冠心病大医英

冠状动脉粥样硬化性心脏病(coronary atherosclerotic heart disease),大连医科大学附属二院心内科 牛 楠,动脉粥样硬化atherosclerosis,Introduction,Arteriosclerosis Thickening and loss of elasticity of arterial walls Hardening of the arteries Greatest morbidity and mortality of all human diseases via Narrowing Weakening,Plaque That Has Been Surgically Removed from Coronary Artery,Courtesy Ronald D. Gregory and John Riley, MD.,Non Modifiable Risk Factors,Age A dominant influence Atherosclerosis begins in the young, but does not precipitate organ injury until later in lifeGender Men more prone than women, but by age 60-70 about equal frequencyFamily History Familial cluster of risk factors Genetic differences,Modifiable Risk Factors (potentially controllable),Hyperlipidemia Hypertension Cigarette smoking Diabetes Mellitus Elevated Homocysteine Factors that affect hemostasis and thrombosis Infections: Herpes virus; Chlamydia pneumoniae Obesity, sedentary lifestyle, stress,Pathogenesis of Atherosclerosis,Response to injury hypothesis Injury to the endothelium(dysfunctional endothelium)Chronic inflammatory responseMigration of SMC from media to intimaProliferation of SMC in intimaExcess production of ECMEnhanced lipid accumulation,Response to injury,Endothelia dysfunction,Initiation of Fatty Streak,Fatty Streak,Fibro-fatty Atheroma,Atherosclerosis Timeline,FoamCells,FattyStreak,IntermediateLesion,Atheroma,FibrousPlaque,ComplicatedLesion/Rupture,Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104).,From FirstDecade,From ThirdDecade,From FourthDecade,AHA Classification of atherosclerosis,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,Coronary Artery Disease,冠心病,Clinical classification(1979 WHO),Asymptomatic CHD(隐匿型）Angina pectoris CHD（心绞痛型）Myocardial infarction CHD(心肌梗死型）Ischemic cardiomyopathy CHD（缺血性心肌病型）Sudden death CHD（猝死型）,Classification of IHD,Chronic ischemic syndrome: stable angina asymptomatic CHD ischemic cardiomyopathy CHDAcute coronary syndrome: unstable angina STEMI/NSTEMI,急性冠脉综合症的病理生理学,Fuster et al. N Engl J Med. 1992;326:310-318.Davies et al. Circulation. 1990;82(Suppl II):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,No ST Elevation,ST Elevation,Acute Coronary Syndrome,Unstable Angina,NQMI,Qw MI,NSTEMI,Myocardial Infarction,Davies MJ Heart 83:361, 2000,Ischemic Discomfort,Presentation,Working Dx,ECG,Biochem. Marker,Final Dx,Hamm Lancet 358:1533,2001,ANGINA PECTORIS,Definition of Angina,A pain or discomfort in the chest or adjacent areas caused by insufficient blood flow to the heart muscle.,Clinical classification and pathology,Stable angina:fixed atheromatous stenosisUnstable angina:dynamic obstruction by plaque rupture with superimposed thrombosis and spasm,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,Nissen SE. Am J Cardiol. 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,Stable angina pectoris,ETIOLOGY,.Ischemia is secondary to coronary artery disease in 95% of patients. The leading cause is certainly atherosclerotic coronary artery disease.A decreased oxygen supply or an increase in oxygen demand can lead to a worsening of symptoms. .Ischemia can occur in patients with normal coronary arteries,Clinical menifestationchest discomfort,Quality - squeezing, griplike, pressurelike, suffocating and heavy”; or a discomfort but not pain. Angina is almost never sharp or stabbing, and usually does not change with position or respiration. Duration - anginal episode is typically minutes in duration. Fleeting discomfort or a dull ache lasting for hours is rarely anginaLocation - usually substernal, but radiation to the neck, jaw, epigastrium, or arms is not uncommon. Pain above the mandible, below the epigastrium, or localized to a small area over the left lateral chest wall is rarely anginal. Provocation - angina is generally precipitated by exertion or emotional stress and commonly relieved by rest. Sublingual nitroglycerin also relieves angina, usually within 30 seconds to several minutes.,Categorize the Severity of Angina,Clinical features,Physical examinationAn S4 gallop may be transiently present during an episode, and the patient may be dyspneic or diaphoretic or have a new heart murmur.High-risk features of angina include heart failure and hypotension. A complete physical exam is crucial in making an assessment of risk.Most pt:(-),Alternative Diagnoses to Angina for Patients with Chest Pain,Non-Ischemic CVaortic dissectionpericarditisPulmonarypulmonary emboluspneumothoraxpneumoniapleuritisChest Wallcostochondritisfibrositisrib fracturesternoclavicular arthritisherpes zoster,GastrointestinalEsophagealesophagitisspasmrefluxBiliarycoliccholecystitischoledocholithiasischolangitisPeptic ulcerPancreatitis,PsychiatricAnxiety disordershyperventilationpanic disorderprimary anxietyAffective disordersdepressionSomatiform disordersThought disordersfixed occlusions,Investigation,12 Lead Resting ECG should be recorded in all patients with symptoms suggestive of angina pectorisnormal in 50% of patientsa normal ECG does not exclude severe CAD; however, it does imply normal LV function with favorable prognosis,CHD,At rest:,ECG,冠心病,Episode of angina:ST-segment depression,ECG,CHD,Holter,Exercise testing,Angina: Exercise TestingHigh Risk Patients,Significant ST-segment depression at low levels of exercise and/or heart rate130Fall in systolic blood pressureDiminished exercise capacityComplex ventricular ectopy at low level of exercise,Exercise TestingContraindications,MIimpending or acuteUnstable anginaAcute myocarditis/pericarditisAcute systemic illnessSevere aortic stenosisCongestive heart failureSevere hypertensionUncontrolled cardiac arrhythmias,Investigation,Echocardiography.The stress echocardiogram is a widely performed test used to assess patients for coronary disease.Baseline echocardiographic images are obtained at rest to evaluate left ventricular function, wall motion, and valve function.Images are then acquired during peak stress (that is, during a GXT or with dobutamine) and compared with those at rest. Regional wall-motion abnormalities with stress indicate areas of hypoperfusion or ischemia.,Investigation,Isotope scanning:obtaining scintiscans of the myocardium at rest and during stress after administration of an intravenous radioactive isotope such as thallium 201,Investigation,Coronary angiography. Used to identify foci of coronary disease. It is the evaluation of choice in patients with angina that is (1) poorly responsive to medication, or (2) unstable. It is also indicated in patients with test results consistent with a high risk for CAD.,冠心病,Coronary angiography,冠心病,冠状动脉造影,冠心病,LAD:stenosis LAD:normal,冠心病,RCA:stenosis LCX:stenosis,Chronic Stable Angina Treatment Objectives,Prevent progression of coronary artery disease and optimise life expectancyRelieve symptoms,Management,Aspirinbeta-adrenoreceptor blocking agents (-blockers)calcium antagonistsNitrates,NCEP Primary CHD Risk Goals for Lowering LDL-C,LDL-C Goal,No CHD 2 RF,160 mg/dL,No CHD 2 RF,130 mg/dL,CHD,100 mg/dL,The NCEP recommends lowering LDL-C even further than these goals, if possible.,Risk Category,NHLBI; September 1993,Coronary revascularisation,Invasive treatment: coronary angioplasty (PTCA); coronary artery bypass grafting (CABG),冠心病,CABG,冠心病,PTCA,冠心病,PTCA,Before PTCA after PTCA,冠心病,PTCA/S,Acute coronary syndrome,Unstable anginaNon-ST elevation myocardial infarction (NSTEMI)ST elevation myocardial infarction(STEMI),Unstable Angina/NSTEMI,Unstable AnginaClinical Presentation and Classification,Diagnosis of unstable angina refers to new or worsening symptoms of myocardial ischemia:rest anginanew-onset severe anginaincreasing angina,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-index 0.83)* 及出院后6个月死亡风险 (c-index 0.81)* 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,*Granger CB, et al. Arch intern Med. 2003;163:2345-2353.*Eagle K, at al. JAMA. 2004;291:2727-2733.,Unstable Angina,Chest pain syndrome, either new onset or progressive angina Transient ST-segment depression on the electrocardiogram (ECG)Without evidence of myocardial infarction by CK, CK-MB, or Troponin,NSTEMI,Chest pain syndrome, either new onset or progressive angina Transient or persistent ST-segment depression on the electrocardiogram (ECG)With evidence of myocardial infarction by CK, CK-MB, or Troponin,Unstable Angina/NSTEMI,Significant likelihood of occurrence of major cardiac eventsA. Incidence of MI: 8 to 10%B. Mortality: 2 to 5%,Unstable Angina/NSTEMI:Pathophysiology,Acute plaque fissuring and ruptureSuperimposed thrombusTransient occlusionMediator-induced vasospasm may be present,Determinants of Plaque Vulnerability,Lipid-rich core sizeCap thicknessCap inflammation and repair,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,Nissen SE. Am J Cardiol. 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,Physical Examinaton,Not that helpfulMay have evidence of CHF: JVD, rales, edemaMay have S4May have murmur of mitral regurgitation from papillary muscle dysfunction,Investigation,ECGCardiac Enzyme or TroponinCoronary angiography,Acute Coronary Syndromes,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-index 0.83)* 及出院后6个月死亡风险 (c-index 0.81)* 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,*Granger CB, et al. Arch intern Med. 2003;163:2345-2353.*Eagle K, at al. JAMA. 2004;291:2727-2733.,management,Admitted to hospitalBest rest,OxygenAnti-platelet:asprin, Clopidogrel , GP IIb/IIIa inhibitors Anticoagulant: UFH or LMWHB-blocker Nitrates (intr