冠心病課件(大醫(yī)英)

冠狀動(dòng)脈粥樣硬化性心臟病

(coronaryatheroscleroticheartdisease)

大連醫(yī)科大學(xué)附屬二院心內(nèi)科牛楠精品冠狀動(dòng)脈粥樣硬化性心臟病

(coronaryatheros1動(dòng)脈粥樣硬化

atherosclerosis精品動(dòng)脈粥樣硬化

atherosclerosis精品2IntroductionArteriosclerosisThickeningandlossofelasticityofarterialwallsHardeningofthearteriesGreatestmorbidityandmortalityofallhumandiseasesviaNarrowingWeakening精品IntroductionArteriosclerosis精3PlaqueThatHasBeenSurgicallyRemovedfromCoronaryArteryCourtesyRonaldD.GregoryandJohnRiley,MD.精品PlaqueThatHasBeenSurgicall4

NonModifiableRiskFactorsAgeAdominantinfluenceAtherosclerosisbeginsintheyoung,butdoesnotprecipitateorganinjuryuntillaterinlifeGenderMenmorepronethanwomen,butbyage60-70aboutequalfrequencyFamilyHistoryFamilialclusterofriskfactorsGeneticdifferences精品

NonModifiableRiskFactorsAg5

ModifiableRiskFactors

(potentiallycontrollable)

HyperlipidemiaHypertensionCigarettesmokingDiabetesMellitusElevatedHomocysteineFactorsthataffecthemostasisandthrombosisInfections:Herpesvirus;ChlamydiapneumoniaeObesity,sedentarylifestyle,stress精品

ModifiableRiskFactors

(pot6PathogenesisofAtherosclerosisResponsetoinjuryhypothesisInjurytotheendothelium(dysfunctionalendothelium)ChronicinflammatoryresponseMigrationofSMCfrommediatointimaProliferationofSMCinintimaExcessproductionofECMEnhancedlipidaccumulation精品PathogenesisofAtherosclerosi7Responsetoinjury精品Responsetoinjury精品8Endotheliadysfunction精品Endotheliadysfunction精品9InitiationofFattyStreak精品精品10FattyStreak精品精品11Fibro-fattyAtheroma精品精品12AtherosclerosisTimelineFoamCellsFattyStreakIntermediateLesionAtheromaFibrousPlaqueComplicatedLesion/RuptureAdaptedfromPepineCJ.AmJCardiol.1998;82(suppl104).FromFirstDecadeFromThirdDecadeFromFourthDecadeEndothelialDysfunction精品AtherosclerosisTimelineFoamFa13AHAClassificationofatherosclerosis精品AHAClassificationofatherosc14動(dòng)脈粥樣硬化血栓形成:

具共同病理基礎(chǔ)的進(jìn)展性過(guò)程正常脂肪條紋纖維斑塊粥樣硬化斑塊斑塊破潰/

裂隙和血栓形成心肌梗死

缺血性中風(fēng)/TIA

嚴(yán)重的下肢缺血臨床無(wú)癥狀心血管死亡年齡增長(zhǎng)穩(wěn)定性心絞痛間歇性跛行不穩(wěn)定性心絞痛}ACS*ACS,急性冠脈綜合征;TIA,一過(guò)性腦缺血發(fā)作缺血性腎病缺血性腸病精品動(dòng)脈粥樣硬化血栓形成:

具共同病理基礎(chǔ)的進(jìn)展性過(guò)程正常脂肪15CoronaryArteryDisease冠心病精品CoronaryArteryDisease冠心病精品16Clinicalclassification(1979WHO)AsymptomaticCHD(隱匿型）AnginapectorisCHD（心絞痛型）MyocardialinfarctionCHD(心肌梗死型）IschemiccardiomyopathyCHD（缺血性心肌病型）SuddendeathCHD（猝死型）精品Clinicalclassification(1979W17ClassificationofIHDChronicischemicsyndrome:stableanginaasymptomaticCHDischemiccardiomyopathyCHDAcutecoronarysyndrome:unstableanginaSTEMI/NSTEMI精品ClassificationofIHDChronici18急性冠脈綜合癥的病理生理學(xué)Fusteretal.NEnglJMed.1992;326:310-318.Daviesetal.Circulation.1990;82(SupplII):II-38,II-46.不穩(wěn)定血栓(UA/NSTEMI)脂肪池巨噬細(xì)胞內(nèi)在的壓力，張力外部的剪切力裂縫大裂縫小裂縫閉合血栓

(STEMI)動(dòng)脈粥樣硬化斑塊斑塊破裂血栓精品急性冠脈綜合癥的病理生理學(xué)Fusteretal.NE19NoSTElevationSTElevationAcuteCoronarySyndromeUnstableAnginaNQMIQwMINSTEMIMyocardialInfarctionDaviesMJ

Heart83:361,2000IschemicDiscomfortPresentationWorkingDxECGBiochem.MarkerFinalDxHammLancet358:1533,2001精品NoSTElevationSTElevationAc20ANGINAPECTORIS精品ANGINAPECTORIS精品21DefinitionofAngina

Apainordiscomfortinthechestoradjacentareascausedbyinsufficientbloodflowtotheheartmuscle.精品DefinitionofAngina 精品22精品精品23ClinicalclassificationandpathologyStableangina:fixedatheromatousstenosisUnstableangina:dynamicobstructionbyplaquerupturewithsuperimposedthrombosisandspasm精品Clinicalclassificationandpa24斑塊破裂引起急性嚴(yán)重事件不穩(wěn)定心絞痛心肌梗死猝死穩(wěn)定性(勞力性)心絞痛不穩(wěn)定斑塊的進(jìn)展過(guò)程穩(wěn)定斑塊的進(jìn)展過(guò)程N(yùn)issenSE.AmJCardiol.2000;86(suppl):12H-17H不穩(wěn)定斑塊斑塊破裂血栓形成穩(wěn)定斑塊斑塊體積增加管腔狹窄精品斑塊破裂引起急性嚴(yán)重事件不穩(wěn)定心肌梗死猝死穩(wěn)定性不穩(wěn)定斑塊25Stableanginapectoris精品Stableanginapectoris精品26ETIOLOGY.Ischemiaissecondarytocoronaryarterydiseasein95%ofpatients.Theleadingcauseiscertainlyatheroscleroticcoronaryarterydisease.Adecreasedoxygensupplyoranincreaseinoxygendemandcanleadtoaworseningofsymptoms..Ischemiacanoccurinpatientswithnormalcoronaryarteries精品ETIOLOGY.Ischemiaissecondary27Clinicalmenifestation

chestdiscomfortQuality-"squeezing,""griplike,""pressurelike,""suffocating"and"heavy”;ora"discomfort"butnot"pain."Anginaisalmostneversharporstabbing,andusuallydoesnotchangewithpositionorrespiration.Duration-anginalepisodeistypicallyminutesinduration.FleetingdiscomfortoradullachelastingforhoursisrarelyanginaLocation-usuallysubsternal,butradiationtotheneck,jaw,epigastrium,orarmsisnotuncommon.Painabovethemandible,belowtheepigastrium,orlocalizedtoasmallareaovertheleftlateralchestwallisrarelyanginal.Provocation-anginaisgenerallyprecipitatedbyexertionoremotionalstressandcommonlyrelievedbyrest.Sublingualnitroglycerinalsorelievesangina,usuallywithin30secondstoseveralminutes.精品Clinicalmenifestation

chestd28CategorizetheSeverityofAnginaCCSClassificationClass0asymptomaticClassIonstrenuousactivityClassIIonmoderateactivity

2blocksor2flightsofstairsClassIIIonmildactivity

2blocksor2flightsofstairsClassIVrestorminimalactivity精品CategorizetheSeverityofAn29Clinicalfeatures

PhysicalexaminationAnS4gallopmaybetransientlypresentduringanepisode,andthepatientmaybedyspneicordiaphoreticorhaveanewheartmurmur.High-riskfeaturesofanginaincludeheartfailureandhypotension.Acompletephysicalexamiscrucialinmakinganassessmentofrisk.Mostpt:(-)精品ClinicalfeaturesPhysicalexa30AlternativeDiagnosestoAnginaforPatientswithChestPainNon-IschemicCVaorticdissectionpericarditisPulmonarypulmonaryemboluspneumothoraxpneumoniapleuritisChestWallcostochondritisfibrositisribfracturesternoclaviculararthritisherpeszosterGastrointestinalEsophagealesophagitisspasmrefluxBiliarycoliccholecystitischoledocholithiasischolangitisPepticulcerPancreatitisPsychiatricAnxietydisordershyperventilationpanicdisorderprimaryanxietyAffectivedisordersdepressionSomatiformdisordersThoughtdisordersfixedocclusions精品AlternativeDiagnosestoAngin31Investigation12LeadRestingECGshouldberecordedinallpatientswithsymptomssuggestiveofanginapectorisnormalin50%ofpatientsanormalECGdoesnotexcludesevereCAD;however,itdoesimplynormalLVfunctionwithfavorableprognosis精品Investigation12LeadResting32CHDAtrest:

ECG精品CHDAtrest:ECG精品33冠心病Episodeofangina:ST-segmentdepressionECG精品冠心病Episodeofangina:ST-segme34CHDHolter精品CHDHolter精品35Exercisetesting精品Exercisetesting精品36Angina:ExerciseTesting

HighRiskPatientsSignificantST-segmentdepressionatlowlevelsofexerciseand/orheartrate<130FallinsystolicbloodpressureDiminishedexercisecapacityComplexventricularectopyatlowlevelofexercise精品Angina:ExerciseTesting

High37ExerciseTesting

ContraindicationsMI—impendingoracuteUnstableanginaAcutemyocarditis/pericarditisAcutesystemicillnessSevereaorticstenosisCongestiveheartfailureSeverehypertensionUncontrolledcardiacarrhythmias精品ExerciseTesting

Contraindicat38Investigation

Echocardiography.Thestressechocardiogramisawidelyperformedtestusedtoassesspatientsforcoronarydisease.Baselineechocardiographicimagesareobtainedatresttoevaluateleftventricularfunction,wallmotion,andvalvefunction.Imagesarethenacquiredduringpeakstress(thatis,duringaGXTorwithdobutamine)andcomparedwiththoseatrest.Regionalwall-motionabnormalitieswithstressindicateareasofhypoperfusionorischemia.精品InvestigationEchocardiography39InvestigationIsotopescanning:obtainingscintiscansofthemyocardiumatrestandduringstressafteradministrationofanintravenousradioactiveisotopesuchasthallium201精品InvestigationIsotopescanning:40Investigation

Coronaryangiography.

Usedtoidentifyfociofcoronarydisease.Itistheevaluationofchoiceinpatientswithanginathatis(1)poorlyresponsivetomedication,or(2)unstable.ItisalsoindicatedinpatientswithtestresultsconsistentwithahighriskforCAD.精品InvestigationCoronaryangiogr41冠心病Coronaryangiography精品冠心病Coronaryangiography精品42冠心病冠狀動(dòng)脈造影精品冠心病冠狀動(dòng)脈造影精品43冠心病LAD:stenosis LAD:normal精品冠心病LAD:stenosis LAD:44冠心病RCA:stenosis LCX:stenosis精品冠心病RCA:stenosis LCX:stenosi45ChronicStableAngina

TreatmentObjectivesPreventprogressionofcoronaryarterydiseaseandoptimiselifeexpectancyRelievesymptoms精品ChronicStableAngina

Treatme46ManagementAspirinbeta-adrenoreceptorblockingagents(-blockers)calciumantagonistsNitrates精品ManagementAspirin精品47NCEPPrimaryCHDRisk

GoalsforLoweringLDL-CLDL-CGoalNoCHD<2RF<160mg/dLNoCHD2RF<130mg/dLCHD100mg/dLTheNCEPrecommendsloweringLDL-Cevenfurtherthanthesegoals,ifpossible.RiskCategoryNHLBI;September1993精品NCEPPrimaryCHDRisk

Goalsf48CoronaryrevascularisationInvasivetreatment:coronaryangioplasty(PTCA);coronaryarterybypassgrafting(CABG)精品CoronaryrevascularisationInva49冠心病CABG精品冠心病CABG精品50冠心病PTCA精品冠心病PTCA精品51冠心病PTCABeforePTCA afterPTCA精品冠心病PTCABeforePTCA aft52冠心病PTCA/S精品冠心病PTCA/S精品53AcutecoronarysyndromeUnstableanginaNon-STelevationmyocardialinfarction(NSTEMI)STelevationmyocardialinfarction(STEMI)精品AcutecoronarysyndromeUnstabl54UnstableAngina/NSTEMI精品UnstableAngina/NSTEMI精品55UnstableAngina

ClinicalPresentationandClassificationDiagnosisofunstableanginareferstoneworworseningsymptomsofmyocardialischemia:restanginanew-onsetsevereanginaincreasingangina精品UnstableAngina

ClinicalPrese56精品精品57評(píng)估住院期間和出院后長(zhǎng)期缺血風(fēng)險(xiǎn)評(píng)估住院期間死亡風(fēng)險(xiǎn)

(c-index0.83)*及出院后6個(gè)月死亡風(fēng)險(xiǎn)(c-index0.81)**多個(gè)大型數(shù)據(jù)庫(kù)中驗(yàn)證其有效性(c-indices分別為0.84*和0.75**)評(píng)價(jià)死亡/再發(fā)心梗的長(zhǎng)期風(fēng)險(xiǎn)網(wǎng)絡(luò)版可下載

/GRACE *GrangerCB,etal.ArchinternMed.2003;163:2345-2353. **EagleK,atal.JAMA.2004;291:2727-2733.精品評(píng)估住院期間和出院后長(zhǎng)期缺血風(fēng)險(xiǎn)評(píng)估住院期間死亡風(fēng)險(xiǎn)

(c58UnstableAnginaChestpainsyndrome,eithernewonsetorprogressiveanginaTransientST-segmentdepressionontheelectrocardiogram(ECG)WithoutevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponin精品UnstableAnginaChestpainsynd59NSTEMIChestpainsyndrome,eithernewonsetorprogressiveanginaTransientorpersistentST-segmentdepressionontheelectrocardiogram(ECG)WithevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponin精品NSTEMIChestpainsyndrome,eit60UnstableAngina/NSTEMISignificantlikelihoodofoccurrenceofmajorcardiacevents A.IncidenceofMI:8to10% B.Mortality:2to5%精品UnstableAngina/NSTEMISignific61UnstableAngina/NSTEMI:

PathophysiologyAcuteplaquefissuringandruptureSuperimposedthrombusTransientocclusionMediator-inducedvasospasmmaybepresent精品UnstableAngina/NSTEMI:

Pathop62DeterminantsofPlaqueVulnerabilityLipid-richcoresizeCapthicknessCapinflammationandrepair精品DeterminantsofPlaqueVulnera63精品精品64斑塊破裂引起急性嚴(yán)重事件不穩(wěn)定心絞痛心肌梗死猝死穩(wěn)定性(勞力性)心絞痛不穩(wěn)定斑塊的進(jìn)展過(guò)程穩(wěn)定斑塊的進(jìn)展過(guò)程N(yùn)issenSE.AmJCardiol.2000;86(suppl):12H-17H不穩(wěn)定斑塊斑塊破裂血栓形成穩(wěn)定斑塊斑塊體積增加管腔狹窄精品斑塊破裂引起急性嚴(yán)重事件不穩(wěn)定心肌梗死猝死穩(wěn)定性不穩(wěn)定斑塊65PhysicalExaminatonNotthathelpfulMayhaveevidenceofCHF:JVD,rales,edemaMayhaveS4Mayhavemurmurofmitralregurgitationfrompapillarymuscledysfunction精品PhysicalExaminatonNotthathe66InvestigationECGCardiacEnzymeorTroponinCoronaryangiography精品InvestigationECG精品67精品精品68AcuteCoronarySyndromes精品AcuteCoronarySyndromes精品69評(píng)估住院期間和出院后長(zhǎng)期缺血風(fēng)險(xiǎn)評(píng)估住院期間死亡風(fēng)險(xiǎn)

(c-index0.83)*及出院后6個(gè)月死亡風(fēng)險(xiǎn)(c-index0.81)**多個(gè)大型數(shù)據(jù)庫(kù)中驗(yàn)證其有效性(c-indices分別為0.84*和0.75**)評(píng)價(jià)死亡/再發(fā)心梗的長(zhǎng)期風(fēng)險(xiǎn)網(wǎng)絡(luò)版可下載

/GRACE *GrangerCB,etal.ArchinternMed.2003;163:2345-2353. **EagleK,atal.JAMA.2004;291:2727-2733.精品評(píng)估住院期間和出院后長(zhǎng)期缺血風(fēng)險(xiǎn)評(píng)估住院期間死亡風(fēng)險(xiǎn)

(c70managementAdmittedtohospitalBestrest,OxygenAnti-platelet:asprin,Clopidogrel,GPIIb/IIIainhibitorsAnticoagulant:UFHorLMWHB-blockerNitrates(intravenous)CCBStatinsACEICoronaryrevascularisation精品managementAdmittedtohospital71DefiniteACSPossibleACS(–)ECG;NormalbiomarkersObserve;repeatECG,markersat4-8hrsNorecurrentpain;(–)follow-upstudiesRecurrentpain;(+)follow-upstudiesStresstest;LVfunctionifischemia(–)test:outptfollow-up(+)testAdmit,UseAcuteIschemiaPathwaySTUseMIGuidelinesNoSTST-T’s,chestpain,

markersInitialChestPain

EvaluationSymptomsSuggestiveofACS精品DefiniteACSPossibleACS(–)EC72AcuteCoronarySyndromes精品AcuteCoronarySyndromes精品73PreparationforDischargeAfterUA/NSTEMIAntiplateletRxASA75-162mg/dayClopidogrel75mg/dayBetaBlockerACEI/ARBEspeciallyifDM,HF,EF<40%,HTNStatinLDL<100mg/dL

(ideally<70mg/dL)SecondaryPreventionMeasuresSmokingCessationBP<140/90mmHGor<130/80mmHGforDMorchronickidneydisease

HbA1C<7%BMI18.5-24.9PhysicalExercise30-60minatleast5days/wk

精品PreparationforDischargeAfte74精品精品75NoSTElevationSTElevationAcuteCoronarySyndromeUnstableAnginaNQMIQwMINSTEMIMyocardialInfarctionDaviesMJ

Heart83:361,2000IschemicDiscomfortPresentationWorkingDxECGBiochem.MarkerFinalDxHammLancet358:1533,2001精品NoSTElevationSTElevationAc76Thankyou精品Thankyou精品77冠狀動(dòng)脈粥樣硬化性心臟病

(coronaryatheroscleroticheartdisease)

大連醫(yī)科大學(xué)附屬二院心內(nèi)科牛楠精品冠狀動(dòng)脈粥樣硬化性心臟病

(coronaryatheros78動(dòng)脈粥樣硬化

atherosclerosis精品動(dòng)脈粥樣硬化

atherosclerosis精品79IntroductionArteriosclerosisThickeningandlossofelasticityofarterialwallsHardeningofthearteriesGreatestmorbidityandmortalityofallhumandiseasesviaNarrowingWeakening精品IntroductionArteriosclerosis精80PlaqueThatHasBeenSurgicallyRemovedfromCoronaryArteryCourtesyRonaldD.GregoryandJohnRiley,MD.精品PlaqueThatHasBeenSurgicall81

NonModifiableRiskFactorsAgeAdominantinfluenceAtherosclerosisbeginsintheyoung,butdoesnotprecipitateorganinjuryuntillaterinlifeGenderMenmorepronethanwomen,butbyage60-70aboutequalfrequencyFamilyHistoryFamilialclusterofriskfactorsGeneticdifferences精品

NonModifiableRiskFactorsAg82

ModifiableRiskFactors

(potentiallycontrollable)

HyperlipidemiaHypertensionCigarettesmokingDiabetesMellitusElevatedHomocysteineFactorsthataffecthemostasisandthrombosisInfections:Herpesvirus;ChlamydiapneumoniaeObesity,sedentarylifestyle,stress精品

ModifiableRiskFactors

(pot83PathogenesisofAtherosclerosisResponsetoinjuryhypothesisInjurytotheendothelium(dysfunctionalendothelium)ChronicinflammatoryresponseMigrationofSMCfrommediatointimaProliferationofSMCinintimaExcessproductionofECMEnhancedlipidaccumulation精品PathogenesisofAtherosclerosi84Responsetoinjury精品Responsetoinjury精品85Endotheliadysfunction精品Endotheliadysfunction精品86InitiationofFattyStreak精品精品87FattyStreak精品精品88Fibro-fattyAtheroma精品精品89AtherosclerosisTimelineFoamCellsFattyStreakIntermediateLesionAtheromaFibrousPlaqueComplicatedLesion/RuptureAdaptedfromPepineCJ.AmJCardiol.1998;82(suppl104).FromFirstDecadeFromThirdDecadeFromFourthDecadeEndothelialDysfunction精品AtherosclerosisTimelineFoamFa90AHAClassificationofatherosclerosis精品AHAClassificationofatherosc91動(dòng)脈粥樣硬化血栓形成:

具共同病理基礎(chǔ)的進(jìn)展性過(guò)程正常脂肪條紋纖維斑塊粥樣硬化斑塊斑塊破潰/

裂隙和血栓形成心肌梗死

缺血性中風(fēng)/TIA

嚴(yán)重的下肢缺血臨床無(wú)癥狀心血管死亡年齡增長(zhǎng)穩(wěn)定性心絞痛間歇性跛行不穩(wěn)定性心絞痛}ACS*ACS,急性冠脈綜合征;TIA,一過(guò)性腦缺血發(fā)作缺血性腎病缺血性腸病精品動(dòng)脈粥樣硬化血栓形成:

具共同病理基礎(chǔ)的進(jìn)展性過(guò)程正常脂肪92CoronaryArteryDisease冠心病精品CoronaryArteryDisease冠心病精品93Clinicalclassification(1979WHO)AsymptomaticCHD(隱匿型）AnginapectorisCHD（心絞痛型）MyocardialinfarctionCHD(心肌梗死型）IschemiccardiomyopathyCHD（缺血性心肌病型）SuddendeathCHD（猝死型）精品Clinicalclassification(1979W94ClassificationofIHDChronicischemicsyndrome:stableanginaasymptomaticCHDischemiccardiomyopathyCHDAcutecoronarysyndrome:unstableanginaSTEMI/NSTEMI精品ClassificationofIHDChronici95急性冠脈綜合癥的病理生理學(xué)Fusteretal.NEnglJMed.1992;326:310-318.Daviesetal.Circulation.1990;82(SupplII):II-38,II-46.不穩(wěn)定血栓(UA/NSTEMI)脂肪池巨噬細(xì)胞內(nèi)在的壓力，張力外部的剪切力裂縫大裂縫小裂縫閉合血栓

(STEMI)動(dòng)脈粥樣硬化斑塊斑塊破裂血栓精品急性冠脈綜合癥的病理生理學(xué)Fusteretal.NE96NoSTElevationSTElevationAcuteCoronarySyndromeUnstableAnginaNQMIQwMINSTEMIMyocardialInfarctionDaviesMJ

Heart83:361,2000IschemicDiscomfortPresentationWorkingDxECGBiochem.MarkerFinalDxHammLancet358:1533,2001精品NoSTElevationSTElevationAc97ANGINAPECTORIS精品ANGINAPECTORIS精品98DefinitionofAngina

Apainordiscomfortinthechestoradjacentareascausedbyinsufficientbloodflowtotheheartmuscle.精品DefinitionofAngina 精品99精品精品100ClinicalclassificationandpathologyStableangina:fixedatheromatousstenosisUnstableangina:dynamicobstructionbyplaquerupturewithsuperimposedthrombosisandspasm精品Clinicalclassificationandpa101斑塊破裂引起急性嚴(yán)重事件不穩(wěn)定心絞痛心肌梗死猝死穩(wěn)定性(勞力性)心絞痛不穩(wěn)定斑塊的進(jìn)展過(guò)程穩(wěn)定斑塊的進(jìn)展過(guò)程N(yùn)issenSE.AmJCardiol.2000;86(suppl):12H-17H不穩(wěn)定斑塊斑塊破裂血栓形成穩(wěn)定斑塊斑塊體積增加管腔狹窄精品斑塊破裂引起急性嚴(yán)重事件不穩(wěn)定心肌梗死猝死穩(wěn)定性不穩(wěn)定斑塊102Stableanginapectoris精品Stableanginapectoris精品103ETIOLOGY.Ischemiaissecondarytocoronaryarterydiseasein95%ofpatients.Theleadingcauseiscertainlyatheroscleroticcoronaryarterydisease.Adecreasedoxygensupplyoranincreaseinoxygendemandcanleadtoaworseningofsymptoms..Ischemiacanoccurinpatientswithnormalcoronaryarteries精品ETIOLOGY.Ischemiaissecondary104Clinicalmenifestation

chestdiscomfortQuality-"squeezing,""griplike,""pressurelike,""suffocating"and"heavy”;ora"discomfort"butnot"pain."Anginaisalmostneversharporstabbing,andusuallydoesnotchangewithpositionorrespiration.Duration-anginalepisodeistypicallyminutesinduration.FleetingdiscomfortoradullachelastingforhoursisrarelyanginaLocation-usuallysubsternal,butradiationtotheneck,jaw,epigastrium,orarmsisnotuncommon.Painabovethemandible,belowtheepigastrium,orlocalizedtoasmallareaovertheleftlateralchestwallisrarelyanginal.Provocation-anginaisgenerallyprecipitatedbyexertionoremotionalstressandcommonlyrelievedbyrest.Sublingualnitroglycerinalsorelievesangina,usuallywithin30secondstoseveralminutes.精品Clinicalmenifestation

chestd105CategorizetheSeverityofAnginaCCSClassificationClass0asymptomaticClassIonstrenuousactivityClassIIonmoderateactivity

2blocksor2flightsofstairsClassIIIonmildactivity

2blocksor2flightsofstairsClassIVrestorminimalactivity精品CategorizetheSeverityofAn106Clinicalfeatures

PhysicalexaminationAnS4gallopmaybetransientlypresentduringanepisode,andthepatientmaybedyspneicordiaphoreticorhaveanewheartmurmur.High-riskfeaturesofanginaincludeheartfailureandhypotension.Acompletephysicalexamiscrucialinmakinganassessmentofrisk.Mostpt:(-)精品ClinicalfeaturesPhysicalexa107AlternativeDiagnosestoAnginaforPatientswithChestPainNon-IschemicCVaorticdissectionpericarditisPulmonarypulmonaryemboluspneumothoraxpneumoniapleuritisChestWallcostochondritisfibrositisribfracturesternoclaviculararthritisherpeszosterGastrointestinalEsophagealesophagitisspasmrefluxBiliarycoliccholecystitischoledocholithiasischolangitisPepticulcerPancreatitisPsychiatricAnxietydisordershyperventilationpanicdisorderprimaryanxietyAffectivedisordersdepressionSomatiformdisordersThoughtdisordersfixedocclusions精品AlternativeDiagnosestoAngin108Investigation12LeadRestingECGshouldberecordedinallpatientswithsymptomssuggestiveofanginapectorisnormalin50%ofpatientsanormalECGdoesnotexcludesevereCAD;however,itdoesimplynormalLVfunctionwithfavorableprognosis精品Investigation12LeadResting109CHDAtrest:

ECG精品CHDAtrest:ECG精品110冠心病Episodeofangina:ST-segmentdepressionECG精品冠心病Episodeofangina:ST-segme111CHDHolter精品CHDHolter精品112Exercisetesting精品Exercisetesting精品113Angina:ExerciseTesting

HighRiskPatientsSignificantST-segmentdepressionatlowlevelsofexerciseand/orheartrate<130FallinsystolicbloodpressureDiminishedexercisecapacityComplexventricularectopyatlowlevelofexercise精品Angina:ExerciseTesting

High114ExerciseTesting

ContraindicationsMI—impendingoracuteUnstableanginaAcutemyocarditis/pericarditisAcutesystemicillnessSevereaorticstenosisCongestiveheartfailureSeverehypertensionUncontrolledcardiacarrhythmias精品ExerciseTesting

Contraindicat115Investigation

Echocardiography.Thestressechocardiogramisawidelyperformedtestusedtoassesspatientsforcoronarydisease.Baselineechocardiographicimagesareobtainedatresttoevaluateleftventricularfunction,wallmotion,andvalvefunction.Imagesarethenacquiredduringpeakstress(thatis,duringaGXTorwithdobutamine)andcomparedwiththoseatrest.Regionalwall-motionabnormalitieswithstressindicateareasofhypoperfusionorischemia.精品InvestigationEchocardiography116InvestigationIsotopescanning:obtainingscintiscansofthemyocardiumatrestandduringstressafteradministrationofanintravenousradioactiveisotopesuchasthallium201精品InvestigationIsotopescanning:117Investigation

Coronaryangiography.

Usedtoidentifyfociofcoronarydisease.Itistheevaluationofchoiceinpatientswithanginathatis(1)poorlyresponsivetomedication,or(2)unstable.ItisalsoindicatedinpatientswithtestresultsconsistentwithahighriskforCAD.精品InvestigationCoronaryangiogr118冠心病Coronaryangiography精品冠心病Coronaryangiography精品119冠心病冠狀動(dòng)脈造影精品冠心病冠狀動(dòng)脈造影精品120冠心病LAD:stenosis LAD:normal精品冠心病LAD:stenosis LAD:121冠心病RCA:stenosis LCX:stenosis精品冠心病RCA:stenosis LCX:stenosi122ChronicStableAngina

TreatmentObjectivesPreventprogressionofcoronaryarterydiseaseandoptimiselifeexpectancyRelievesymptoms精品ChronicStableAngina

Treatme123ManagementAspirinbeta-adrenoreceptorblockingagents(-blockers)calciumantagonistsNitrates精品ManagementAspirin精品124NCEPPrimaryCHDRisk

GoalsforLoweringLDL-CLDL-CGoalNoCHD<2RF<160mg/dLNoCHD2RF<130mg/dLCHD100mg/dLTheNCEPrecommendsloweringLDL-Cevenfurtherthanthesegoals,ifpossible.RiskCategoryNHLBI;September1993精品NCEPPrimaryCHDRisk

Goalsf125CoronaryrevascularisationInvasivetreatment:coronaryangioplasty(PTCA);coronaryarterybypassgrafting(CABG)精品CoronaryrevascularisationInva126冠心病CABG精品冠心病CABG精品127冠心病PTCA精品冠心病PTCA精品128冠心病PTCABeforePTCA afterPTCA精品冠心病PTCABeforePTCA aft129冠心病PTCA/S精品冠心病PTCA/S精品130AcutecoronarysyndromeUnstableanginaNon-STelevationmyocardialinfarction(NSTEMI)STelevationmyocardialinfarction(STEMI)精品AcutecoronarysyndromeUnstabl131UnstableAngina/NSTEMI精品UnstableAngina/NSTEMI精品132UnstableAngina

ClinicalPresentationandClassificationDiagnosisofunstableanginareferstoneworworseningsymptomsofmyocardialischemia:restanginanew-onsetsevereanginaincreasingangina精品UnstableAngina

ClinicalPrese133精品精品134評(píng)估住院期間和出院后長(zhǎng)期缺血風(fēng)險(xiǎn)評(píng)估住院期間死亡風(fēng)險(xiǎn)

(c-index0.83)*及出院后6個(gè)月死亡風(fēng)險(xiǎn)(c-index0.81)**多個(gè)大型數(shù)據(jù)庫(kù)中驗(yàn)證其有效性(c-indices分別為0.84*和0.75**)評(píng)價(jià)死亡/再發(fā)心梗的長(zhǎng)期風(fēng)險(xiǎn)網(wǎng)絡(luò)版可下載

/GRACE *GrangerCB,etal.ArchinternMed.2003;163:2345-2353. **EagleK,atal.JAMA.2004;291:2727-2733.精品評(píng)估住院期間和出院后長(zhǎng)期缺血風(fēng)險(xiǎn)評(píng)估住院期間死亡風(fēng)險(xiǎn)

(c135UnstableAnginaChestpainsyndrome,eithernewonsetorprogressiveanginaTransientST-segmentdepressionontheelectrocardiogram(ECG)WithoutevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponin精品UnstableAnginaChestpainsynd136NSTEMIChestpainsyndrome,eithernewonsetorprogressiveanginaTransientorpersistentST-segmentdepressionontheelectrocardiogram(ECG)WithevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponin精品NSTEMIChestpainsyndrome,eit137UnstableAngina/NSTEMISignificantlikelihoodofoccurrenceofmajorcardiacevents A.IncidenceofMI:8to10% B.