内科学概论心脏血管内科课件

1、內科學概論高雄醫學大學Lin CC心臟血管內科内科学概论心脏血管内科1內科學概論高雄醫學大學Lin CC心内科学概论心脏血管内科1血壓的形成收縮壓舒張壓LCC内科学概论心脏血管内科2血壓的形成收縮壓LCC内科学概论心脏血管内科2高血壓分類原發性高血壓 Primary Hypertension續發性高血壓 Secondary HypertensionLCC内科学概论心脏血管内科3高血壓分類原發性高血壓 LCC内科学概论心脏血管内科遺傳基因的影響鈉鹽的過度攝取Renin-Angiotensin system交感神經系統細胞膜的異常血管的增生肥厚內皮細胞功能異常胰島素抗性原發性高血壓致病機轉LCC内

2、科学概论心脏血管内科4遺傳基因的影響原發性高血壓致病機轉LCC内科学概论心脏續發性高血壓内科学概论心脏血管内科5續發性高血壓内科学概论心脏血管内科5高血壓的分類JNC7Normal 120 80Prehypertetnsion 120-139 or 80-89 Stage 1 hypertension 140-159 or 90-99Stage 2 hypertension 160 or100内科学概论心脏血管内科6高血壓的分類JNC7Normal Initial Measurements内科学概论心脏血管内科7Initial Measurements内科学概论心脏血管内血壓的測定基礎血壓隨時

3、血壓休息血壓LCC内科学概论心脏血管内科8血壓的測定基礎血壓LCC内科学概论心脏血管内科8Clinical pressureAmbulatory pressureHome pressure血壓的測定LCC内科学概论心脏血管内科9Clinical pressure血壓的測定LCC内科学概论Blood Pressure Measurement内科学概论心脏血管内科10Blood Pressure Measurement内科学概Ambulatory Measurement内科学概论心脏血管内科11Ambulatory Measurement内科学概论心脏血Advantages of Self-Mea

4、surement内科学概论心脏血管内科12Advantages of Self-Measurement高血壓臨床表現頭重 頭痛耳鳴 眼花 失眠頭頸部酸痛兩肩酸痛大部分沒有症狀 40歲 20%罹患高血壓隱形殺手LCC内科学概论心脏血管内科13高血壓臨床表現頭重 頭痛40歲 20%罹患高血壓隱形殺高血壓自然病程高血壓前期遺傳-環境因素惡性高血壓心臟大血管腎眼腦合併症高血壓高血壓早期年齡0-3020-4030-50LCC内科学概论心脏血管内科14高血壓自然病程高血壓前期惡性心臟大血管腎眼腦合併症高血壓高正確測量血壓外觀: 脂肪分布 皮膚 肌肉 及神智狀況眼底檢查頸部頚動脈及甲狀腺觸診聽診心臟大小節律

5、及心音異常肺有無囉音腹部腫瘤? 動脈雜音 股動脈搏動四肢動脈博動 水腫神經檢查 高血壓臨床檢查重點LCC内科学概论心脏血管内科15正確測量血壓高血壓臨床檢查重點LCC内科学概论心脏血管内科Laboratory tests内科学概论心脏血管内科16Laboratory tests内科学概论心脏血管内科16Optimal Tests内科学概论心脏血管内科17Optimal Tests内科学概论心脏血管内科17What is the target of BP with therapy?General: 140/90 mmHgDiabetes: 130/80 mmHgCHF or renal dise

6、ase: 30分鐘對舌下nitroglycerine反應不好急性心肌梗塞LCC内科学概论心脏血管内科51Ischemic Heart Disease胸痛流冷汗呼吸猝心絞痛 心肌梗塞Sudden death 心肌梗塞 Sudden death50%到達醫院前發生 ventricular fibrillation sudden death發生時機胸痛後4小時早期送醫電擊器的使用可以救命CPRLCC内科学概论心脏血管内科52猝心絞痛 心肌梗塞Sudden death 心肌梗塞冠狀動脈疾病心肌梗塞不穩定型心絞痛PTCA24%的男性和42%的女性會在發生心肌梗塞後的一年內死亡不穩定型心絞痛的病人在三個月

7、內的死亡率將近10 %進行PTCA的病人中 有40 %可能在六個月內需要再進行手術LCC内科学概论心脏血管内科53冠狀動脈疾病心肌梗塞24%的男性和42%的女性會在發生心肌梗 New Definition of MI-biochemistTroponin or CK-MB elevations are defined as 3xabove the normal (99% of normal)Total CK, SGOT, and LDH are not recommended(low specificity)Employ the full clinical picture to diagnos

8、e MI, not merely lab valuesLCC内科学概论心脏血管内科54 New Definition of MI-biochemiNew Definition of MI-ECGNon-ST segment elevation AMI Criteria are not adequate to define AMIST segment elevation AMINew ST elevation in 2 or more leads (0.2 In V1-V3)0.1 in other leadsLCC内科学概论心脏血管内科55New Definition of MI-ECGNon

9、-ST急性心肌梗塞 Acute MYOCARDIAL INFARCTIONST segment elevationPathologic Q waveLCC内科学概论心脏血管内科56急性心肌梗塞 Acute MYOCARDIAL INFARNew Definition of MI-established MIIn the absence of QRS confounders (BBB,LVH, WPW)Any Q wave in leads V1-V3Q waves must be 30 msec durationQ waves in other leads must have Qs in 2

10、contiguous leads (eg, II and III)Qs must be 1mm in depthLCC内科学概论心脏血管内科57New Definition of MI-establishNew Definition of MI-imageInfarct manifests itself as decreased wall motion by echo or hypoperfusion by radionuclide SPECTIschemia, stunning, and hibernation will produce similar changesLCC内科学概论心脏血管

11、内科58New Definition of MI-imageInfaUse of cardiac markers in ACSCardiac troponin after classical AMICK-MB after AMICardiac troponin aftermicroinfarctionDays after onset of AMILCC内科学概论心脏血管内科59Use of cardiac markers in ACSCChest painTroponin I/T, CK-MBECG changesEchocardiographyNuclear cardiologyCardia

12、c catheterization急性心肌梗塞-診斷LCC内科学概论心脏血管内科60Chest pain急性心肌梗塞-診斷LCC内科学概论心急性心肌梗塞 Acute MYOCARDIAL INFARCTIONHypokinesiaakinesiaHyperkinesiaLV aneurysmLV size EFMRLV thrombusLCC内科学概论心脏血管内科61急性心肌梗塞 Acute MYOCARDIAL INFAR急性心肌梗塞 Acute MYOCARDIAL INFARCTIONHypoperfusionLV systolic functionLV diastolic functi

13、onLCC内科学概论心脏血管内科62急性心肌梗塞 Acute MYOCARDIAL INFAR急性心肌梗塞-心導管Filling defectContrast造影劑LCC内科学概论心脏血管内科63急性心肌梗塞-心導管Filling defectContraMyocardial infarctionarrhythmiaLoss of muscleSudden deathVentricular remodelingVentricular dilationHeart failuredeathLCC内科学概论心脏血管内科64Myocardial infarctionarrhythmiLCC Throm

14、bin/FibrinPlateletthrombus内科学概论心脏血管内科65LCC Thrombin/FibrinPlateletthrPre-PCIASAStatinACEIClopidogrelPost-PCIASAStatinACEIClopidogrelGP IIb/IIIA Embolic protectionAnti-inflammatoryCoated stentPlaquerupturethrombusLCC内科学概论心脏血管内科66Pre-PCIPost-PCIGP IIb/IIIA PlReperfusionintervensionthrombolysisLCC内科学概论

15、心脏血管内科67ReperfusionintervensionthromboOptimal Strategy UA/NSTEMITIMI IIIB2002ConservativeInvasiveVANQWISHMATEFRISC IITACTICS-TIMI 18VINORITA-3TRUCS内科学概论心脏血管内科68Optimal Strategy UA/NSTEMITI急性心肌梗塞 Primary PTCAInitiate PTCA if available and suitableGoals: PTCA within 90 30 minLCC内科学概论心脏血管内科69急性心肌梗塞 Pri

16、mary PTCAInitiate P氣球擴張術内科学概论心脏血管内科70氣球擴張術内科学概论心脏血管内科70StentingStentingLCC網狀支架置放術内科学概论心脏血管内科71StentingStentingLCC網狀支架置放術内科学概Interventional CardiologypostStenting内科学概论心脏血管内科72Interventional CardiologypostSSites of Anti-thrombotic Drug ActionTissue factorPlasma clottingcascadeProthrombinThrombinFibrin

17、ogenFibrinThrombusPlatelet aggregationConformational activation of GPIIb/IIIaCollagenThromboxane A2ADPATATFactorXaCoagulationcascadePlateletcascade内科学概论心脏血管内科73Sites of Anti-thrombotic Drug PlaquerupturethrombusLCCFibrinThrombinPlateletFibrinolysisAntiplateletAnti-thrombin内科学概论心脏血管内科74Plaquethrombus

18、LCCFibrinThrombiTHROMBUSPLATELETAntiplatelet therapy-aspirin-clopidogrel-GP IIb/IIIa inhibitors-persantin-ticlopidineThrombinAntithrombin therapy-heparinFibrinPlasminogenActivators-t-PAR-PASKTNK-tPALCC内科学概论心脏血管内科75THROMBUSPLATELETAntiplatelet tStreptokinaseUrokinase内科学概论心脏血管内科76Streptokinase内科学概论心脏血

19、管内科76急性心肌梗塞 Thrombolysis一般原則胸痛12小時內ST segment elevation180/110 mmHg)History of PRIOR CVD or known INTRACEREBRAL PATHOLOGY Current use of ANTICOAGULANTS ( INR2-3 ) Known BLEEDING DIATHESISRECENT TRAUMA (Within 2-4 WKS) Including head injuryNONCOMPRESSIBLE VASCULAR PUNCTURESLCC内科学概论心脏血管内科83 FIBRINOLYS

20、IS RELATIVE CONTRNo benefitharmful20%40% Decreased mortalityNon-ST segment elevation ACSST segment elevation ACSPlaque ruptureACSThrombolysisLCC内科学概论心脏血管内科84No benefit20%40% Decreased No内科学概论心脏血管内科85内科学概论心脏血管内科85THROMBUSPLATELETAntiplatelet therapy-aspirin-clopidogrel-GP IIb/IIIa inhibitors-persanti

21、n-ticlopidineThrombinAntithrombin therapy-heparinFibrinPlasminogenActivators-t-PAR-PASKTNK-tPALCC内科学概论心脏血管内科86THROMBUSPLATELETAntiplatelet tAdhesionPlatelets Role in thrombosisAggregation1Activation23内科学概论心脏血管内科87AdhesionPlatelets Role in throGP IIb/IIIa Inhibitors1. Platelet Adhesion2. Platelet Act

22、ivationPlateletGP Ib Plaque ruptureActivated Platelet GP IIb/IIIa 3. Platelet AggregationASA, Clopidogrel/TiclopidineTxA2FibrinogenPlatelets Role in Thrombosis内科学概论心脏血管内科88GP IIb/IIIa Inhibitors1. PlatActs by selective inhibition of ADP binding to its platelet receptor and prevents subsequent platel

23、et aggregationADPADPFibrinogen Binding SiteClopidogrelClopidogrelFibrinogen Binding ReducedFibrinogenPlateletLCCClopidogrelmechanism of action内科学概论心脏血管内科89Acts by selective inhibition oPlatelet aggregationInhibition of aggregationby GP IIb/IIIa inhibitorsLCC内科学概论心脏血管内科90Platelet aggregationInhibitio

24、nThrombinSerotoninEpinephrineCollagenADPActivationTXA2ActivatedPlateletCOXDegranulationAspirinGp IIb/IIIa fibrinogenreceptorTo neighboringplateletClopidogrelTiclopidinePlatelet agonistsADPATPserotonincalciummagnesiumAdhesive proteinsthrombospondinfibrinogenp-selectinvWFCoagulation factorsfactor Vfac

25、tor XIPAI-1Inflammatory factorsplatelet factor 4CD 154 (CD 40 ligand)PDGFIV Gp IIb/IIIaInhibitors内科学概论心脏血管内科91ThrombinADPActivationTXA2ActivTHROMBUSPLATELETAntiplatelet therapy-aspirin-clopidogrel-GP IIb/IIIa inhibitors-persantin-ticlopidineThrombinAntithrombin therapy-heparinFibrinPlasminogenActiva

26、tors-t-PAR-PASKTNK-tPALCC内科学概论心脏血管内科92THROMBUSPLATELETAntiplatelet tUnfractionated heparinLow molecular weight heparinEnoxaparinDalteparinNadroparinDirect Thrombin inhibitorsHirudinBivalirudinwarfarinLCCAntithrombotic Treatment内科学概论心脏血管内科93Unfractionated heparinLCCAntitSites of Anti-thrombotic Drug

27、ActionTissue factorPlasma clottingcascadeProthrombinThrombinFibrinogenFibrinThrombusPlatelet aggregationConformational activation of GPIIb/IIIaCollagenThromboxane A2ADPATATAspirinTiclopidineClopidogrelGPIIb/IIIainhibitorsFactorXaBivalirudinHirudinArgatrobanLMWHHeparinThrombo-lyticsCoagulationcascade

28、Plateletcascade内科学概论心脏血管内科94Sites of Anti-thrombotic Drug MONAMorphine 靜脈注射Oxygen 4L/minNitroglycerine 舌下錠或噴劑Aspirin 160-325mg急性心肌梗塞 胸痛LCC内科学概论心脏血管内科95MONA急性心肌梗塞 胸痛LCC内科学概论心脏血管内科95急性心肌梗塞 Morphine解除胸痛鎮靜 減少焦慮每5-10分鐘 靜脈注射2-4mg低血壓病人平躺補充生理食鹽水液呼吸抑制Naloxone 0.4mg IV每三分鐘注射一次可重複三劑量LCC内科学概论心脏血管内科96急性心肌梗塞 Morp

29、hine解除胸痛低血壓LCC内科学概Management non-ST segment elevation ACSVery high15%intermediate38%Very high815%DeathMIAspirin heparinGP IIb/IIIaUrgent cathClopidogrel prior PCIAspirin LMWH GP IIb/IIIaClopidogrelCoronary angioAspirin LMWHIschemia-guided RxLCC内科学概论心脏血管内科97Management non-ST segment elevACC/AHA UA/NS

30、TEMI Guidelines Recommendations for Long-term Medical TherapyClass IAspirin 75 to 325 mg/dayClopidogrel 75 mg daily (in the absence of contraindications) when aspirin is not tolerated because of hypersensitivity or gastrointestinal intolerance The combination of aspirin and clopidogrel for 9 months after UA/NSTEMI-Blockers in the absence of contraindications Lipid-lowering agents and diet in post-ACS and postrevascularization patients with LDL-C 130 mg/dL Lipid-lowering agents if LDL-C level after diet is 100 mg/dLACE inhibitors for patients with CHF, LV dysfuncti