冠心病PPT课件.ppt

CORONARYATHEROSCLEROTICHEARTDISEASE,冠状动脉粥样硬化性心脏病,1,.,冠状动脉粥样硬化性心脏病冠状动脉性心脏病冠心病缺血性心脏病,2,.,Definition,冠状动脉粥样硬化性心脏病是指冠状动脉粥样硬化使血管腔狭窄或阻塞，或（和）因冠状动脉功能性改变（痉挛）导致心肌缺血缺氧而坏死引起的心脏病，统称冠状动脉性心脏病，简称冠心病，亦称缺血性心脏病。,4,.,Definition,5,.,Definition,冠状动脉粥样硬化性心脏病+冠状动脉功能性改变=冠状动脉性心脏病=冠心病=缺血性心脏病,6,.,EPIDEMIOLOGY,Coronaryheartdisease许多工业国家致死的最主要原因；致死率、致残率高，是医疗消费的最主要原因,7,.,EPIDEMIOLOGY,No.1KillerAHAAMI:1,500,000/yDeath:650,000/y,8,.,EPIDEMIOLOGY,TheNorthTheSouthNo.1Killer(City),9,.,Classification,无症状性心肌缺血心绞痛心肌梗死缺血性心肌病猝死,1979WHO,10,.,Classification,急性冠脉综合征（acutecoronarysyndrome,ACS）,不稳定型心绞痛（UA）（unstableangina）非ST段抬高心肌梗死（NSTEMI）（non-ST-segmentelevationmyocardialinfarction）ST段抬高心肌梗死（STEMI）（ST-segmentelevationmyocardialinfarction）,11,.,共同病理基础+不同程度的继发性病理改变,12,.,稳定型心绞痛,13,.,Definition,稳定型心绞痛是在冠状动脉狭窄的基础上，由于心肌负荷的增加引起心肌急剧的、暂时的缺血与缺氧的临床综合征。其特点为阵发的前胸压榨性疼痛感觉，主要位于胸骨后部，可放射至心前区和左上肢尺侧，常发生于劳力负荷增加时，持续数分钟，休息或用硝酸酯制剂后消失。,机制性质部位放射痛诱因持续时间缓解方式,14,.,Mechanisms,心率收缩压,15,.,Mechanisms,CoronaryFlowReserve=,coronarybloodPeakflow/Basalflow,Adenosine,StrenuousExercise：P/Bflow=67,Hypoxia：P/Bflow=45,16,.,Mechanisms,心肌细胞摄取血氧含量6575%其他组织仅摄取1025%Inthenormalstate,oxygeninthebloodismaximallyextractedbytheheartandanincreaseinmyocardialoxygendemandmustthereforebemetbyaproportionalincreaseinmyocardialbloodflow.,17,.,Mechanisms,demand,18,.,Mechanisms,19,.,ClinicalManifestations,20,.,性质,闷、憋、堵、胀、压迫或紧缩感,21,.,常见部位胸骨后,不常见部位,right,jaw,stomach,shoulder-blade,部位,UsuallyoccursdownthemedialaspectoftheleftarmAlsooccurtobotharms，throat，lowerjaw，back，betweentheshoulderbladesandepigastriumRarelythediscomfortmaystartdistally，inarms，elbows，andwrists，andradiatecentrallytowardthechestTheabsenceofradiationdoesnotexcludeadiagnosisofanginapectoris,放射痛,23,.,持续时间,35min,24,.,诱发因素,寒冷劳累饱餐吸烟情绪刺激心动过速休克贫血,缓解因素,STOP,A,Nitroglycerin,B,26,.,Signs,交感神经兴奋HR；BP；焦虑；皮肤冷；出汗,27,.,Signs,S3、S4GallopApicalsystolicmurmursIschemiaPapillarymuscledysfunction,Testing,ChestX-RayECGRestingElectrocardiogram（静息心电图）Normalinnearlyone-halfofpatientsOldmyocardialinfarction（OMI）NonspecificST-TchangedConductiondisturbance：LBBB,LAFB,29,.,Testing,30,.,31,.,OnsetECG（发作心电图）STsegmentdepression0.1mV（Horizontal，downwardsloping）（水平型，下斜型下移）Twaveinverted,32,.,33,.,34,.,Pseudo-normalizedTwaves（假正常化T波）：InpatientswithinvertedTwavesontheirrestingECG,normalizationoftheTwavemayoccurduringangina（正常静息T波倒置，心绞痛发作T波正常）,35,.,ExerciseECG踏板(Treadmill)、蹬车、二阶梯(Mastertest)Simple5、室上速可用洋地黄或直流电转复。,117,.,控制休克1、补充血容量中心静脉压18cmH2O肺小动脉楔压1518mmHg2、应用升压药；3、应用血管扩张剂肺小动脉楔压血压四肢厥冷。治疗心衰左心衰减轻后负荷，慎用（24h内）洋地黄治疗；右心衰慎用利尿剂,118,.,其它治疗促进心肌代谢药物；极化液：促进心肌摄取和代谢葡萄糖，使钾离子进入细胞内，恢复细胞膜极化状态；受体阻滞剂，钙通道阻滞剂和血管紧张素转换酶抑制剂;伴交感神经功能亢进者，小剂量使用,119,.,恢复期的处理34周出院，24个月恢复日常工作。右室梗死处理右心衰竭伴低血压，而无左心衰竭表现时宜扩张血容量。30006000ml/24h可用正性肌力药。无Q波心梗处理注意再梗