heparin can be given early to prevent infarction, but should prevent overdose If there is a pericardial friction sound, the anticoagulant should be stopped in time.
Complication
Elderly patients with heart and brain syndrome complications Complications Cerebral infarction
Complications include central nervous system fungi, bacteria, viral infections, cerebral infarction, cerebral hemorrhage and metabolic encephalopathy.
Symptom
Symptoms of heart and brain syndrome in the elderly common symptoms arrhythmia dysfunction tachycardia mitral valve prolapse heart murmur coma myocardial infarction syncope meningitis
1. Acute myocardial infarction (AMI) 2200 cases of autopsy in the Tokyo Metropolitan Center Hospital, 233 cases (10.6%) with cerebrovascular disease (CVD) and AMI, 121 males and 112 females, with an average age of 78.8 years, including The brain accounted for 36%, and the brain to the heart was 48%. After AMI, the left ventricular wall thrombus caused more cerebral infarction. The incidence of heart and brain was higher than that of the brain in one month. Left ventricular thrombus (LVT) was more important in recent years. About one-third of cases have LVT before AMI, AMI with LVT has a higher risk of cerebral embolism than AMI without LVT, and cerebral embolism occurs within weeks (2 to 4 weeks) after AMI, clinically Once the presence of LVT is found, anticoagulant therapy should be performed for 3 to 6 months. Alpes caused by AMI is classified into 5 types:
(1) syncope type: can be painless in the anterior region but has syncope episodes, should be done for ECG examination.
(2) Hemiplegic type: Both can occur simultaneously or within a few hours to several days after AMI. ECG shows premyocardial infarction and myocardial infarction.
(3) Hypertensive crisis type: can be painless in the anterior region.
(4) Brain stem type: ECG shows extensive myocardial infarction in the anterior wall.
(5) Brain type: sudden onset, headache, disturbance of consciousness, convulsions, loss of vision, psychomotor excitement, sudden death and paralysis, atypical symptoms, cerebral blood circulation disorder, patients did not appear The heart symptoms are 29.7% in the coma. In the early stage of myocardial infarction, the blood pressure can be normal or temporarily elevated. Emergency ECG and various serum enzyme tests are performed to confirm the diagnosis.
2. Cerebral symptoms caused by rheumatic heart disease: more common in young and middle-aged patients; but elderly patients with rheumatic heart disease caused by brain symptoms are also common, Cui et al reported 98 cases of brain symptoms accounted for 26.5%, no clear history, valve The damage is mainly mitral valve (95.9%), which leads to enlargement of the left atrium. The formation of left heart embolus leads to 18% to 48% of cerebral embolism. For example, the incidence of atrial fibrillation can be doubled. Old age with heart failure The incidence rate is higher. Peterson pointed out in 1990 that the heart rhythm changes from normal to atrial fibrillation or vice versa. It is easy to cause cerebral embolism in the heart. The cerebral embolism in one month after atrial fibrillation accounts for 1/3 of the total. Paroxysmal atrial fibrillation was also highest in 1 month, and 33% in 426 cases caused cerebral embolism; while paroxysmal atrial fibrillation had a 2% incidence of cerebral embolism; although left ventricular output was 20 % into the brain, but cerebral embolism can account for 50% of embolism in all parts of the body; middle cerebral artery or branch involvement accounted for 73% to 85%, mostly on the left side, the recurrence rate is 2 years after the first onset 30%, 50% in two years, atrial natriuretic peptide concentration during atrial fibrillation, when restoring sinus rhythm Decreased to normal; atrial natriuretic peptide can increase hematocrit to cause atrial fibrillation, and there is also a peptide receptor in brain microvessels, so the increase of atrial natriuretic peptide can cause cerebral blood flow in patients with atrial fibrillation and cerebral infarction, bacteria Endocarditis causes central nervous system comorbidities. Since Osler first reported that the natural history of the disease has changed significantly in the past 30 years or so, in 1991 Salgado reported on nerves in three large studies. Systemic complication rates ranged from 27% to 39%, compared with 12% to 17% for starters.
Divided into 3 categories according to clinical manifestations:
(1) Cerebrovascular disease: the most common, the incidence of cerebral embolism before the onset of CT brain scan technology was 11.4% to 17.0%; the embolization rate of brain and ophthalmic artery was 19% and 18% respectively after the advent, the cause of which was in the onset of endocarditis. Staphylococcus aureus, enterococci or Escherichia coli in 2 weeks, often multiple; more than 2 weeks of cerebral embolism is more common with streptococcus, usually single, intracerebral or subarachnoid hemorrhage in endocarditis Those accounted for 2.7% to 7%; traditionally, those who were diagnosed with fungal aneurysms accounted for only 0.3% to 1.8% of cerebral vascular complications in angiography or autopsy.
(2) Infection complications: the incidence of acute meningitis or brain abscess is 1.8% to 16.5% and 1% to 4%, respectively. The former CSF leukocytes increase, and the culture-positive persons account for 15.9% to 26%, the most easy to separate the golden Staphylococcus; brain abscess is mainly micro-multiple, not suitable for surgical drainage.
(3) Other encephalopathy accounts for 1.3% to 8.5%, with epileptic foci or generalized tonic-clonic hair as the most common, often secondary to multiple encephalopathy.
3. Non-rheumatic atrial fibrillation: The incidence of atrial fibrillation (AF) in adults is 0.4%, and the incidence increases with age; up to 2% to 4% in people over 60 years old, AF is chronic, There are three categories of paroxysmal and persistent, while the latter refers to those without evidence of heart disease; due to the increase of the elderly population, AF patients have higher mortality than sinus rhythm, and cerebral embolism is also high, making the prognosis of AF patients increasingly Arousing the attention of scholars, Framingham reported that in 1007 cases of non-rheumatic AF, males accounted for 54%, and the risk of stroke in chronic AF patients was 5 times higher than that of sinus rhythm control group; the risk of chronic AF stroke was due to heart disease patients. The sex increased by 17 times. Treseden reported that the average age of 414 elderly patients was 80 years old; among them, 276 cases of chronic AF and 138 cases of paroxysmal AF; combined with the other group of 426 cases of similar patients, the incidence of embolism in paroxysmal AF 2%, but up to 5% after switching to chronic AF; 33% for chronic AF, 34 months for chronic AF, and 63 years for transition AF , the untransformed person is 68 years old, hyperthyroidism AF, 10% to 15% AF in hyperthyroidism It is most common in people over 60 years old, and AF may be the most prominent feature. The prevalence of thyrotoxicosis in AF cases is 2% to 5%, 262 cases of toxic thyroid diseases such as Yuen and 210 cases of arterial embolism and AF Up to 10%, Barsela 30 cases of this disease with AF with 12 cases of cerebral infarction, and 112 cases of sinus rhythm occurred in 1 case, showing that toxic thyroid disease complicated with AF has a high risk of concurrent embolization.
4. A variety of arrhythmia caused by cerebral symptoms Sick sinus syndrome can be absent, vertigo attacks, more common in elderly and severe arteriosclerosis, in 1982, Manggang Xiaoxiong reported 100 cases, 1989 Sherman reported 156 cases, brain symptoms The incidence rate is 66% and 8% to 10%, respectively. High-grade atrioventricular block can cause Adam-Strokes syndrome. Ventricular or supraventricular tachycardia can cause transient disturbance of consciousness, convulsion or focal Neurological signs and ventricular fibrillation are one of the causes of violent death.
5. Other causes: The incidence of cerebral embolism caused by cardiac catheterization was 3.4% in 1968 and 1.5% in 1974. Only cases were reported after the 1980s. Holson reported that 54% of the 85 heart transplants had a nerve. Systemic complications, 16% have more than two neurological complications, 20% die due to complications, mitral valve prolapse and cardiac myxoma are mostly young and middle-aged, and there are a few reports of elderly people. Sherman reported in 1989. The rate of cerebral infarction caused by cusp prolapse was 6%. Histology showed mucinous mitral valve, loose structure, and cellulose deposition with blood cell components; -thrombosis and platelet factor IV in platelet granules (PF4) Increased, can cause increased platelet activity and accumulation, atrial myxoma in 1988 Thompson reported that 25% to 55% of patients with cerebral embolism; pedicled gelatinous tumor heart murmur changes with body position, and can be multiple times different The cerebral embolism at the site should be diagnosed by cardiac echocardiography. In 1987, Stewart reported that the incidence of cerebral embolism in 30 patients with heart valve replacement was 10%.
Early monitoring of the whole process of cerebral infarction from the heart into the circulatory blood flow into the brain is impossible until the 1990s, due to the continuous development of transcranial Doppler detection technology (TCD), a small number of domestic and foreign The large hospital has adopted the four-channel TCD micro-embolic monitor and the sensor that can automatically adjust the depth. It has become possible to use the synchronous dynamic monitoring of the intracranial and extracranial cerebral artery trunks; it can not only distinguish the structure of microemboli (cellulose, platelets, white blood cells, Cholesterol crystallization, etc., while monitoring its source, quantity and flow path, so the micro-emboli monitoring of various heart and heart surgery patients, combined with preoperative, intraoperative, postoperative and anticoagulant therapy dynamic observation has become In reality, according to the statistics of 2000 cases of cerebral embolism in foreign countries, the cerebral embolism caused by cardiomyopathy caused by TCD has reached 23.5%~31.5%; combined with MRI and pathological results, cerebral embolism shows that bloody infarction accounts for 40%. The cerebral thrombosis was only 1.9%, the mobility emboli accounted for 1/5 of the brain in the posterior circulation, and the anterior circulation (ACA) accounted for 3% to 12%. The main cardiogenic embolism was located in the ipsilateral MCA; The TCD signal of sexual emboli is characterized by high Short-degree phase signal (high intensity transient signal; HITS), so the heart and brain syndrome occurrence, development, diagnosis, treatment, prognosis has a very important value.
Examine
Examination of heart and brain syndrome in the elderly
Appearance in patients with complications such as meningitis CSF increased white blood cells, abnormal blood culture. Electrocardiogram, CT scan, MRI, TCD, abnormalities can be found.
Diagnosis
Diagnosis and diagnosis of heart and brain syndrome in the elderly
diagnosis
Based on medical history and clinical manifestations, reference to an auxiliary examination is helpful for diagnosis.
Differential diagnosis
ECG abnormalities in CVD are differentiated from other heart diseases.
1. AMI ST segment depression or elevation, inverted T wave, abnormal Q wave is more common in myocardial ischemic lesions, may have serum CK, LDH and other enzyme activity abnormal value identification, CVD serum enzyme value increase rate is slower than AMI, but need to combine Clinical history and symptoms.
2. Heart and stroke without chest pain, stroke-like AMI is unique to senile AMI. Teng reports that the incidence of AMI and CVD is 5% to 10%, so it is difficult to diagnose when not at the same time.
3. Acute reversible myocardial infarction: Features:
1 Abnormal Q waves are more common in V1 ~ V3 lead, ST segment elevation, coronary T wave and other typical AMI waveforms;
2 can be converted to normal after 1 to 2 weeks of duration;
3 myocardial enzymes escape light;
4 autopsy showed AMI changes in the naked eye, myocardial histology showed wall thrombus, small blood vessel thrombus and scattered necrosis of surrounding myocardial tissue;
5 combined with DIC, coagulation and other factors such as coronary microvascular dysfunction.
