冠心病课件(大医英)

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,suffocatingandheavy”;oradiscomfortbutnotpain.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,12LeadRestingECGshouldberecordedinallpatientswithsymptomssuggestiveofanginapectorisnormalin50%ofpatientsanormalECGdoesnotexcludesevereCAD;however,itdoesimplynormalLVfunctionwithfavorableprognosis,CHD,Atrest:,ECG,冠心病,Episodeofangina:ST-segmentdepression,ECG,CHD,Holter,Exercisetesting,Angina:ExerciseTestingHighRiskPatients,SignificantST-segmentdepressionatlowlevelsofexerciseand/orheartrate130FallinsystolicbloodpressureDiminishedexercisecapacityComplexventricularectopyatlowlevelofexercise,ExerciseTestingContraindications,MIimpendingoracuteUnstableanginaAcutemyocarditis/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,NoCHD2RF,160mg/dL,NoCHD2RF,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/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/GRACE,*GrangerCB,etal.ArchinternMed.2003;163:2345-2353.*EagleK,atal.JAMA.2004;291:2727-2733.,management,AdmittedtohospitalBestrest,OxygenAnti-platelet:asprin,Clopidogrel,GPIIb/IIIainhibitorsAnticoagulant:UFHorLMWHB-blockerNitrat