课件：qianjy冠心病英.ppt

Atherosclerosis & Coronary heart diseases,Fudan University, Zhongshan Hospital Dept. of Cardiology, Shanghai Institute of CVD Juying Qian, M.D. ,2009,Cardiovascular Diseases,Coronary heart disease,atherosclerosis,Coronary stenosis,coronary spasm,Myocardial ischemia, anoxaemia,Coronary heart disease, CHD Ischemic heart disease,Atherosclerosis Stable angina pectoris(SAP) Acute coronary syndrome Unstable angina(UAP) and non-STEMI (UA/NSTEMI) ST elevation myocardial infarction(STEMI) elevation .elivein ,Atherosclerosis.rusklirusis,leading cause of death and disability Common location: Coronarykr.neri circulation: Proximalprksiml left anteriorntiri descendingdisendi coronary artery(LAD) Proximal portion of renal arteries Extracranial.ekstrkreini:l 颅外的circulation to the brain Carotid颈动 krtid bifurcation,Atherosclerosis,Three fundamental biological processes of atherosclerosis,Accumulation of intimalintml cells: smooth muscle cells Macrophagesmkrfeid T-lymphocyteslimfsait Proliferatedprlif.reit connective tissue matrixmeitriks 结缔组织基质增生 : collagenkldn elasticilstik fibers proteoglycans.prutiuglaikns蛋白聚糖 3. Accumulation of lipid: cholesteryl estersist free cholesterolklst,rol,Hypothesis of lipoprotein infiltration Aggregation of platelets and thrombosis Clonal theory克隆(选择)学说 the response-to-injury hypothesis,Atherosclerosis-Hypothesis,Response-to-injury,Atherosclerosis: hypothesis,High blood pressure,bacterium,virus,toxin,ox-LDL, immune factor,vasoactive substance endothelium damage, metergasis (vasoactive substance, adhesion and aggregation of monocytes-foam cell, platelets) Lipidoses, growth factor, proliferation of smooth mucle cells, collagen, lipolytic enzyme,atherosclerosis,Pathology and pathophysiology Fatty steak Fibrous plaque Complicated lesionli:n,Atherosclerosis,Initiation of Atherosclerosis,Fatty steak formation,Initiation of Atherosclerosis,Fatty steak formation Lipoprotein.lippruti:n oxidation Nonenzymaticnnenzaimtik glycation Leukocyte recruitment rikru:tmnt Foam cell formation,Atheroma evolution: fibrous plaquepl:k,Atheroma evolution and complications,Vascular remodeling: compensatory enlargement,Atheroma evolution: Involvement of arterial smooth-muscle cells Blood coagulationkugjulein microvesselsmaikruvesl,Atheroma evolution and complications,Intimaintim,Complicated lesionli:n: thrombosis,Atheroma evolution and complications,Atheroma evolution and complications,Vulnerable plaque: Thin fibrous cap Relativelyreltivli large lipid core High content of macrophages,Inflammatory mediatorsmi:di.eit,Intravascular ultrasoundltr.saund,Classicification of atherosclerotic lesion using IVUS,Clinicl stages and classification Absence of symptom or stage of delitescencedeilitesns潜伏 ischemia necrosis(targett:git organ ) fibrosis,Atherosclerosis,General manifestation Aortic atherosclerosis Coronary artery atherosclerosis Cerebralseribrl atherosclerosis RA atherosclerosis Mesentericmesnterik atherosclerosis Peripheralprifrl artery atherosclerosis,Atherosclerosis,clinical manifestation,laboratory lbrtri examination Lack of sensitive and specific methods for early diagnosis.daignusis Dyslipidemiadislipidemi： X-ray：DSA show severity of stenosis Doppler ultrasound: blood flow radionuclide： detection of ischemia Echocardiogram： CHD ECG and stress test: CHD New techniques: intravascular ultrasound, angioscope CT, MRI,Atherosclerosis,Risk factors and prevention,1.Lifestyle modification 2.Lipid disorders (Dyslipidemia): cholesterol screening in all 20yrs Elevated: cholesterol (Tc and LDL-c), TG, ApoB/ApoA,Lp(a), Low: HDL-c LDL lowering by HMG-CoA reductase(statins): cardiovascular events 30%，risk of MI 62% 3.Hypertension： 4.DM,Metabolic syndrome or insulin resistance syndrome: BP, BMI ,TG, serum insulin HDL-c, OGTT,Diabetes mellitus(DM): RR 1.9 for male, 3.3 for female more diffuse lesion. CAD equivalent 75-80% cause of death in adult DM are vascular diseases: CAD, cerebrovascular disease, or peripheral vascular disease,Risk factors and prevention,7 years incidence of death/non-fatal MI (East West Study),* These patients had no history of myocardial infarction Haffner SM, et al. N Engl J Med. 1998;339:229234.,0,5,10,15,20,25,30,35,40,45,50,Events of MI in 7 years,No history of MI OMI No history of MI* OMI,non-diabetics diabetics n = 1373 n = 1059,P 0.001,P 0.001,4%,19%,20%,45%,DM: CAD equivalent,5. Cigarette smoking：more thrombogenic 6. Family history： 7. Aging：40yrs adults ，4/5 fatal myocardial infarction occured in patiens 65 yrs 8. Male gender/ postmenopausal state： male:female = 2：1, man develop CHD 10-15 yrs earlier than woman 9. alcohol 10. Others: diet,homocysteine, hemostatic factors inflammation/infection,Risk factors and prevention,Drug therapy： anti-platelet： aspirin, clopidogrel, GPIIb/IIIa inhitibor, Dipyridamole, cilostazol Lipid-lowering,Risk factors and prevention,HMG-CoA reductase inhibitors（statins） Atorvastatin,Fluvastatin,Lovastatin,Pravastatin,Simvastatin,Cerivastatin, Rosuvastatin： *elevation of aminopherase, rhabdomyolysis 2. Bile acid-binding Resins cholestyramine，colestipol 3. Nicotinic Acid： 4. Fibric acid derivatives（fibrates） Gemifibrozil, clofibrate, Fenofibrate 5. Cholesterol absorption inhibitors: ezetimibe 6. Probucol,Lipid-lowering drugs,A: aspirin,ACEI B: blood pressure, -blocker, C: cigarette smoking, Cholesterol D: diet, diabetes E: exercise, education,Prevention of CAD,Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults ATP III (adult treatment panel III) Circulation 2002 17/24: 3144-3373,Atherosclerosis,Coronary heart disease (CHD),Coronary heart disease (CHD),most common cause: obstruction of atheromatous plaque other causes: spasm arterial thrombi coronary emboli ostial narrowing due to luetic aortitis congential abnormalitieds severe LV hypertrophy,Factors effect myocardial oxygen supply and demand,Oxygen supply,Oxygen demand,Heart rate,Myocardial contractility,Systolic wall stress,oxygen carrying capacity of blood,Coronary blood flow,Vascular resistance,Extravascular compressive forces,autoregulation,Metabolic regulation,Humoral factor,Neural regulation,Duration of diastole,Pressure gradient,Endothelial control,Coronary heart disease,Type： slient ischemia: delitescence： (ECG change) Angina pectoris： angina, caused by myocardial ischemia myocardial infarction：acute myocardial ischemic necrosis caused by the occlusion of coronary artery Ischemia cardiomyopathy (Heart failure and arrhythmia)： cardiac enlargement, heart failure, arrhythmia, caused by the myocardial fibrosis as the consequence of chronic mycardial ischemia Sudden death： sudden cardiac arrest caused death,Coronary heart disease (CHD),Type： slient ischemia: delitescence Angina pectoris： myocardial infarction： Ischemic cardiomyopathy (Heart failure and arrhythmia) Sudden death,Acute Coronary Syndrome(ACS),Resting ischemia,Non-ST elevation,STelevation,Unstable angina,Non-Q wave AMI,Q wave AMI,*positive serum cardiac markers,*,*,*,*,#,# occasionally variant angina,Stable angina pectoris (SAP),definition: acute and transient myocardial ischemia and anoxaemia usually caused by coronary insufficiency during exertion Characteristics: paroxysmal precordial squeezing-like chest pain, behind the mid sternum， radiated to left shoulder and upper arm precipitated by stress or exertion relieved rapidly by rest or nitrates,Stable angina pectoris,Factors effect myocardial oxygen supply and demand,Oxygen supply,Oxygen demand,Heart rate,Myocardial contractility,Systolic wall stress,oxygen carrying capacity of blood,Coronary blood flow,Vascular resistance,Extravascular compressive forces,autoregulation,Metabolic regulation,Humoral factor,Neural regulation,Duration of diastole,Pressure gradient,Endothelial control,hypoxia,Coronary stenosis (others:aortic valve disease, HOCM, MB) + precipitation Myocardial oxygen demand（HRXSBP）increased myocardial hypoxia acumulation of metabolic product, stimulate C1-5 to cause the sensation of chest pain,Stable angina pectoris,mechanism,in angiography Significant coronary lesion with diameter stenosis 70% in 75% pts No significant stenosis in about 5-10% pts, Ischemia may be related to coronary spasm or microvascular dysfunction.,Pathology,Stable angina pectoris,pathophysiology,1.Metabolic and electrophysiology ATP reduced, accumulation of acid substances Dysfunction of iron pump (Na+-K+, and Na+-Ca+) Early depolarization (ST deviation) 2.LV function and hemodynamic situation LV contractility and speed, systolic BP, stroke volume, cardiac output decreased LVED pressure and volume,Stunning of myocardium,Stable angina pectoris,symptom：chest pain or oppression location behind or slightly to the left of the mid sternum no definite borderline radiated to the left shoulder and upper arm Atypical location: lower jaw, the back of neck,Clinical manifestation,Stable angina pectoris,chest pain characteristics： tightness, squeezing, burning, pressing, choking, bursting,rarely sharp, not spasmodic force the patient stop the activity till the symptom relieved precipitation exertion or emotional agitation。 duration： 35 mins pain relief: within several mins after rest or using nitroglycerin,Clinical manifestation,Stable angina pectoris,Physical examination increased HR, elevated BP anxiety zaiti crymo-skin, sweating occasionallykeinli gallop rhythm，transient systolic murmur,Clinical manifestation,Stable angina pectoris,Laboratory,Stable angina pectoris,Stress test,rest,Exerscise,Stable angina pectoris,2.Echocardiography: 3. Scintigraphy assessment: TL201，Tc99m-sestamibi myocardial perfusion scintigraphy 4.X-ray of heart 5.coronary angiography：final diagnose 6.others: IVUS、intracoronary Doppler flow 、intracoronary pressure,Laboratory,Stable angina pectoris,Coronary Angiography,Typing of angina pectoris 1.exertional angina：（provocated by the increase of myocardial oxygen demand） stable angina recent onset angina progressive (deteriorative) angina 2.spontaneous angina：（not related to the increase of myocardial oxygen demand） angina decubitus variant angina pectoris(Prinzmetal angina) acute coronary insufficiency postinfarction angina pectoris 3.mixed angina： New typing: stable and unstable angian pectoris,Angina Pectoris,1.Cardiogenic pain：aortic dissection, HOCM, aortic stenosis 2.Throacic- respiratory：PE, pneumothorax, pleuritis 3.Gastrointestinal: gastro-esophageal diseases, Hiatal hernia, cholecystitis, peptic ulceration, pancreatitis 4.Neuromuscular/skeletal ：Tietze Syndrome (Costochondritis), intercostal neuralgia, Herpes zoster 5.Psychologic: anxiety, depression, panic attacks,Stable angina pectoris,Diagnosis,Chest pain, risk factors, ECG evidence of ischemia during chest pain, angiography,Differentiation,Chest pain, risk factors, ECG, angiography Differentiation: 1.Cardiogenic pain：aortic dissecion, myocarditis, pericarditis, myocardiopathy, severe valvular diseases (aortic stenosis） 2.Throacic- respiratory：pulmonary embolism, infarction, pneumothorax, pleuritis, intrathoracic malignancy, pneumonia 3.Gastrointestinal:gastroesophageal reflux, esophagitis, esophageal spasm, Hiatal hernia, cholecystitis, gallstones, peptic ulcer disease, Pancreatitis 4.Neuromuscular/skeletal ：Tietze Syndrome(Costochondritis),intercostal neuralgia, Cervical or thoracic degenerative arthristis, cardiac causalgia, Herpes zoster 5.Psychologic: anxiety, depression, panic attacks,Diagnosis,Stable angina pectoris,Functional classification of SAP(CCS ) CCS I： no chest pain at ordinary activity. Angina at strenuous or rapid or prolonged exertion CCS II： Slight limitation of ordinary activity. Walking or climbing stairs rapidly, after meals, in cold, in wind. Walking more than 2 blocks,climbing more than stairs of 3rd floor. CCS III： Marked limitation of ordinary activity. Walking 1 to 2 blocks, climbing stairs of 3rd floor CCS IV：Inability to carry on any activity without discomfort anginal symdrome may be present at rest.,Stable angina pectoris,General consideration： rest，avoid provocative factors , risk factors control 2. Drug therapy: prevent MI and death symptom relief and quality of life improvment 3. Coronary revascularization: percutaneous coronary intervention (PCI) Coronary artery bypass surgery (CABG) SVG, LIMA,Prevention and treatment,Stable angina pectoris,antianginal and anti-ischemic therapy,Drug therapy,Oxygen supply,Oxygen demand,a.nitrates b.beta-adrenergic blockers c.Calcium antagonists d.Drugs improving metabolism,Stable angina pectoris,Drug therapy,a.nitrates lower oxygen demand: decrease arteriolar and venous tone, reduce preload and afterload increase coronary supply: Coronary dilatation Nitroglycerin Isosorbide dinitrate isosorbide 5-mononitrate (long-acting nitrates),Stable angina pectoris,b. blockers: reduce myocardial oxygen: reduce HR, myocardial contractility, BP,the LV wall stress Abslute contraindications： sever bradycardia: high-degree A-V block, SSS, severe unstable LV failure Relative contraindications: asthma and bronchospastic disease peripheral vascular disease 1-selective：metoprolol, atenolol, bisoprolol,Drug therapy,Stable angina pectoris,c.Calcium antagonists： Increase oxygen supply: dilate conduit and resistance vessels, release spasm, improve microvascular function Decrease oxygen demand: negative inotropic effect, decrease BP Antiplatelet effect,d. Drugs improving metabolism： trimethazine（vasorel），selectively inhibit 3-KAT（3-酮酰辅酶A硫解酶），partly inhibit FA oxidation,Drug therapy,Stable angina pectoris,prevent MI and death therapy a.antiplatelet angents： ASA，75-325mg/d clopidogrel; ticlopidine: ADP receptor- antagonists: Cilostazol: phosphodiesterase inhititor,50-100mg bid b. Lipid-lowering angents: statins c. Angiotesin-converting enzyme inhibitor (ACEI),Drug therapy,Stable angina pectoris,stenting,Stable angina pectoris,Unstable angina(UAP) and non-STEMI,Resting ischemia,Non-ST elevation,STelevation,Unstable angina,Non-Q wave AMI,Q wave AMI,*positive serum cardiac markers,*,*,*,*,#,# occasionally variant angina,Acute Coronary Syndrome(ACS),Pathophysiology of ACS,stable angina UAP&non-Q-w AMI Q-w AMI Angiographic thrombus 0-1% 75% 90% Increased FPA/TAT 0-5% 60-80% 80-90% Activated platelets 0-5% 70-80% 80-90% Acute coronary occlusion 0-1% 10-25% 90% mortality 1-2% 3-8% 6-15%,FPA：fibrinopeptide A TAT：thrombin-antithrombin complexes,UAP and non-STEMI,Occuring at rest (or with mininal exertion)ectoris: last 20 mins sever and of new-onset: within 1-2 months, CCS III Occuring with a crescendo pattern: Deterioration of CCS classfication, at least CCS III variant angina pectoris (Prinzmetal angina): transient ST elevation, caused by the coronary spasm,Definition (main type),UAP and non-STEMI,Angina pectoris or equivalent ischemic discomfort with at least one of the three features,Braunwald classification of unstable angina,Severity： Class I： New-onset, or accelerated severe angina no rest pain within 2 months Class II： Angina at rest, subacute angina at rest (within the preceding month but not within 48 h) Class III： Angina at rest, acute ( within the preceding 48 h),UAP and non-STEMI,Braunwald classification of unstable angina,Clinical Circumstances Class A：Secondary UAP a clearly identified condition extrinsic to the coronary vascular bed that has intensified myocardial ischemia, e.g. anemia, hypotension, tachy-arrhythmia Class B：Primary unstable angina Class C：Post-infarction UAP (within 2 weeks of a documented MI),UAP and non-STEMI,mechanism：,1.plaque rupture and erosion, with nonocclusive thrombus 2.dynamic obstruction: Vasoconstruction 3.progressive mechnial obstruction(rapidly advancing or ISR following stenting) 4.secondary UA Inflammation Thrombogenesis,UAP and non-STEMI,ECG: Non-STEMI: ST depression last 12 hr,Cardiac biomarkers of myocardium damage: cTnT, cTnI CK-MB,UAP and non-STEMI,Coronary angiography Angioscopy and IVUS Other laboratory tests,Risk stratification：TIMI Risk Score Age =65yrs More than 3 coronary risk factors Prior angiographic coronary obstruction ST-segment deviation 0.5 mm More than 2 angina events within 24 hours Development of UA/NSTEMI while on aspirin Elevated cardiac markers,Antaman, JAMA 2000; 284:835-42,TIMI IIB, ESSENCE, PRISM-PLUS,TACTICS-TIMI18,UAP and non-STEMI,Treatment,1.Genearl management: rest, oxygen, CCU 2. Drug therapy A. Anti-ischemic drug: intravenously, orally nitrates -blocker calciumklsim antagnoist: first choice for variant angina Morphine sulfate,UAP and non-STEMI,Treatment,2. Drug therapy: B. antithrombotic therapy a. Anti-platelet Aspirin: early, 300mg loading dose ADP-receptor antagonist: clopidogrel 300mg-600mg loading dose, 75 mg/d GP IIb/IIIa receptor inhibitor: used in pts planned to PCI b. Anticoagulation therapy: Heparin Low molecular weight heparin(LMWH) Direct anti-thrombin drug: bivalirudin, hirudin,UAP and non-STEMI,Treatment,2. Drug therapy: C. other medical therapy a. lipid-lowering drugs: statins, early use(in first 24 hrs) LDL-c target: 100 mg/dl b. ACEI: long-term secondary prevention,UAP and non-STEMI,Treatment,3. Invasive versus conservative strategy early invasive strategy indicated for high risk patients: within 48-72 hrs, Following by coronary revascularization(PCI or CABG) 4. Long-term management -blockers, Statin, ACEI,aspirin clopidegrel(12m),UAP and non-STEMI,ST elevation myocardial infarction STEMI,Acute Coronary Syndrome(ACS),Resting ischemia,Non-ST elevation,STelevation,Unstable angina,Non-Q wave AMI,Q wave AMI,*positive serum cardiac markers,*,*,*,*,#,# occasionally varia