冠心病课件(大医).ppt

冠状动脉粥样硬化性心脏病 coronaryatheroscleroticheartdisease 大连医科大学附属二院心内科牛楠 动脉粥样硬化atherosclerosis Introduction ArteriosclerosisThickeningandlossofelasticityofarterialwallsHardeningofthearteriesGreatestmorbidityandmortalityofallhumandiseasesviaNarrowingWeakening PlaqueThatHasBeenSurgicallyRemovedfromCoronaryArtery CourtesyRonaldD GregoryandJohnRiley MD NonModifiableRiskFactors AgeAdominantinfluenceAtherosclerosisbeginsintheyoung butdoesnotprecipitateorganinjuryuntillaterinlifeGenderMenmorepronethanwomen butbyage60 70aboutequalfrequencyFamilyHistoryFamilialclusterofriskfactorsGeneticdifferences ModifiableRiskFactors potentiallycontrollable HyperlipidemiaHypertensionCigarettesmokingDiabetesMellitusElevatedHomocysteineFactorsthataffecthemostasisandthrombosisInfections Herpesvirus ChlamydiapneumoniaeObesity sedentarylifestyle stress PathogenesisofAtherosclerosis ResponsetoinjuryhypothesisInjurytotheendothelium dysfunctionalendothelium ChronicinflammatoryresponseMigrationofSMCfrommediatointimaProliferationofSMCinintimaExcessproductionofECMEnhancedlipidaccumulation Responsetoinjury Endotheliadysfunction InitiationofFattyStreak FattyStreak Fibro fattyAtheroma AtherosclerosisTimeline FoamCells FattyStreak IntermediateLesion Atheroma FibrousPlaque ComplicatedLesion Rupture AdaptedfromPepineCJ AmJCardiol 1998 82 suppl104 FromFirstDecade FromThirdDecade FromFourthDecade AHAClassificationofatherosclerosis 动脉粥样硬化血栓形成 具共同病理基础的进展性过程 正常 脂肪条纹 纤维斑块 粥样硬化斑块 斑块破溃 裂隙和血栓形成 心肌梗死 缺血性中风 TIA 严重的下肢缺血 临床无症状 心血管死亡 年龄增长 稳定性心绞痛间歇性跛行 不稳定性心绞痛 ACS ACS 急性冠脉综合征 TIA 一过性脑缺血发作 缺血性肾病缺血性肠病 CoronaryArteryDisease 冠心病 Clinicalclassification 1979WHO AsymptomaticCHD 隐匿型 AnginapectorisCHD 心绞痛型 MyocardialinfarctionCHD 心肌梗死型 IschemiccardiomyopathyCHD 缺血性心肌病型 SuddendeathCHD 猝死型 ClassificationofIHD Chronicischemicsyndrome stableanginaasymptomaticCHDischemiccardiomyopathyCHDAcutecoronarysyndrome unstableanginaSTEMI NSTEMI 急性冠脉综合症的病理生理学 Fusteretal NEnglJMed 1992 326 310 318 Daviesetal Circulation 1990 82 SupplII II 38 II 46 不稳定血栓 UA NSTEMI 脂肪池巨噬细胞内在的压力 张力外部的剪切力 裂缝 大裂缝 小裂缝 闭合血栓 STEMI 动脉粥样硬化斑块 斑块破裂 血栓 NoSTElevation STElevation AcuteCoronarySyndrome UnstableAngina NQMI QwMI NSTEMI MyocardialInfarction DaviesMJHeart83 361 2000 IschemicDiscomfort Presentation WorkingDx ECG Biochem Marker FinalDx HammLancet358 1533 2001 ANGINAPECTORIS DefinitionofAngina Apainordiscomfortinthechestoradjacentareascausedbyinsufficientbloodflowtotheheartmuscle Clinicalclassificationandpathology Stableangina fixedatheromatousstenosisUnstableangina dynamicobstructionbyplaquerupturewithsuperimposedthrombosisandspasm 斑块破裂引起急性严重事件 不稳定心绞痛 心肌梗死 猝死 稳定性 劳力性 心绞痛 不稳定斑块的进展过程 稳定斑块的进展过程 NissenSE AmJCardiol 2000 86 suppl 12H 17H 不稳定斑块 斑块破裂 血栓形成 稳定斑块 斑块体积增加 管腔狭窄 Stableanginapectoris ETIOLOGY Ischemiaissecondarytocoronaryarterydiseasein95 ofpatients Theleadingcauseiscertainlyatheroscleroticcoronaryarterydisease Adecreasedoxygensupplyoranincreaseinoxygendemandcanleadtoaworseningofsymptoms Ischemiacanoccurinpatientswithnormalcoronaryarteries Clinicalmenifestationchestdiscomfort Quality 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 CategorizetheSeverityofAngina Clinicalfeatures PhysicalexaminationAnS4gallopmaybetransientlypresentduringanepisode andthepatientmaybedyspneicordiaphoreticorhaveanewheartmurmur High riskfeaturesofanginaincludeheartfailureandhypotension Acompletephysicalexamiscrucialinmakinganassessmentofrisk Mostpt AlternativeDiagnosestoAnginaforPatientswithChestPain Non IschemicCVaorticdissectionpericarditisPulmonarypulmonaryemboluspneumothoraxpneumoniapleuritisChestWallcostochondritisfibrositisribfracturesternoclaviculararthritisherpeszoster GastrointestinalEsophagealesophagitisspasmrefluxBiliarycoliccholecystitischoledocholithiasischolangitisPepticulcerPancreatitis PsychiatricAnxietydisordershyperventilationpanicdisorderprimaryanxietyAffectivedisordersdepressionSomatiformdisordersThoughtdisordersfixedocclusions Investigation 12LeadRestingECGshouldberecordedinallpatientswithsymptomssuggestiveofanginapectorisnormalin 50 ofpatientsanormalECGdoesnotexcludesevereCAD however itdoesimplynormalLVfunctionwithfavorableprognosis CHD Atrest ECG 冠心病 Episodeofangina ST segmentdepression ECG CHD Holter Exercisetesting Angina ExerciseTestingHighRiskPatients SignificantST segmentdepressionatlowlevelsofexerciseand orheartrate 130FallinsystolicbloodpressureDiminishedexercisecapacityComplexventricularectopyatlowlevelofexercise ExerciseTestingContraindications MI impendingoracuteUnstableanginaAcutemyocarditis pericarditisAcutesystemicillnessSevereaorticstenosisCongestiveheartfailureSeverehypertensionUncontrolledcardiacarrhythmias Investigation Echocardiography Thestressechocardiogramisawidelyperformedtestusedtoassesspatientsforcoronarydisease Baselineechocardiographicimagesareobtainedatresttoevaluateleftventricularfunction wallmotion andvalvefunction Imagesarethenacquiredduringpeakstress thatis duringaGXTorwithdobutamine andcomparedwiththoseatrest Regionalwall motionabnormalitieswithstressindicateareasofhypoperfusionorischemia Investigation Isotopescanning obtainingscintiscansofthemyocardiumatrestandduringstressafteradministrationofanintravenousradioactiveisotopesuchasthallium201 Investigation Coronaryangiography Usedtoidentifyfociofcoronarydisease Itistheevaluationofchoiceinpatientswithanginathatis 1 poorlyresponsivetomedication or 2 unstable ItisalsoindicatedinpatientswithtestresultsconsistentwithahighriskforCAD 冠心病 Coronaryangiography 冠心病 冠状动脉造影 冠心病 LAD stenosisLAD normal 冠心病 RCA stenosisLCX stenosis ChronicStableAnginaTreatmentObjectives PreventprogressionofcoronaryarterydiseaseandoptimiselifeexpectancyRelievesymptoms Management Aspirinbeta adrenoreceptorblockingagents blockers calciumantagonistsNitrates NCEPPrimaryCHDRiskGoalsforLoweringLDL C LDL CGoal NoCHD 2RF 160mg dL NoCHD 2RF 130mg dL CHD 100mg dL TheNCEPrecommendsloweringLDL Cevenfurtherthanthesegoals ifpossible RiskCategory NHLBI September1993 Coronaryrevascularisation Invasivetreatment coronaryangioplasty PTCA coronaryarterybypassgrafting CABG 冠心病 CABG 冠心病 PTCA 冠心病 PTCA BeforePTCAafterPTCA 冠心病 PTCA S Acutecoronarysyndrome UnstableanginaNon STelevationmyocardialinfarction NSTEMI STelevationmyocardialinfarction STEMI UnstableAngina NSTEMI UnstableAnginaClinicalPresentationandClassification Diagnosisofunstableanginareferstoneworworseningsymptomsofmyocardialischemia restanginanew onsetsevereanginaincreasingangina 评估住院期间和出院后长期缺血风险 评估住院期间死亡风险 c index0 83 及出院后6个月死亡风险 c index0 81 多个大型数据库中验证其有效性 c indices分别为0 84 和0 75 评价死亡 再发心梗的长期风险 网络版可下载www outcomes umassmed org GRACE GrangerCB etal ArchinternMed 2003 163 2345 2353 EagleK atal JAMA 2004 291 2727 2733 UnstableAngina Chestpainsyndrome eithernewonsetorprogressiveanginaTransientST segmentdepressionontheelectrocardiogram ECG WithoutevidenceofmyocardialinfarctionbyCK CK MB orTroponin NSTEMI Chestpainsyndrome eithernewonsetorprogressiveanginaTransientorpersistentST segmentdepressionontheelectrocardiogram ECG WithevidenceofmyocardialinfarctionbyCK CK MB orTroponin UnstableAngina NSTEMI SignificantlikelihoodofoccurrenceofmajorcardiaceventsA IncidenceofMI 8to10 B Mortality 2to5 UnstableAngina NSTEMI Pathophysiology AcuteplaquefissuringandruptureSuperimposedthrombusTransientocclusionMediator inducedvasospasmmaybepresent DeterminantsofPlaqueVulnerability Lipid richcoresizeCapthicknessCapinflammationandrepair 斑块破裂引起急性严重事件 不稳定心绞痛 心肌梗死 猝死 稳定性 劳力性 心绞痛 不稳定斑块的进展过程 稳定斑块的进展过程 NissenSE AmJCardiol 2000 86 suppl 12H 17H 不稳定斑块 斑块破裂 血栓形成 稳定斑块 斑块体积增加 管腔狭窄 PhysicalExaminaton NotthathelpfulMayhaveevidenceofCHF JVD rales edemaMayhaveS4Mayhavemurmurofmitralregurgitationfrompapillarymuscledysfunction Investigation ECGCardiacEnzymeorTroponinCoronaryangiography AcuteCoronarySyndromes 评估住院期间和出院后长期缺血风险 评估住院期间死亡风险 c index0 83 及出院后6个月死亡风险 c index0 81 多个大型数据库中验证其有效性 c indices分别为0 84 和0 75 评价死亡 再发心梗的长期风险 网络版可下载www outcomes umassmed org GRACE GrangerCB etal ArchinternMed 2003 163 2345 2353 EagleK atal JAMA 2004 291 2727 2733 management AdmittedtohospitalBestrest OxygenAnti platelet asprin Clopidogrel GPIIb IIIainhibitorsAnticoagulant UFHorLMWHB blockerNit