冠心病 (2)课件.ppt

冠状动脉粥样硬化性心脏病 coronaryatheroscleroticheartdisease 牛楠 1 动脉粥样硬化atherosclerosis 2 Introduction ArteriosclerosisThickeningandlossofelasticityofarterialwallsHardeningofthearteriesGreatestmorbidityandmortalityofallhumandiseasesviaNarrowingWeakening 3 PlaqueThatHasBeenSurgicallyRemovedfromCoronaryArtery CourtesyRonaldD GregoryandJohnRiley MD 4 NonModifiableRiskFactors AgeAdominantinfluenceAtherosclerosisbeginsintheyoung butdoesnotprecipitateorganinjuryuntillaterinlifeGenderMenmorepronethanwomen butbyage60 70aboutequalfrequencyFamilyHistoryFamilialclusterofriskfactorsGeneticdifferences 5 ModifiableRiskFactors potentiallycontrollable HyperlipidemiaHypertensionCigarettesmokingDiabetesMellitusElevatedHomocysteineFactorsthataffecthemostasisandthrombosisInfections Herpesvirus ChlamydiapneumoniaeObesity sedentarylifestyle stress 6 PathogenesisofAtherosclerosis ResponsetoinjuryhypothesisInjurytotheendothelium dysfunctionalendothelium ChronicinflammatoryresponseMigrationofSMCfrommediatointimaProliferationofSMCinintimaExcessproductionofECMEnhancedlipidaccumulation 7 Responsetoinjury 8 Endotheliadysfunction 9 InitiationofFattyStreak 10 FattyStreak 11 Fibro fattyAtheroma 12 AtherosclerosisTimeline FoamCells FattyStreak IntermediateLesion Atheroma FibrousPlaque ComplicatedLesion Rupture AdaptedfromPepineCJ AmJCardiol 1998 82 suppl104 FromFirstDecade FromThirdDecade FromFourthDecade 13 AHAClassificationofatherosclerosis 14 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 15 CoronaryArteryDisease 冠心病 16 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 17 ClassificationofIHD Chronicischemicsyndrome stableanginaasymptomaticCHDischemiccardiomyopathyCHDAcutecoronarysyndrome unstableanginaSTEMI NSTEMI 18 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 19 NoSTElevation STElevation AcuteCoronarySyndrome UnstableAngina NQMI QwMI NSTEMI MyocardialInfarction DaviesMJHeart83 361 2000 IschemicDiscomfort Presentation WorkingDx ECG Biochem Marker FinalDx HammLancet358 1533 2001 20 ANGINAPECTORIS 21 DefinitionofAngina Apainordiscomfortinthechestoradjacentareascausedbyinsufficientbloodflowtotheheartmuscle 22 23 Clinicalclassificationandpathology Stableangina fixedatheromatousstenosisUnstableangina dynamicobstructionbyplaquerupturewithsuperimposedthrombosisandspasm 24 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 25 Stableanginapectoris 26 ETIOLOGY Ischemiaissecondarytocoronaryarterydiseasein95 ofpatients Theleadingcauseiscertainlyatheroscleroticcoronaryarterydisease Adecreasedoxygensupplyoranincreaseinoxygendemandcanleadtoaworseningofsymptoms Ischemiacanoccurinpatientswithnormalcoronaryarteries 27 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 28 CategorizetheSeverityofAngina 29 Clinicalfeatures PhysicalexaminationAnS4gallopmaybetransientlypresentduringanepisode andthepatientmaybedyspneicordiaphoreticorhaveanewheartmurmur High riskfeaturesofanginaincludeheartfailureandhypotension Acompletephysicalexamiscrucialinmakinganassessmentofrisk Mostpt 30 AlternativeDiagnosestoAnginaforPatientswithChestPain Non IschemicCVaorticdissectionpericarditisPulmonarypulmonaryemboluspneumothoraxpneumoniapleuritisChestWallcostochondritisfibrositisribfracturesternoclaviculararthritisherpeszoster GastrointestinalEsophagealesophagitisspasmrefluxBiliarycoliccholecystitischoledocholithiasischolangitisPepticulcerPancreatitis PsychiatricAnxietydisordershyperventilationpanicdisorderprimaryanxietyAffectivedisordersdepressionSomatiformdisordersThoughtdisordersfixedocclusions 31 Investigation 12LeadRestingECGshouldberecordedinallpatientswithsymptomssuggestiveofanginapectorisnormalin 50 ofpatientsanormalECGdoesnotexcludesevereCAD however itdoesimplynormalLVfunctionwithfavorableprognosis 32 CHD Atrest ECG 33 冠心病 Episodeofangina ST segmentdepression ECG 34 CHD Holter 35 Exercisetesting 36 Angina ExerciseTestingHighRiskPatients SignificantST segmentdepressionatlowlevelsofexerciseand orheartrate 130FallinsystolicbloodpressureDiminishedexercisecapacityComplexventricularectopyatlowlevelofexercise 37 ExerciseTestingContraindications MI impendingoracuteUnstableanginaAcutemyocarditis pericarditisAcutesystemicillnessSevereaorticstenosisCongestiveheartfailureSeverehypertensionUncontrolledcardiacarrhythmias 38 Investigation Echocardiography Thestressechocardiogramisawidelyperformedtestusedtoassesspatientsforcoronarydisease Baselineechocardiographicimagesareobtainedatresttoevaluateleftventricularfunction wallmotion andvalvefunction Imagesarethenacquiredduringpeakstress thatis duringaGXTorwithdobutamine andcomparedwiththoseatrest Regionalwall motionabnormalitieswithstressindicateareasofhypoperfusionorischemia 39 Investigation Isotopescanning obtainingscintiscansofthemyocardiumatrestandduringstressafteradministrationofanintravenousradioactiveisotopesuchasthallium201 40 Investigation Coronaryangiography Usedtoidentifyfociofcoronarydisease Itistheevaluationofchoiceinpatientswithanginathatis 1 poorlyresponsivetomedication or 2 unstable ItisalsoindicatedinpatientswithtestresultsconsistentwithahighriskforCAD 41 冠心病 Coronaryangiography 42 冠心病 冠状动脉造影 43 冠心病 LAD stenosisLAD normal 44 冠心病 RCA stenosisLCX stenosis 45 ChronicStableAnginaTreatmentObjectives PreventprogressionofcoronaryarterydiseaseandoptimiselifeexpectancyRelievesymptoms 46 Management Aspirinbeta adrenoreceptorblockingagents blockers calciumantagonistsNitrates 47 NCEPPrimaryCHDRiskGoalsforLoweringLDL C LDL CGoal NoCHD 2RF 160mg dL NoCHD 2RF 130mg dL CHD 100mg dL TheNCEPrecommendsloweringLDL Cevenfurtherthanthesegoals ifpossible RiskCategory NHLBI September1993 48 Coronaryrevascularisation Invasivetreatment coronaryangioplasty PTCA coronaryarterybypassgrafting CABG 49 冠心病 CABG 50 冠心病 PTCA 51 冠心病 PTCA BeforePTCAafterPTCA 52 冠心病 PTCA S 53 Acutecoronarysyndrome UnstableanginaNon STelevationmyocardialinfarction NSTEMI STelevationmyocardialinfarction STEMI 54 UnstableAngina NSTEMI 55 UnstableAnginaClinicalPresentationandClassification Diagnosisofunstableanginareferstoneworworseningsymptomsofmyocardialischemia restanginanew onsetsevereanginaincreasingangina 56 57 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 GrangerCB etal ArchinternMed 2003 163 2345 2353 EagleK atal JAMA 2004 291 2727 2733 58 UnstableAngina Chestpainsyndrome eithernewonsetorprogressiveanginaTransientST segmentdepressionontheelectrocardiogram ECG WithoutevidenceofmyocardialinfarctionbyCK CK MB orTroponin 59 NSTEMI Chestpainsyndrome eithernewonsetorprogressiveanginaTransientorpersistentST segmentdepressionontheelectrocardiogram ECG WithevidenceofmyocardialinfarctionbyCK CK MB orTroponin 60 UnstableAngina NSTEMI SignificantlikelihoodofoccurrenceofmajorcardiaceventsA IncidenceofMI 8to10 B Mortality 2to5 61 UnstableAngina NSTEMI Pathophysiology AcuteplaquefissuringandruptureSuperimposedthrombusTransientocclusionMediator inducedvasospasmmaybepresent 62 DeterminantsofPlaqueVulnerability Lipid richcoresizeCapthicknessCapinflammationandrepair 63 64 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 65 PhysicalExaminaton NotthathelpfulMayhaveevidenceofCHF JVD rales edemaMayhaveS4Mayhavemurmurofmitralregurgitationfrompapillarymuscledysfunction 66 Investigation ECGCardiacEnzymeorTroponinCoronaryangiography 67 68 AcuteCoronarySyndromes 69 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 GrangerCB etal ArchinternMed 2003 163 2345 2353 EagleK atal JAMA 2004 291 2727 2733 70 management AdmittedtohospitalBestrest OxygenAnti platelet asprin Clopidogrel GPIIb IIIainhibitorsAnticoagulant UFHorLMWHB blockerNitrates intravenous CCBStatinsACEICoronar