缺血性心脏病-教学201X1216ppt课件

.,北京大学人民医院心脏中心孙艺红,Coronary(Ischemic)HeartDisease冠心病缺血性心脏病,.,CHD,EpidemiologyPathophysiologyRiskfactorsandPreventionClinicalmanifestation,Diagnosisandmanagement,.,MostcommonformofheartdiseaseSinglemostimportantcauseofprematuredeath,Epidemiology,.,Epidemiology-USA,1/2deaths(1/2million)1.5millionMIeachyear45%MIunderage6550-100billion$peryear,.,.,Onein4men/onein5womendiefromCHD300000peoplehaveMIeachyear1.7millionpeoplehaveangina,Epidemiology-UK,.,TheincidenceofCHDEasternEuropeManydevelopingcountriesChinaIndia,Epidemiology,.,ProportionateMortalityfortheTenLeadingCausesofDeathinChina,1991-2001,HeJ11:1124-34,.,Pathophysiology,Almostalwaysduetoathromaanditscomplicationsparticularlythrombosis,.,OccasionallyotherdisordersCongenitalanomaliesAnomalousoriginFistular/MalformationofamajorcoronaryarteryAortitisPolyarteritisConnectivetissuedisorders,Pathophysiology,.,PathophysiologyAtheroma/Atherosclerosis,DiffuseddiseaseofthearterialwallCoronaryarteryathighriskCerebral/peripheralvasculardiseaseoftencoexistRadial/Internalmammaryarterylargelyspared,.,.,Plaquesbegintoappearin2ndand3rddecadeoflifeThenature/compositionofplaqueschanges,PathophysiologyPlaqueFormation1,.,Soldiersdiedinthekoreanwar,77.3%atherosclerosis39%occlusiveplaque,ENOSJAMA1953,300Casesautopsy(age,22.1y),.,TuzcuCirc1999,5.07mm2,EEMArea13.2mm2,AtheromaArea8.13mm2,Female,32y,Incidenceofatherosclerosisindonorheart,.,.,PathophysiologyPlaqueFormation2,.,Fattystreaksdevelopemigrateintointimatake-upoxidisedLDLfromplasmabecomelipid-ladenfoamcells,CirculatingMonocytes,PathophysiologyPlaqueFormation3,.,.,LipidPoolFoamcellsdieThecontentsrelease,PathophysiologyPlaqueFormation4,.,EarlyAtheromaSmoothmusclecellsmigrateintoproliferatewithinPlaque,PathophysiologyPlaqueFormation5,.,LesionGrowsEncroachesintolumenErodesmedia,PathophysiologyPlaqueFormation6,.,MatureFibrolipidPlaqueLipidcoreSurroundedbySMCFibrouscap,PathophysiologyPlaqueFormation7,.,PlagueRupture/FissureThrombosis+LocalspasmVesselOcclusionACS,Pathophysiology,PathophysiologyPlaqueRupture,.,CHDclinicalmanifestationandpathology,.,CHD:RiskFactors,FixedModifiableAgeLipiddisordersMaleSmokingFamilyhistoryDiabetesmellitusHypertensionObesitySedentarylifestyleDietarydeficienciesoffruitsandvegetablesalchole,IMPORTANTRISKFACTORSFORCORONARYARTERYDISEASE,.,PathophysiologyAtherosclerosis,.,PREVENTABLEANDCONTROLLABLEDISEASE,Every10MIpts，9PredictableEvery6MIpts，5Preventable,CHDPrevention,.,CHDPrevention,PrimaryPreventionSecondaryPrevention,.,ModifyRiskFactorsTherapeuticLifestyleChangeEvidence-basedoptimaldrugmanagement,CHDPrevention,.,PopulationAdviceTLC,DonotsmokeTakeregularexerciseMaintain“ideal”bodyweightEatamixeddietrichinfreshfruitandvegetablesAimtogetnomorethan30%ofenergyintakefromfatStresscontrol,CHDPrevention,.,Examplesofthebenefitsoflong-termsecondarypreventionfollowingmyocardialinfarction,PreventivemeasureEventspreventedper1000patientyearsSmokingcessation15deaths46non-fatalmyocardialinfarctions(Mls)Aspirin7deaths9non-fatalMls9non-fatalstrokes-adrenoceptor21deathsantagonist21non-fatalMlsStatins(HMGCoA7deathsreductaseinhibitors)12non-fatalMls3non-fatalstrokes11revascularisations4casesofheartfailureN.B.Eveninahigh-riskrimaryprevention(theWestofScotlandstudy),fourtimesasmanypeopleneededtobetreatedwithalipid-loweringagenttopreventacardiaceventcomparedtosecondaryprevention.,.,Optimalevidence-baseddrugtreatmentAnti-hypertensiondrugsLipid-lowerdrugstatinsAspirin-blockerACEI,CHDPrevention,.,ClinicalManifestationClassification,MyocardialIschemiaAnginaPectorisStableUnstableMyocardialInfarctionQ-Wavenon-Q-WaveSuddenDeath,.,ClinicalManifestationAnginaPectoris,DiscomfortduetotransientmyocardialischaemiaClinicalsyndromeratherthanadiseaseImbalance:O2supplyanddemand,.,FactorsInfluecingMyocardialO2SupplyandDemand,OxygendemandOxygensupplyCardiacworkCoronarybloodflow*HeartrateDurationofdiastoleBloodpressureCoronaryperfusionMyocardialcontractilitypressure(aorticdiastoliccoronarysinusorrightatrialdiastolicpressure)CoronaryvasomotortoneOxygenationHaemoglobinOxygensaturation*N.B.Coronarybloodflowoccursmainlyindiastole.,ClinicalManifestationAnginaPectoris,.,ClinicalManifestationAnginaPectoris:Causes,MostCommon:CoronaryAtheromaOthers:AorticstenosisHypertrophicCardiomyopathy,.,Case1,.,Casediscussion1,ClinicalfeaturesFemale,40yAtypicalchestpainNohistoryofHTN,dyslipidemiaanddiabetesECG:normalDiagnosisdecision?,.,Casediscussion1,ClinicalfeaturesFemale,40yAtypicalchestpainNohistoryofHTN,dyslipidemiaanddiabetesECG:normalDiagnosisdecisionSymptom,.,ClinicalManifestationSymptom,keyfactorinDiagnosismaking(Stable/UnstableAngina),.,ClinicalManifestationSymptom:StableAngina,Location:CentralRadiation:neck/jaw/armCharacteristics:Worseningfactors:“Start-upangina”,.,CLINICALSITUATIONSPRECIPITATINGANGINACommonPhysicalexertionColdexposureHeavymealsIntenseemotionRareLyingflat(decubitusangina)Vividdreams(nocturnalangina),ClinicalManifestationSymptom:StableAngina,.,ClinicalManifestationPhysicalExamination,FrequentlyNegativeBut:Acarefulsearchfor-ImportantRiskFactors-ContributoryDisease(obesity,anemia)-LVdysfunction:galloprhythm,murmur,.,Casediscussion1,ClinicalfeaturesFemale,40yAtypicalchestpainNohistoryofHTN,dyslipidemiaanddiabetesECG:normalDiagnosisdecisionSymptomNoncardiacchestpain,.,AnginaPectorisDifferentialDiagnosis,AcutemyocardialinfarctionXsyndromeCardiacNeurosis,.,ClinicalManifestationDifferentialDiagnosis,MusculoskeletalPericardialPainOesophageal,.,AnginaPectorisDifferentialDiagnosis,MusculoskeletalPainProvokedbyspecialmovementratherthanwalkingBackgroundpainoftenpersistsatrestAssociatedchestwalltendernessPainofPericarditisProvokedbychangesinpostureordeepinspirationPainDuetooesophagitiswithorwithouthiatusherniaBurningqualityRelievedbyantacids,.,Casediscussion1,ClinicalfeaturesFemale,40yAtypicalchestpainNohistoryofHTN,dyslipidemiaanddiabetesECG:normalDiagnosisdecisionSymptomNoncardiacchestpainTests,.,DiagnosisSpecialTest-ECG,RestingECGEvidenceofOMINormalinmostpatientsTwaveflattening/inversionNon-Specific!,.,DiagnosisSpecialTest-ECG,ThemostconvincingEvidenceREVERSIBLESTorwith/withoutTinversionDuringChestPain(Spontaneouslyorbyexercisetesting),.,DiagnosisSpecialTest-ETT,Treadmill/BicycleergometerConfirm/RefutediagnosisAssessSeverityofdiseaseIdentifyhighriskpatient,ExerciseToleranceTest,.,DiagnosisSpecialTest-ETT,.,DiagnosisSpecialTestIsotopeScanning,EvaluatingPtswithequivocal/uninterpretableETTPtsunabletoexercisePredictiveaccuracyETT,.,TechniqueScintiscanofMyocardiumAtrestandduringstress(ETTorDobutamine)AfterIVradioactiveisotope(201TI),DiagnosisSpecialTest-IsotopeScanning,.,IsotopeScanningTechniqueThallium-AnalogueofpotassiumTake-upbyviablemyocardium,DiagnosisSpecialTest-IsotopeScanning,.,Ischemia:duringstressPerfusiondefectReversiblenotatrestInfarction:PerfusiondefectPersistent,DiagnosisSpecialTest-IsotopeScanning,.,DiagnosisSpecialTest,VentricularFunctionRadionuclidebloodpoolscanningECHO,.,DiagnosisSpecialTest-MSCT,.,CoronaryArteriography,Extent/natureofCAD?DecidePTCA/CABGDiagnostic-AtypicalchestpainNon-invasivetestfailed,DiagnosisSpecialTest,.,Casediscussion1,ClinicalfeaturesFemale,40yAtypicalchestpainNohistoryofHTN,dyslipidemiaanddiabetesECG:normalDiagnosisdecisionSymptomNoncardiacchestpainTestsStresstestAngiographyCTA,.,Rapidworseningangina(Crescendo)SevereanginaatrestNew-onsetanginaPost-infarctionanginaWithoutevidenceofInfarction(ECG/Enzyme),ClinicalManifestationSymptom:UnstableAngina,.,ClinicalManifestationRiskstratificationinAngina,HighriskLowriskUnstableanginaPredictableexertionalanginaPost-infarctanginaPoorefforttoleranceGoodefforttoleranceIschaemiaatlowworkload(ETT)Ischaemiaonlyathighworkload(ETT)Leftmainorthree-vesseldiseaseSingle-vesselorminortwo-vesseldiseasePoorLVfunctionGoodLVfunctionN.B.Patientsmayfallbetweenthesecategories.,.,ManagementAnginaPectoris,RiskfactorscontrolSymptomsControlLifeexpectancyimprovement,.,ADVICETOPATIENTSWITHANGINADonotsmokeAimatidealbodyweightTakeregularexercise(Exerciseupto,butnotbeyond,thepointofchestpainisbeneficialandmaypromotecoll