冠心病完整(大医英)ppt课件

.,1,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,.,2,动脉粥样硬化atherosclerosis,.,3,Introduction,ArteriosclerosisThickeningandlossofelasticityofarterialwallsHardeningofthearteriesGreatestmorbidityandmortalityofallhumandiseasesviaNarrowingWeakening,.,4,PlaqueThatHasBeenSurgicallyRemovedfromCoronaryArtery,CourtesyRonaldD.GregoryandJohnRiley,MD.,.,5,NonModifiableRiskFactors,AgeAdominantinfluenceAtherosclerosisbeginsintheyoung,butdoesnotprecipitateorganinjuryuntillaterinlifeGenderMenmorepronethanwomen,butbyage60-70aboutequalfrequencyFamilyHistoryFamilialclusterofriskfactorsGeneticdifferences,.,6,ModifiableRiskFactors(potentiallycontrollable),HyperlipidemiaHypertensionCigarettesmokingDiabetesMellitusElevatedHomocysteineFactorsthataffecthemostasisandthrombosisInfections:Herpesvirus;ChlamydiapneumoniaeObesity,sedentarylifestyle,stress,.,7,PathogenesisofAtherosclerosis,ResponsetoinjuryhypothesisInjurytotheendothelium(dysfunctionalendothelium)ChronicinflammatoryresponseMigrationofSMCfrommediatointimaProliferationofSMCinintimaExcessproductionofECMEnhancedlipidaccumulation,.,8,Responsetoinjury,.,9,Endotheliadysfunction,.,10,InitiationofFattyStreak,.,11,FattyStreak,.,12,Fibro-fattyAtheroma,.,13,AtherosclerosisTimeline,FoamCells,FattyStreak,IntermediateLesion,Atheroma,FibrousPlaque,ComplicatedLesion/Rupture,AdaptedfromPepineCJ.AmJCardiol.1998;82(suppl104).,FromFirstDecade,FromThirdDecade,FromFourthDecade,.,14,AHAClassificationofatherosclerosis,.,15,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,.,16,CoronaryArteryDisease,冠心病,.,17,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）,.,18,ClassificationofIHD,Chronicischemicsyndrome:stableanginaasymptomaticCHDischemiccardiomyopathyCHDAcutecoronarysyndrome:unstableanginaSTEMI/NSTEMI,.,19,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,.,20,NoSTElevation,STElevation,AcuteCoronarySyndrome,UnstableAngina,NQMI,QwMI,NSTEMI,MyocardialInfarction,DaviesMJHeart83:361,2000,IschemicDiscomfort,Presentation,WorkingDx,ECG,Biochem.Marker,FinalDx,HammLancet358:1533,2001,.,21,ANGINAPECTORIS,.,22,DefinitionofAngina,Apainordiscomfortinthechestoradjacentareascausedbyinsufficientbloodflowtotheheartmuscle.,.,23,.,24,Clinicalclassificationandpathology,Stableangina:fixedatheromatousstenosisUnstableangina:dynamicobstructionbyplaquerupturewithsuperimposedthrombosisandspasm,.,25,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,.,26,Stableanginapectoris,.,27,ETIOLOGY,.Ischemiaissecondarytocoronaryarterydiseasein95%ofpatients.Theleadingcauseiscertainlyatheroscleroticcoronaryarterydisease.Adecreasedoxygensupplyoranincreaseinoxygendemandcanleadtoaworseningofsymptoms.Ischemiacanoccurinpatientswithnormalcoronaryarteries,.,28,Clinicalmenifestationchestdiscomfort,Quality-squeezing,griplike,pressurelike,suffocatingandheavy”;oradiscomfortbutnotpain.Anginaisalmostneversharporstabbing,andusuallydoesnotchangewithpositionorrespiration.Duration-anginalepisodeistypicallyminutesinduration.FleetingdiscomfortoradullachelastingforhoursisrarelyanginaLocation-usuallysubsternal,butradiationtotheneck,jaw,epigastrium,orarmsisnotuncommon.Painabovethemandible,belowtheepigastrium,orlocalizedtoasmallareaovertheleftlateralchestwallisrarelyanginal.Provocation-anginaisgenerallyprecipitatedbyexertionoremotionalstressandcommonlyrelievedbyrest.Sublingualnitroglycerinalsorelievesangina,usuallywithin30secondstoseveralminutes.,.,29,CategorizetheSeverityofAngina,.,30,Clinicalfeatures,PhysicalexaminationAnS4gallopmaybetransientlypresentduringanepisode,andthepatientmaybedyspneicordiaphoreticorhaveanewheartmurmur.High-riskfeaturesofanginaincludeheartfailureandhypotension.Acompletephysicalexamiscrucialinmakinganassessmentofrisk.Mostpt:(-),.,31,AlternativeDiagnosestoAnginaforPatientswithChestPain,Non-IschemicCVaorticdissectionpericarditisPulmonarypulmonaryemboluspneumothoraxpneumoniapleuritisChestWallcostochondritisfibrositisribfracturesternoclaviculararthritisherpeszoster,GastrointestinalEsophagealesophagitisspasmrefluxBiliarycoliccholecystitischoledocholithiasischolangitisPepticulcerPancreatitis,PsychiatricAnxietydisordershyperventilationpanicdisorderprimaryanxietyAffectivedisordersdepressionSomatiformdisordersThoughtdisordersfixedocclusions,.,32,Investigation,12LeadRestingECGshouldberecordedinallpatientswithsymptomssuggestiveofanginapectorisnormalin50%ofpatientsanormalECGdoesnotexcludesevereCAD;however,itdoesimplynormalLVfunctionwithfavorableprognosis,.,33,CHD,Atrest:,ECG,.,34,冠心病,Episodeofangina:ST-segmentdepression,ECG,.,35,CHD,Holter,.,36,Exercisetesting,.,37,Angina:ExerciseTestingHighRiskPatients,SignificantST-segmentdepressionatlowlevelsofexerciseand/orheartrate130FallinsystolicbloodpressureDiminishedexercisecapacityComplexventricularectopyatlowlevelofexercise,.,38,ExerciseTestingContraindications,MIimpendingoracuteUnstableanginaAcutemyocarditis/pericarditisAcutesystemicillnessSevereaorticstenosisCongestiveheartfailureSeverehypertensionUncontrolledcardiacarrhythmias,.,39,Investigation,Echocardiography.Thestressechocardiogramisawidelyperformedtestusedtoassesspatientsforcoronarydisease.Baselineechocardiographicimagesareobtainedatresttoevaluateleftventricularfunction,wallmotion,andvalvefunction.Imagesarethenacquiredduringpeakstress(thatis,duringaGXTorwithdobutamine)andcomparedwiththoseatrest.Regionalwall-motionabnormalitieswithstressindicateareasofhypoperfusionorischemia.,.,40,Investigation,Isotopescanning:obtainingscintiscansofthemyocardiumatrestandduringstressafteradministrationofanintravenousradioactiveisotopesuchasthallium201,.,41,Investigation,Coronaryangiography.Usedtoidentifyfociofcoronarydisease.Itistheevaluationofchoiceinpatientswithanginathatis(1)poorlyresponsivetomedication,or(2)unstable.ItisalsoindicatedinpatientswithtestresultsconsistentwithahighriskforCAD.,.,42,冠心病,Coronaryangiography,.,43,冠心病,冠状动脉造影,.,44,冠心病,LAD:stenosisLAD:normal,.,45,冠心病,RCA:stenosisLCX:stenosis,.,46,ChronicStableAnginaTreatmentObjectives,PreventprogressionofcoronaryarterydiseaseandoptimiselifeexpectancyRelievesymptoms,.,47,Management,Aspirinbeta-adrenoreceptorblockingagents(-blockers)calciumantagonistsNitrates,.,48,NCEPPrimaryCHDRiskGoalsforLoweringLDL-C,LDL-CGoal,NoCHD2RF,160mg/dL,NoCHD2RF,130mg/dL,CHD,100mg/dL,TheNCEPrecommendsloweringLDL-Cevenfurtherthanthesegoals,ifpossible.,RiskCategory,NHLBI;September1993,.,49,Coronaryrevascularisation,Invasivetreatment:coronaryangioplasty(PTCA);coronaryarterybypassgrafting(CABG),.,50,冠心病,CABG,.,51,冠心病,PTCA,.,52,冠心病,PTCA,BeforePTCAafterPTCA,.,53,冠心病,PTCA/S,.,54,Acutecoronarysyndrome,UnstableanginaNon-STelevationmyocardialinfarction(NSTEMI)STelevationmyocardialinfarction(STEMI),.,55,UnstableAngina/NSTEMI,.,56,UnstableAnginaClinicalPresentationandClassification,Diagnosisofunstableanginareferstoneworworseningsymptomsofmyocardialischemia:restanginanew-onsetsevereanginaincreasingangina,.,57,.,58,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.,.,59,UnstableAngina,Chestpainsyndrome,eithernewonsetorprogressiveanginaTransientST-segmentdepressionontheelectrocardiogram(ECG)WithoutevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponin,.,60,NSTEMI,Chestpainsyndrome,eithernewonsetorprogressiveanginaTransientorpersistentST-segmentdepressionontheelectrocardiogram(ECG)WithevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponin,.,61,UnstableAngina/NSTEMI,SignificantlikelihoodofoccurrenceofmajorcardiaceventsA.IncidenceofMI:8to10%B.Mortality:2to5%,.,62,UnstableAngina/NSTEMI:Pathophysiology,AcuteplaquefissuringandruptureSuperimposedthrombusTransientocclusionMediator-inducedvasospasmmaybepresent,.,63,DeterminantsofPlaqueVulnerability,Lipid-richcoresizeCapthicknessCapinflammationandrepair,.,64,.,65,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,.,66,PhysicalExaminaton,NotthathelpfulMayhaveevidenceofCHF:JVD,rales,edemaMayhaveS4Mayhavemurmurofmitralregurgitationfrompapillarymuscledysfunction,.,67,Investigation,ECGCardiacEnzymeorTroponinCoronaryangiography,.,68,.,69,AcuteCoronarySyndromes,.,70,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.,.,71,management,AdmittedtohospitalBestrest,OxygenAnti-platelet:asprin,Clopidogrel,GPIIb/IIIainhibitorsAnticoagulant:UFHorLMWHB-blocke