冠心病英文版ppt课件

.,Atherosclerosis339:229234.,0,5,10,15,20,25,30,35,40,45,50,EventsofMIin7years,NohistoryofMIOMINohistoryofMI*OMI,non-diabeticsdiabeticsn=1373n=1059,P65yrs8.Malegender/postmenopausalstate：male:female=2：1,mandevelopCHD10-15yrsearlierthanwoman9.alcohol10.Others:diet,homocysteine,hemostaticfactorsinflammation/infection,Riskfactorsandprevention,.,Drugtherapy：anti-platelet：aspirin,clopidogrel,GPIIb/IIIainhitibor,Dipyridamole,cilostazolLipid-lowering,Riskfactorsandprevention,.,HMG-CoAreductaseinhibitors（statins）Atorvastatin,Fluvastatin,Lovastatin,Pravastatin,Simvastatin,Cerivastatin,Rosuvastatin：*elevationofaminopherase,rhabdomyolysis2.Bileacid-bindingResinscholestyramine，colestipol3.NicotinicAcid：4.Fibricacidderivatives（fibrates）Gemifibrozil,clofibrate,Fenofibrate5.Cholesterolabsorptioninhibitors:ezetimibe6.Probucol,Lipid-loweringdrugs,.,PreventionofCAD,A:aspirin,ACEIB:bloodpressure,-blocker,C:cigarettesmoking,CholesterolD:diet,diabetesE:exercise,education,.,ThirdReportoftheNationalCholesterolEducationProgram(NCEP)ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdultsATPIII(adulttreatmentpanelIII)Circulation200217/24:3144-3373,Atherosclerosis,.,Coronaryheartdisease(CHD),.,Coronaryheartdisease(CHD),mostcommoncause:obstructionofatheromatousplaqueothercauses:spasmarterialthrombicoronaryemboliostialnarrowingduetolueticaortitiscongenitalabnormalitiessevereLVhypertrophy,.,Factorseffectmyocardialoxygensupplyanddemand,Oxygensupply,Oxygendemand,Heartrate,Myocardialcontractility,Systolicwallstress,oxygencarryingcapacityofblood,Coronarybloodflow,Vascularresistance,Extravascularcompressiveforces,autoregulation,Metabolicregulation,Humoralfactor,Neuralregulation,Durationofdiastole,Pressuregradient,Endothelialcontrol,.,Coronaryheartdisease,Type：slientischemia:delitescence：(ECGchange)Anginapectoris：angina,causedbymyocardialischemiamyocardialinfarction：acutemyocardialischemicnecrosiscausedbytheocclusionofcoronaryarteryIschemiacardiomyopathy(Heartfailureandarrhythmia)：cardiacenlargement,heartfailure,arrhythmia,causedbythemyocardialfibrosisastheconsequenceofchronicmycardialischemiaSuddendeath：suddencardiacarrestcausedbyventricularfibrillation/flutter,.,Coronaryheartdisease(CHD),Type：slientischemia:delitescenceAnginapectoris：myocardialinfarction：Ischemiccardiomyopathy(Heartfailureandarrhythmia)Suddendeath,.,AcuteCoronarySyndrome(ACS),Restingischemia,Non-STelevation,STelevation,Unstableangina,Non-QwaveAMI,QwaveAMI,*positiveserumcardiacmarkers,*,*,*,*,#,#occasionallyvariantangina,.,Stableanginapectoris(SAP),.,definition:acuteandtransientmyocardialischemiaandanoxaemiausuallycausedbycoronaryinsufficiencyduringexertionoremotionalstressCharacteristics:paroxysmalprecordialsqueezing-likechestpain,behindthemidsternum，radiatedtoleftshoulderandupperarmprecipitatedbystressorexertionduration:2-5mintypicallyrelievedrapidlybyrestornitrates,Stableanginapectoris,.,Coronarystenosis(others:aorticvalvedisease,HOCM,MB)+Myocardialoxygendemand（HRXSBP）increasedmyocardialhypoxiaacumulationofmetabolicproduct,stimulateC1-5nervetocausethesensationofchestpain,Stableanginapectoris,mechanism,.,inangiographySignificantcoronarylesionwithdiameterstenosis70%in75%ptsNosignificantstenosisinabout5-10%pts,Ischemiamayberelatedtocoronaryspasmormicrovasculardysfunction.,Pathology,Stableanginapectoris,.,pathophysiology,1.MetabolicandelectrophysiologyATPreduced,accumulationofacidsubstancesDysfunctionofironpump(Na+-K+,andNa+-Ca+)Earlydepolarization(STdeviation)2.LVfunctionandhemodynamicsituationLVcontractilityandspeed,systolicBP,strokevolume,cardiacoutputdecreasedLVEDpressureandvolume,Stunningofmyocardium,Stableanginapectoris,.,symptom：chestpainoroppressionlocationbehindorslightlytotheleftofthemidsternumnodefiniteborderlineradiatedtotheleftshoulderandupperarmAtypicallocation:lowerjaw,thebackofneck,Clinicalmanifestation,Stableanginapectoris,.,chestpaincharacteristics：tightness,squeezing,burning,pressing,choking,bursting,rarelysharp,notspasmodicforcethepatientstoptheactivitytillthesymptomrelievedprecipitationexertionoremotionalagitation。duration：35minspainrelief:withinseveralminsafterrestorusingnitroglycerin,Clinicalmanifestation,Stableanginapectoris,.,PhysicalexaminationincreasedHR,elevatedBPanxietysweatingoccasionallygalloprhythm，transientsystolicmurmur,Clinicalmanifestation,Stableanginapectoris,.,Laboratory,Stableanginapectoris,.,Stresstest,rest,Exerscise,Stableanginapectoris,.,2.Echocardiography:3.Radionuclideimagingassessment:TL201，Tc99m-sestamibimyocardialperfusionscintigraphy4.X-rayofheart5.coronaryangiography：finaldiagnose6.others:IVUS、intracoronaryDopplerflow、intracoronarypressure,Laboratory,Stableanginapectoris,.,CoronaryAngiography,.,1.Cardiogenicpain：aorticdissection,HOCM,aorticstenosis2.Respiratory：PE,pneumothorax,pleuritis3.Gastrointestinal:gastro-esophagealdiseases,Hiatalhernia,cholecystitis,pepticulceration,pancreatitis4.Neuromuscular/skeletal：TietzeSyndrome(Costochondritis),intercostalneuralgia,Herpeszoster5.Psychologic:anxiety,depression,panicattacks,Stableanginapectoris,Diagnosis,Chestpain,riskfactors,ECGevidenceofischemiaduringchestpain,angiography,Differentiation,.,FunctionalclassificationofSAP(CCS)CCSI：nochestpainatordinaryactivity.AnginaatstrenuousorrapidorprolongedexertionCCSII：Slightlimitationofordinaryactivity.Walkingorclimbingstairsrapidly,aftermeals,incold,inwind.Walkingmorethan2blocks,climbingmorethanstairsof3rdfloor.CCSIII：Markedlimitationofordinaryactivity.Walking1to2blocks,climbingstairsof3rdfloorCCSIV：Inabilitytocarryonanyactivitywithoutdiscomfortanginalsymdromemaybepresentatrest.,Stableanginapectoris,.,Generalconsideration：rest，avoidprovocativefactors,riskfactorscontrol2.Drugtherapy:preventMIanddeathsymptomreliefandqualityoflifeimprovment3.Coronaryrevascularization:percutaneouscoronaryintervention(PCI)Coronaryarterybypasssurgery(CABG)SVG,LIMA,Preventionandtreatment,Stableanginapectoris,.,antianginalandanti-ischemictherapy,Drugtherapy,Oxygensupply,Oxygendemand,a.nitratesb.beta-adrenergicblockersc.Calciumantagonistsd.Drugsimprovingmetabolism,Stableanginapectoris,.,Drugtherapy,a.nitratesloweroxygendemand:decreasearteriolarandvenoustone,reducepreloadandafterloadincreasecoronarysupply:CoronarydilatationNitroglycerinIsosorbidedinitrateisosorbide5-mononitrate(long-actingnitrates),Stableanginapectoris,.,b.blockers:reducemyocardialoxygen:reduceHR,myocardialcontractility,BP,theLVwallstressAbslutecontraindications：severbradycardia:high-degreeA-Vblock,SSS,severeunstableLVfailureRelativecontraindications:asthmaandbronchospasticdiseaseperipheralvasculardisease1-selective：metoprolol,atenolol,bisoprolol,Drugtherapy,Stableanginapectoris,.,c.Calciumantagonists：Increaseoxygensupply:dilateresistancevessels,releasespasm,improvemicrovascularfunctionDecreaseoxygendemand:negativeinotropiceffect,decreaseBPAntiplateleteffect,d.Drugsimprovingmetabolism：trimethazine（vasorel），selectivelyinhibit3-KAT（3-酮酰辅酶A硫解酶），partlyinhibitFAoxidation,Drugtherapy,Stableanginapectoris,.,preventMIanddeaththerapya.antiplateletangents：ASA，75-325mg/dclopidogrel;ticlopidine:ADPreceptor-antagonists:Cilostazol:phosphodiesteraseinhititor,50-100mgbidb.Lipid-loweringangents:statinsc.Angiotesin-convertingenzymeinhibitor(ACEI),Drugtherapy,Stableanginapectoris,.,stenting,Stableanginapectoris,.,Unstableangina(UAP)andnon-STEMI,.,Restingischemia,Non-STelevation,STelevation,Unstableangina,Non-QwaveAMI,QwaveAMI,*positiveserumcardiacmarkers,*,*,*,*,#,#occasionallyvariantangina,AcuteCoronarySyndrome(ACS),.,PathophysiologyofACS,stableanginaUAP284:835-42,TIMIIIB,ESSENCE,PRISM-PLUS,TACTICS-TIMI18,UAPandnon-STEMI,.,Treatment,1.Genearlmanagement:rest,oxygen,CCU2.DrugtherapyA.Anti-ischemicdrug:intravenously,orallynitrates-blockerCalciumantagnoist:firstchoiceforvariantanginaMorphine,UAPandnon-STEMI,.,Treatment,2.Drugtherapy:B.antithrombotictherapya.Anti-plateletAspirin:early,300mgloadingdoseADP-receptorantagonist:clopidogrel300mg-600mgloadingdose,75mg/dGPIIb/IIIareceptorinhibitor:usedinptsplannedtoPCIb.Anticoagulationtherapy:HeparinLowmolecularweightheparin(LMWH)Directanti-thrombindrug:bivalirudin,hirudin,UAPandnon-STEMI,.,Treatment,2.Drugtherapy:C.othermedicaltherapya.lipid-loweringdrugs:statins,earlyuse(infirst24hrs)LDL-ctarget:30mins，lesseffectiveofsublingualnitroglycerin,retrosternalinlocation,sweating,scared,andfeelingofimpendingdeathinsomepatients,AMIismanifestedbyshockandacuteLVfailure,notbychestpain(theelderly)alerttheepigastriumpainandabdominaldisorders,STEMI,Clinicalmanifestation,.,symptomsGeneral：fever、HRincrease、WBC，ESRfastingGastrointestinalsymptom：nausea,vomiting,arrhythmias：VPs、AVblock,atrialarrhythmiasoccurredmoreofteninpatientswithHFHeartfailure:mainlyacuteLVfailure,maydevelopeRVfailure.InitialRVfailureoccureinpatientswithRVinfarction,associatedwithhypotensionHypotensionandshock：SBP18.CI2.2；ClassIII:peripheralhypoperfusion,PCWP18,CI0.2mVinatleasttwocontiguousleads;neworpresumablynewLBBB3.Timefromonsetofsymptoms12hrs：diminishingbenefitsbutmaystillbeusefulinselectedpatinets4.age180/110mmHgonatleasttworeading2.Historyofchronic,severehypertensionwithorwithoutdrugtherapy3.activepepticulcer4.Historyofcerebrovascularaccident5.Knownbleedingdiathesisorcurrentuseofanticoagulants6.Prolongedortraumaticcardiopulmonaryresuscitation7.Diabetichemorrhageretinopathyorotherhemorrhageophthalmiccondition8.priorexposuretoSKorAPSAC（thiscontraindicationisparticularlyimportantintheinitial6-to9-monthperiodafterSKorAPSACadministrationandappliestoreuseofanySK-containingagentbutdoesnotapplytot-PAorUK,CriteriaforthrombolysisinSTEMI,.,JudgementofthepatencyDirect：coronaryangiographyTIMIflowgrade2-3Indirect：ReturnoftheelevatedST50%within2hrsReliefofchestpainwithin2hrs；3.Reperfusionarrhythmias,within2hrs：prematureventricularrhythm,accelratedidioventricularrhythm,non-sustainedventriculartachycardia,transientbradycardia,A-Vblock4.peakserumcardiacenzymeoccurredearly,within14hrs,thrombolysisinSTEMI,.,Managementofcomplication1.arrhythmiaVentriculartachycardia：ivlidocaine,amidarone,beta-blockerVF：defibrillationbradyca