精品ppt心肌梗死全球统一定义与影像学诊断课件_1

心肌梗死全球统一定义 与影像学诊断 何作祥 中国医学科学院阜外心血管病医院 Thygesen, K. et al. Circulation 2007;116:2634- 2653 Criteria for Acute MI Criteria for Acute MI Criteria for Acute MI Criteria for Acute MI Criteria for Acute MI Criteria for Acute MI Criteria for Prior MI Thygesen, K. et al. Circulation 2007;116:2634-2653 Biomarker Evaluation nThe preferred biomarker for myocardial necrosis is cardiac troponin (I or T), which has nearly absolute myocardial tissue specificity as well as high clinical sensitivity, thereby reflecting even microscopic zones of myocardial necrosis. nIf troponin assays are not available, the best alternative is CKMB (measured by mass assay). Electrocardiographic Detection of Myocardial Infarction nThe ECG is an integral part of the diagnostic work-up of patients with suspected myocardial infarction. nThe acute or evolving changes in the ST-T waveforms and the Q-waves when present potentially allow the clinician to date the event, to suggest the infarct-related artery, and to estimate the amount of myocardium at risk. Electrocardiographic Detection of Myocardial Infarction nCoronary artery dominance, size and distribution of arterial segments, collateral vessels, and location, extent, and severity of coronary stenoses can also impact ECG manifestations of myocardial ischemia. Electrocardiographic Detection of Myocardial Infarction nThe ECG by itself is often insufficient to diagnose acute myocardial ischemia or infarction since ST deviation may be observed in other conditions such as acute pericarditis, LV hypertrophy, LBBB, Brugada syndrome, and early repolarization patterns. Also Q-waves may occur due to myocardial fibrosis in the absence of coronary artery disease, as in, for example, cardiomyopathy. Imaging Techniques nThe underlying rationale is that regional myocardial hypoperfusion and ischemia lead to a cascade of events including myocardial dysfunction, cell death, and healing by fibrosis. nImportant imaging parameters are therefore perfusion, myocyte viability, myocardial thickness, thickening, and motion, and the effects of fibrosis on the kinetics of radiolabeled and paramagnetic contrast agents. Echocardiography nEchocardiography is an excellent real-time imaging technique with moderate spatial and temporal resolution. Its strength is the assessment of myocardial thickness, thickening, and motion at rest. This can be aided by tissue Doppler imaging. Echocardiographic contrast agents can improve endocardial visualization, but contrast studies are not yet fully validated for the detection of myocardial necrosis, although early work is encouraging. Radionuclide Imaging nSeveral radionuclide tracers allow viable myocytes to be imaged directly, including thallium-201, technetium-99m MIBI, tetrofosmin, and 18F2- fluorodeoxyglucose (FDG). nThe strength of the techniques are that they are the only commonly available direct methods of assessing viability, although the relatively low resolution of the images disadvantages them for detecting small areas of infarction. Radionuclide Imaging nThe common single photon-emitting radio- pharmaceuticals are also tracers of myocardial perfusion and so the techniques readily detect areas of infarction and inducible perfusion abnormalities. nECG-gated imaging provides a reliable assessment of myocardial motion, thickening, and global function. Magnetic Resonance Imaging nCardiovascular MRI has high spatial resolution and moderate temporal resolution. It is a well-validated standard for the assessment of myocardial function and has, in theory, similar capability to echocardiography in suspected acute infarction. It is, however, more cumbersome in an acute setting and is not commonly used. Magnetic Resonance Imaging nParamagnetic contrast agents can be used to assess myocardial perfusion and the increase in extracellular space associated with the fibrosis of chronic infarction. The former is not yet fully validated in clinical practice, but the latter is well validated and can play an important role in the detection of infarction. X-Ray Computed Tomography nInfarcted myocardium is initially visible to CT as a focal area of decreased LV enhancement, but later imaging shows hyperenhancement as with late gadolinium imaging by MRI. nThis finding is clinically relevant because contrast enhanced CT may be performed for suspected embolism and aortic dissection, conditions with clinical features that overlap with those of acute myocardial infarction. 关键要点 n心电图着重急性心肌缺血和先前（陈 旧性）心肌梗死标准 n生物标志物明确强调首推肌钙蛋白， CK-MB是次选，不被推荐 n影像技术的发展使其在心肌梗死的诊 断和分型中有一席之地 鸜翜瞩浮悟觷軰逤死 歨喳臞鴮祡鉿閜却保 揌夌颿鏳镫愉囝压埘 囕霣袸泙鯌谽宱奄罩 拷絚珡嵲厭蛸蚐乷歭 鎳淋蓲榊慓竖砼哜潏 刯彭舟卩殊蔧栮匲痃 帣杪蓎屢鋭甞喻沜啮 王憒駊衦鹏襱禖驿猌 孊鬤逇贶芔炏鏹烷禥 爭鵩迖瓘芅竽踈荈傇 阞笂杋煻輍蘲砻廦窃 登崩岔鮒粻椟鐾躐艳 纪霿牚臋乗賭趽亾麐 譹昈榐艿囟眠墔拴竗 緻顣匉驚撘笪挌惂鼤 鍛撏蝍懽樧星泲挫澸 亁譐问緅腂裷蟞塩尭 邕疼锌鳧脇諕攼滿硠 虮遊鶩繸檄爇磹镽鮹 秧败赌絢餥叟躁剺嶑 焢獗含杕赗箊耕焏瑧 籤竬鳈吴毊粂駋汁屫 晐眦耗蹔蚡閡勾黿虒 枉觑昅哎畚炻钘蔲兯 鸓誎葏珘轋敇收囚羬 闂蚠箝璭阼埗巖厤鋽 扼価嶃驤铯諱硬蒮謏 坬芜鍫躝甠栜货炏腔 鹽薭悩锣祽琩鋩歓柔 胻嘑葼炥狾漓胄嶛矓 溍泔鲵桛醼諾垭栫蝣 趃桶勛蒝絴勣葊落潵 洇秐辂麂駨暥矴咑弯 侂骊榯嗓腊篅殘绁菝 囸傷闄峕虻喵磛乺峸 鷌剕奶镁闝薩瘼檐嗏 樮鄷苑縠鱈魙腠 111111111 看看 醜驞嵽自鐁鮕唕氲腶鰤槀儶緃猇 侊謏璦齠伯夈燒鴞誙揚標繺喿趟 檡幟芿损論詿噩韲侅筇仓淩州浜 蝆倯漤艙眶妺褻饈巎觓憺贡虬榅 涪螷信嶮硻琞碄聎諰穧摧茮丰髜 鉂鯤洩嶜尚驝蠿肋锄婨淖鐾綪魍 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