心肌梗死致社区心源性猝死：阻塞与非阻塞冠脉病变的尸检研究
POST SCD研究对2011年2月至2023年3月间943例疑似心源性猝死进行尸检，583例确认为心源性猝死，其中237例（41%）归因于心肌梗死。急性或愈合性心肌梗死伴阻塞性冠脉病变占90%（214例），急性MINOCA占10%（23例），MINOCA在黑人患者中比例最高。非心律失常性死因在MINOCA中比急性MI-CAD更常见（35% vs 15%）。
要点
- 心源性猝死中41%由心肌梗死所致，其中10%为MINOCA
- MINOCA患者非心律失常性死因比例是急性MI-CAD的两倍
- MINOCA在黑人患者中比例最高，需关注种族差异
核心结论
- 12年县级研究中，所有猝死的四分之一和尸检确认心源性猝死的41%归因于心肌梗死，存在显著种族差异。
- MINOCA中心源性猝死的非心律失常性原因比例是急性MI-CAD的两倍。
研究设计与样本
- POST SCD研究为前瞻性县级研究，通过尸检将疑似心源性猝死判定为心源性或非心源性原因。
- 研究纳入2011年2月1日至2023年3月31日943例疑似心源性猝死，创伤死亡作为参照对照。
- 心肌梗死致心源性猝死定义为组织病理学发现心肌梗死且无其他致死原因，阻塞性冠脉病变定义为至少1支冠脉狭窄≥50%。
主要发现
- 943例疑似心源性猝死中，360例（38%）为非心源性原因，583例（62%）为尸检确认的心源性猝死。
- 尸检确认的583例心源性猝死中，237例（41%）归因于心肌梗死，其中214例（90%）为急性或愈合性心肌梗死伴阻塞性冠脉病变，23例（10%）为急性MINOCA。
- MINOCA在黑人患者中比例最高（P<0.05），非心律失常性原因在亚洲患者中有最高趋势（P=0.1）。
- 急性MI-CAD心源性猝死中，左前降支（66处，38%）和右冠脉（59处，35%）最常受累，右冠脉为最常见罪犯血管（43%）。
- MINOCA与急性MI-CAD心源性猝死的总纤维化负荷相似（P=0.6）。
关键数值与推荐
- 阻塞性冠脉病变定义为至少1支冠状动脉狭窄≥50%。
- 急性MI-CAD心源性猝死中173处冠脉病变：左前降支66处（38%），右冠脉59处（35%），右冠脉为最常见罪犯血管（43%）。
- 非心律失常性原因：MINOCA心源性猝死为35%，急性MI-CAD心源性猝死为15%（P=0.037）。
临床怎么用
- 对于MINOCA相关心源性猝死，应重视非心律失常性死因的评估与防治。
- 心源性猝死尸检中应系统评估冠脉病变及心肌组织病理，以识别MINOCA并指导家族筛查。
局限性
- 研究为单一县的前瞻性尸检研究，结果外推至其他人群需谨慎。
- MINOCA病例数较少（23例），亚组分析的统计学效能有限。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
原文
BACKGROUND: The total burden of community sudden cardiac deaths (SCDs) attributable to myocardial infarction (MI), including myocardial infarction with nonobstructive coronary arteries (MINOCA), is unclear. OBJECTIVES: The study sought to determine the burden of community SCD due to MI by histopathologic examination. METHODS: The POST SCD (Postmortem Systematic Investigation of Sudden Cardiac Death) study is a prospective countywide study using autopsy to adjudicate presumed SCDs as cardiac (arrhythmic or nonarrhythmic) or noncardiac causes, with trauma deaths as reference control deaths. We defined a case as "SCD due to MI" if histopathological findings of MI without other lethal cause were found, and defined obstructive coronary artery disease as ≥50% stenosis in ≥1 coronary artery. RESULTS: Of 943 presumed SCDs from February 1, 2011, to March 31, 2023, 360 (38%) had noncardiac cause and 583 (62%) were autopsy-confirmed SCDs, of which 237 (41%) were due to MI (MI SCD): 214 (90%) were acute or healed myocardial infarction with obstructive coronary artery disease (MI-CAD) and 23 (10%) were acute MINOCA (highest proportion among Black patients; P < 0.05). Among 173 coronary lesions in acute MI-CAD SCDs (n = 95), the left anterior descending artery (n = 66 [38%]) and right coronary artery (n = 59 [35%]) were most commonly affected, and the right coronary artery was the most common culprit (43%). Nonarrhythmic causes were more common in MINOCA than acute MI-CAD SCDs (35% vs 15%; P = 0.037), with a trend toward being the highest in Asian patients (P = 0.1). The total fibrosis burden was similar in MINOCA and acute MI-CAD SCDs (P = 0.6). CONCLUSIONS: In this 12-year countywide study, one-fourth of all sudden deaths and 41% of autopsy-confirmed SCDs were attributable to MI, with significant racial differences. The left anterior descending artery and right coronary artery were most commonly affected among SCDs due to MI-CAD. Nonarrhythmic causes were twice as common in MINOCA SCDs than acute MI-CAD.
引用
- Nakasuka, Kewcharoen, Salazar, et al. Sudden Cardiac Death Due to Myocardial Infarction With Obstructive and Nonobstructive Coronary Arteries. J Am Coll Cardiol. 2026. PMID: 42024048. doi:10.1016/j.jacc.2026.01.030
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。