心绞痛的鉴别心绞痛.ppt

病史特点,男性，59岁反复胸痛4个月，加重1个月。胸痛呈压榨性与劳力有关。有高血压，吸烟史。有心脑血管病阳性家族史。查体：体胖，无明显其他阳性发现。ECG：V4V6，I，aVLST0.5-1mm.,思考,胸痛的鉴别心绞痛的特点心绞痛的分级心绞痛的分类不同类型心绞痛的病理基础进一步检查冠心病的易患因素,心绞痛的鉴别(1),Non-ischemicCVAorticdissectionPericarditisPulmonaryPulmonaryembolusPneumothoraxPneumoniaPleuritis,GastrointestinalEsophagealEsophagitis,Spasm,RefluxBiliaryColicCholecystitisCholedocholithiasisCholangitisPepticulcerPancreatitis,心绞痛的鉴别(2),ChestWallCostochondritisFibrositisRibfractureSternoclaviculararthritisHerpeszoster(beforetherash),PsychiatricAnxietydisordersHyperventilationPanicdisorderPrimaryanxietyAffectivedisorders(e.g.,depression)SomatiformdisordersThoughtdisorders(e.g.,fixeddelusions),心绞痛特点,SAVESU：Suddenonset;Anteriorchest;Vaguesensation;Exerciseprecipitated;Shortduration;Unanimousattack.,GradingofAnginaPectorisbyCCSC,ClassI:日常体力活动不引起心绞痛.ClassII:日常体力活动轻度受限.ClassIII:日常体力活动明显受限.ClassIV:任何体力活动都引起症状，可以有休息时心绞痛。,UAP的主要临床表现,Restangina:Occurringatrest,usu.20min,occurringwithinaweekofpresentation.Newonsetangina:AtleastCCSCIIIseverity,200mmHg;DBP110mmHg;Tachy-orBrady-arrhythmias;HighdegreeAVBHCMPorotherformsofOTobstruction;Mentalorphysicalimpairment;,NoninvasiveTesting:ExerciseECG(3),Risk:MIanddeath1/2500tests.Astandardpercentage(often85%)ofage-predicatedmaximumheartrateistargeted.ReportedinestimatedMETsofexercise(OneMETisthestandardbasaloxygenuptakeof3.5ml/kgpermin.)STdepression1mmfor60-80msaftertheendofQRS,duringorafterexercise.,NoninvasiveTesting:ExerciseECG(4)(Absoluteindicationforstopping):,SBPdrop10mmHgwithischemia;Moderatetosevereangina;Increasingataxia;Dizzinessornearsyncope;Signofpoorperfusion;Technicaldifficulties;SustainedVT;STelevationinleadswithoutQwaves.,NoninvasiveTesting:ExerciseECG(5)(Relativeindicationforstopping):,SBPdrop10mmHgwithoutischemia;SBP250orDBP115mmHg;STdepression2mm;Markedaxisdeviation;MultifocalPVCs,tripletsPVCs,SVT,heartblockorbradyarrhythmias,BBBorIVCBIncreasingchestpain;Serioussymptoms.,NoninvasiveTesting:ExerciseECG(6),Sensitivity:68%;Specificity:77%Influenceofotherfactorsontest:Digoxin:25-40%abnormalSTdepression.Betablockers:Graduallywithheld48hrs.Anti-HBP,vasodilators,nitrates,flacainide.LBBB:RBBB:LVhypertrophy:Morefalse-positive.RestSTdepression:AdditionalSTsignificant.,StressImagingStudies,Goodcandidatesforstressimaging,asopposedtoexerciseECG:CLBBB,Pacedrhythm,WPWetc.ST1mmatrest,Unabletoexercise,AnginawithpriorRevascularization.,PharmacologicModalities(Vasodilators)UsedinStressImaging,Dipyridamole(DIP)inhibitingcellularuptakeofadenosine(apotentcoronaryvasodilators).Theflowincreasebyadenosineisoflessermagnitudethroughstenosticarteries,creatingheterogeneousmyocardialperfusion.SideeffectsofbothDIPandADEarerare,butmaycauseseverebronchospasminpatientswithasthmaorCOPD.,PharmacologicModalities(Dobutamine)UsedinStressImaging,Inhighdoses(20to40g/kg/min)increasesHR,SBPandmyocardialcontractility.Theflowincrease(2-3times)islessthanthatelicitedbyadenosineordipyridamole.Sideeffectsarefrequent,butthetestappearstobesafeevenintheelderly,includingnausea,anxiety,headache,tremor,VPC,APC,SVT,nonsust-VT,chestpainandangina(8%).,InvasiveTesting-Angiography(Indications),Chestpain,possibleischemic,coexistingCOPDnotacandidateforExercisetestbecauseofdyspnea;Perfusionimagingwithdipyridamoleoradenosinebecauseofbronchospasmandtheophyllinetherapy;StressECHObecauseofpoorimages.,InvasiveTesting-Angiography(Indications),TypicaloratypicalsymptomsandahighclinicalprobabilityofseverCAD.Mostappropriateforapatientwithahigh-risktreadmilloutcome.Symptomssuggestivebutnotcharacteristic,specialoccupation,eg.Pilots,firefightersetc.Alowthresholdangiographyisappropriatefordiabetics.,RISKSTRATIFICATION,A.ClinicalAssessmentB.ECG/ChestX-RayNoninvasiveTestingCoronaryAngiographyandLeftVentriculography,RiskStratification(ClinicalAssessment),PrognosisofCADforDeathorNonfatalMI:LVfunction:thestrongestpredictor,EFisthemostcommonlyused;Anatomicextentandseverityofcoronarytreeinvolvement.Thenumberofdiseasedvessels.Arecentcoronaryplaquerupture:worseningclinicalsymptomswithunstablefeature;Generalhealthandnoncoronarycomorbidity.,RiskStratification(ClinicalAssessment),ClinicalParametersPredictiveofSevere(leftmainorthreevessel)CADAge,Gender,Typicalangina,PreviousMI,DManduseofinsulin,RiskStratification(ECG/ChestX-ray),ECGEvidenceof1previousMI,PersistentST-Tinversion,LBBB,LAB+RBBB,IIorIIIAVB,Af,VT,LVhypertrophy,ChestX-rayCardiomegaly,LVaneurysm,PVcongestionCoronarycalcification,RiskStratification(NoninvasiveTesting),RestingLVFunctionImportanceofassessmentGlobalLVFunctionSWMAMR,LVAneurysm,LVThrombosis,TREATMENT,PharmacologicTherapySuccessfulandInitiatingTreatmentEducationofPatientswithCSARiskFactorsRevascularizationforCSA,OverviewofTreatment,Stableangina-Twopurposes:TopreventMIanddeath.Toreducesymptomsofanginaandoccurrenceofischemia.,稳定心绞痛的A，B，C，D，E治疗,A=AspirinandAntianginalB=Beta-blockerandBloodpressureC=CigarettesmokingandCholesterolD=DietandDiabetesE=EducationandExercise,ToPreventMIandDeath（1,抗血小板药物阿斯匹林抑制环氧化酶和TXA2合成。抵克力得（Ticlopidineathienopyridinederivative抑制血小板聚集副作用：中心粒细胞减少,TTPClopidogrel:如上潘生丁（Dipyridamole口服增加运动性缺血，不能用做抗血小板药。,ToPreventMIandDeath（2,抗血栓治疗用于稳定型心绞痛的资料极有限。降脂药物胆固醇降低1使心血管事件下降2。抗心绞痛和抗缺血治疗受体阻滞剂钙拮抗剂硝酸甘油和硝酸盐类,UAP的治疗,阿斯匹林肝素阻滞剂硝酸甘油积极治疗24小时无效时需冠状动脉造影,PTCA和CABG,CABG：左主干病变。三支病变。二支病变，但其中一支病变在前降支近段。一或二支，无前降支病变，但有SCD或持续VT史。PTCA：二或三支病变，包括前降支近端，但病变适合导管治疗，LV功能正常，无需用药的DM。,ConditionsProvokingorExacerbatingIschemia(IncreasedOxygenDemand),Non-CardiacHyperthermiaHyperthyroidismSympathomimetictoxicity(e.g.,cocaineuse)HypertensionAnxietyArteriovenousfistulae,CardiacHCMAorticstenosisDilatedCMTachycardiaVentricularSuperventricular,ConditionsProvok