动脉粥样硬化、冠心病.ppt

心血管系统疾病动脉粥样硬化（Atherosclerosis,AS）,南方医科大学病理学系周洁,CaseReport,朱某，男，57岁。半年前，提水时突感胸骨后疼痛，同时伴左肩、左上臂疼痛，并有气急、肢体冷、面色苍白，出冷汗，经休息后缓解。以后，每当劳累后，上述症状时有发生并有加重。在医院检查时发现，血总胆固醇、脂蛋白。数周前上楼后，胸骨后剧痛，出现呼吸困难、咳粉红泡沫痰，今晨解大便时，突然昏倒，经抢救无效死亡。,尸检(autopsy)左冠状A前降支动脉粥样硬化,血栓形成，管腔闭塞。前壁心肌梗死Coronaryatherosclerosiswiththrombosisandinfarction,Coronaryatherosclerosiswiththrombosisandinfarction,血脂过多沉积于动脉内膜并形成坏死粥糜样物质的动脉硬化性疾病血脂异常及血管壁成分改变有关的动脉性疾病,Whatsatherosclerosis?,Howtounderstandatherosclerosis?,Cause:lipiddeposition脂质代谢障碍/内皮损伤Feature:gruelplaques坏死粥糜样物Site:large&middlevessels大中A,弹力肌型AOutcomes:ischemia管壁增厚变硬,管腔阻塞,器官缺血(心脑),Definition:动脉硬化(Arteriosclerosis)(HardeningofArteries)动脉粥样硬化(Atherosclerosis)大、中A,粥样硬化斑块动脉中膜钙化(MedialCalcificationSclerosis)颞A、四肢A,临床意义不大细动脉硬化(Arteriolosclerosis)Hyalinedegeneration高血压病,(1)脂斑脂纹（fattyspot&streak)黄色斑点或条纹,1.基本病变(basicpathology),fattypatch,fattyspot&plaque,Basicpathology:atherosclerosis,(2)纤维斑块（fibrousplaque）纤维增生,内膜表面突出灰白色斑块纤维帽(玻璃样变纤维,SMC)FC,SMC,基质,脂质,炎C,fibrousplaque,(3)粥样斑块(atheromatousplaque)“粥瘤”（atheroma）斑块内坏死黄色粥糜样物质,Basicpathology:atherosclerosis,Basicpathology:atherosclerosis,Basicpathology:atherosclerosis,Basicpathology:atherosclerosis,Basicpathology:atherosclerosis,表层纤维帽,大量胶原玻变,基质,SMC深部大量无定形坏死物,胆固醇结晶,钙化底周肉芽组织，少许FC、淋巴C中膜SMC萎缩变薄,弹力纤维破坏,Summary:morphologyofAS,复合病变(Complicatedlesion)斑块内出血斑块破溃血栓形成；钙化；动脉瘤形成,动脉粥样硬化出血(Hemorrhage),动脉粥样硬化溃疡(Ulceration),动脉粥样硬化血栓形成(Thrombosis),动脉粥样硬化钙盐沉积(Calcification),动脉粥样硬化动脉瘤(aneurysm),aneurysm,夹层动脉瘤形成(AortaDissectingAneurisms),Summary:复合病变(complicatedlesion),斑块内出血(Hemorrhage):斑块突大,阻塞斑块破裂(Rupture):溃疡形成(Ulceration)血栓形成(Thrombosis):附壁血栓,栓塞,梗死钙化(Calcification):A壁硬脆A瘤形成(Aneurysm):局限性扩张或壁内大血腔,2.主要动脉病变,(1)主动脉粥样硬化(AortaAS)部位腹主A,后壁,分支开口，病变主动脉瘤形成Rupture大出血致命,(2)冠状动脉粥样硬化(CoronaryAS),左冠状A前降支右冠状A干左冠状A旋支Outcomes心肌急剧暂时缺血心绞痛（Anginapectoris)严重持久缺血心肌梗死(Myocardialinfarction)慢性供血不足心肌硬化(Myocardialfibrosis)突然停搏,心室颤动心源性猝死(左室后壁，右室,室间隔后13左室侧壁,膈面,左房,2.心肌梗死(myocardialinfarction),AtheromawithThrombosis,Types:myocardialinfarction(MI),(1)心内膜下心肌梗死（SubendocardialMI）室壁内侧1/3,小灶多发,环状梗死三大支严重狭窄+诱因,(2)区域透壁心肌梗死(RegionaltransmuralMI)室壁全层,2.5cm,厚层梗死(2/3)某大支严重狭窄+血栓形成/痉挛,Lesion:myocardialinfarction(6h),Lesion:myocardialinfarction,Myocardialinfarction:凝固性坏死,生化变化(Biochemicalchanges)肌红蛋白释放血尿谷-草转氨酶（GOT）谷-丙转氨酶（GPT）(GOTGPT)肌酸磷酸激酶（CPK）(CK-MB)肌钙蛋白（cTnT/cTnI）,Myocardialinfarction,Complications:myocardialinfarction,乳头肌功能失调(Papillarymuscledysfunction)50%,1%(二尖瓣乳头肌断裂),二尖瓣关闭不全,心脏破裂(Ruptureofheart)1-3%左室前壁下1/3破裂心包填塞急死室间隔断裂(Septalrupture)血室入右右心功能不全,Papillarymusclerupture,Ruptureofheart,Complications:myocardialinfarction,室壁瘤(Ventricularaneurysm)10-30%薄弱局限性膨出无博动或反常搏动,室壁瘤(Ventricularaneurysm),Complications:myocardialinfarction,附壁血栓形成（Muralthrombosis）10%急性心包炎(Acutepericarditis)15-30%心力衰竭(Heartfailure)32-48%心源性休克(Cardiogenicshock)20%(40%)心律失常(Arrhythmia)75-95%,Muralthrombosis,Advanceinetiology&pathogenesisofatherosclerosis,RiskFactors,NonmodifiablemiddletolateAgeMaleSex,Genetic-Hyperchol.Familyhistory,PotentiallyModifiableHyperlipidemiaHDL/LDLratio.Hypertension.Smoking.Diabetes.,血流剪应力