冠心病的知識課件

冠心病的知識課件動脈粥樣硬化

atherosclerosisIntroductionArteriosclerosisThickeningandlossofelasticityofarterialwallsHardeningofthearteriesGreatestmorbidityandmortalityofallhumandiseasesviaNarrowingWeakeningPlaqueThatHasBeenSurgicallyRemovedfromCoronaryArteryCourtesyRonaldD.GregoryandJohnRiley,MD.

NonModifiableRiskFactorsAgeAdominantinfluenceAtherosclerosisbeginsintheyoung,butdoesnotprecipitateorganinjuryuntillaterinlifeGenderMenmorepronethanwomen,butbyage60-70aboutequalfrequencyFamilyHistoryFamilialclusterofriskfactorsGeneticdifferences

ModifiableRiskFactors

(potentiallycontrollable)

HyperlipidemiaHypertensionCigarettesmokingDiabetesMellitusElevatedHomocysteineFactorsthataffecthemostasisandthrombosisInfections:Herpesvirus;ChlamydiapneumoniaeObesity,sedentarylifestyle,stressPathogenesisofAtherosclerosisResponsetoinjuryhypothesisInjurytotheendothelium(dysfunctionalendothelium)ChronicinflammatoryresponseMigrationofSMCfrommediatointimaProliferationofSMCinintimaExcessproductionofECMEnhancedlipidaccumulationResponsetoinjuryEndotheliadysfunctionInitiationofFattyStreakFattyStreakFibro-fattyAtheromaAtherosclerosisTimelineFoamCellsFattyStreakIntermediateLesionAtheromaFibrousPlaqueComplicatedLesion/RuptureAdaptedfromPepineCJ.AmJCardiol.1998;82(suppl104).FromFirstDecadeFromThirdDecadeFromFourthDecadeEndothelialDysfunctionAHAClassificationofatherosclerosis動脈粥樣硬化血栓形成:

具共同病理基礎(chǔ)的進(jìn)展性過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癥狀心血管死亡年齡增長穩(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,一過性腦缺血發(fā)作缺血性腎病缺血性腸病CoronaryArteryDisease冠心病Clinicalclassification(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）ClassificationofIHDChronicischemicsyndrome:stableanginaasymptomaticCHDischemiccardiomyopathyCHDAcutecoronarysyndrome:unstableanginaSTEMI/NSTEMI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)動脈粥樣硬化斑塊斑塊破裂血栓NoSTElevationSTElevationAcuteCoronarySyndromeUnstableAnginaNQMIQwMINSTEMIMyocardialInfarctionDaviesMJ

Heart83:361,2000IschemicDiscomfortPresentationWorkingDxECGBiochem.MarkerFinalDxHammLancet358:1533,2001ANGINAPECTORISDefinitionofAngina

Apainordiscomfortinthechestoradjacentareascausedbyinsufficientbloodflowtotheheartmuscle.ClinicalclassificationandpathologyStableangina:fixedatheromatousstenosisUnstableangina:dynamicobstructionbyplaquerupturewithsuperimposedthrombosisandspasm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)展過程穩(wěn)定斑塊的進(jìn)展過程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StableanginapectorisETIOLOGY.Ischemiaissecondarytocoronaryarterydiseasein95%ofpatients.Theleadingcauseiscertainlyatheroscleroticcoronaryarterydisease.Adecreasedoxygensupplyoranincreaseinoxygendemandcanleadtoaworseningofsymptoms..IschemiacanoccurinpatientswithnormalcoronaryarteriesClinicalmenifestation

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.CategorizetheSeverityofAnginaCCSClassificationClass0asymptomaticClassIonstrenuousactivityClassIIonmoderateactivity

2blocksor2flightsofstairsClassIIIonmildactivity

2blocksor2flightsofstairsClassIVrestorminimalactivityClinicalfeatures

PhysicalexaminationAnS4gallopmaybetransientlypresentduringanepisode,andthepatientmaybedyspneicordiaphoreticorhaveanewheartmurmur.High-riskfeaturesofanginaincludeheartfailureandhypotension.Acompletephysicalexamiscrucialinmakinganassessmentofrisk.Mostpt:(-)AlternativeDiagnosestoAnginaforPatientswithChestPainNon-IschemicCVaorticdissectionpericarditisPulmonarypulmonaryemboluspneumothoraxpneumoniapleuritisChestWallcostochondritisfibrositisribfracturesternoclaviculararthritisherpeszosterGastrointestinalEsophagealesophagitisspasmrefluxBiliarycoliccholecystitischoledocholithiasischolangitisPepticulcerPancreatitisPsychiatricAnxietydisordershyperventilationpanicdisorderprimaryanxietyAffectivedisordersdepressionSomatiformdisordersThoughtdisordersfixedocclusionsInvestigation12LeadRestingECGshouldberecordedinallpatientswithsymptomssuggestiveofanginapectorisnormalin50%ofpatientsanormalECGdoesnotexcludesevereCAD;however,itdoesimplynormalLVfunctionwithfavorableprognosisCHDAtrest:

ECG冠心病Episodeofangina:ST-segmentdepressionECGCHDHolterExercisetestingAngina:ExerciseTesting

HighRiskPatientsSignificantST-segmentdepressionatlowlevelsofexerciseand/orheartrate<130FallinsystolicbloodpressureDiminishedexercisecapacityComplexventricularectopyatlowlevelofexerciseExerciseTesting

ContraindicationsMI—impendingoracuteUnstableanginaAcutemyocarditis/pericarditisAcutesystemicillnessSevereaorticstenosisCongestiveheartfailureSeverehypertensionUncontrolledcardiacarrhythmiasInvestigation

Echocardiography.Thestressechocardiogramisawidelyperformedtestusedtoassesspatientsforcoronarydisease.Baselineechocardiographicimagesareobtainedatresttoevaluateleftventricularfunction,wallmotion,andvalvefunction.Imagesarethenacquiredduringpeakstress(thatis,duringaGXTorwithdobutamine)andcomparedwiththoseatrest.Regionalwall-motionabnormalitieswithstressindicateareasofhypoperfusionorischemia.InvestigationIsotopescanning:obtainingscintiscansofthemyocardiumatrestandduringstressafteradministrationofanintravenousradioactiveisotopesuchasthallium201Investigation

Coronaryangiography.

Usedtoidentifyfociofcoronarydisease.Itistheevaluationofchoiceinpatientswithanginathatis(1)poorlyresponsivetomedication,or(2)unstable.ItisalsoindicatedinpatientswithtestresultsconsistentwithahighriskforCAD.冠心病Coronaryangiography冠心病冠狀動脈造影冠心病LAD:stenosis LAD:normal冠心病RCA:stenosis LCX:stenosisChronicStableAngina

TreatmentObjectivesPreventprogressionofcoronaryarterydiseaseandoptimiselifeexpectancyRelievesymptomsManagementAspirinbeta-adrenoreceptorblockingagents(

-blockers)calciumantagonistsNitratesNCEPPrimaryCHDRisk

GoalsforLoweringLDL-CLDL-CGoalNoCHD<2RF<160mg/dLNoCHD

2RF<130mg/dLCHD

100mg/dLTheNCEPrecommendsloweringLDL-Cevenfurtherthanthesegoals,ifpossible.RiskCategoryNHLBI;September1993CoronaryrevascularisationInvasivetreatment:coronaryangioplasty(PTCA);coronaryarterybypassgrafting(CABG)冠心病CABG冠心病PTCA冠心病PTCABeforePTCA afterPTCA冠心病PTCA/SAcutecoronarysyndromeUnstableanginaNon-STelevationmyocardialinfarction(NSTEMI)STelevationmyocardialinfarction(STEMI)UnstableAngina/NSTEMIUnstableAngina

ClinicalPresentationandClassificationDiagnosisofunstableanginareferstoneworworseningsymptomsofmyocardialischemia:restanginanew-onsetsevereanginaincreasingangina評估住院期間和出院后長期缺血風(fēng)險評估住院期間死亡風(fēng)險

(c-index0.83)*及出院后6個月死亡風(fēng)險(c-index0.81)**多個大型數(shù)據(jù)庫中驗證其有效性(c-indices分別為0.84*和0.75**)評價死亡/再發(fā)心梗的長期風(fēng)險網(wǎng)絡(luò)版可下載

*GrangerCB,etal.ArchinternMed.2003;163:2345-2353. **EagleK,atal.JAMA.2004;291:2727-2733.UnstableAnginaChestpainsyndrome,eithernewonsetorprogressiveanginaTransientST-segmentdepressionontheelectrocardiogram(ECG)WithoutevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponinNSTEMIChestpainsyndrome,eithernewonsetorprogressiveanginaTransientorpersistentST-segmentdepressionontheelectrocardiogram(ECG)WithevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponinUnstableAngina/NSTEMISignificantlikelihoodofoccurrenceofmajorcardiacevents A.IncidenceofMI:8to10% B.Mortality:2to5%UnstableAngina/NSTEMI:

PathophysiologyAcuteplaquefissuringandruptureSuperimposedthrombusTransientocclusionMediator-inducedvasospasmmaybepresentDeterminantsofPlaqueVulnerabilityLipid-richcoresizeCapthicknessCapinflammationandrepair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)展過程穩(wěn)定斑塊的進(jìn)展過程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PhysicalExaminatonNotthathelpfulMayhaveevidenceofCHF:JVD,rales,edemaMayhaveS4MayhavemurmurofmitralregurgitationfrompapillarymuscledysfunctionInvestigationECGCardiacEnzymeorTroponinCoronaryangiographyAcuteCoronarySyndromes評估住院期間和出院后長期缺血風(fēng)險評估住院期間死亡風(fēng)險

(c-index0.83)*及出院后6個月死亡風(fēng)險(c-index0.81)**多個大型數(shù)據(jù)庫中驗證其有效性(c-indices分別為0.84*和0.75**)評價死亡/再發(fā)心梗的長期風(fēng)險網(wǎng)絡(luò)版可下載

*GrangerCB,etal.ArchinternMed.2003;163:2345-2353. **EagleK,atal.JAMA.2004;291:2727-2733.managementAdmittedtohospitalBestrest,OxygenAnti-platelet:asprin,Clopidogrel,GPIIb/IIIainhibitorsAnticoagulant:UFHorLMWHB-blocker