内科护理学英语考试资料CoronaryArteryDisease

内科护理学英语考试资料CoronaryArteryDisease第1页/共31页CoronaryArteryDiseaseAtherosclerosis动脉粥样硬化isoftenreferredtoas“hardeningofthearteries”.Althoughthisconditioncanoccurinanyarteryinthebody,theatheromas血管硬化(fattydeposits)haveapreferenceforthecoronaryarteries.AterioscleroticHeartDisease(ASHD)动脉粥样硬化性心脏病,CardiovascularHeartDisease(CHD)心血管心脏病,andCoronaryArteryDisease(CAD)冠状动脉疾病aresynonymoustermsusedtodescribethisdiseaseprocess.第2页/共31页Etiologyandpathophysiology病因和病理生理

Atherosclerosis动脉粥样硬化isthemajorcauseofCAD.Itischaracterizedbyafocaldepositofcholesterol胆固醇andlipids血脂,primarilywithintheintimalwalloftheartery.Theconceptofendothelialinjury内皮损伤iscentraltocurrenttheoriesofatherogensis.Thegenesisofplague斑块

formationistheresultofcomplexinteractionsbetweenthecomponentsofthebloodandtheelementsformingthevascularwall.第3页/共31页第4页/共31页第5页/共31页Etiologyandpathophysiology病因和病理生理

Developmentstages发展过程CADtakesmanyyearstodevelops.Whenitbecomessymptomatic,thediseaseprocessisusuallywelladvanced.Thestatesofdevelopmentinatherosclerosisare:Fattystreak脂肪条纹Raisedfibrousplaqueresultingfromsmoothmusclecellproliferation纤维斑块增加Complicatedlesion复杂病变第6页/共31页第7页/共31页第8页/共31页第9页/共31页Riskfactors风险因素Threemostsignificantrisksare:elevatedserumlipids血脂,hypertensionandcigarettesmoking.RiskfactorscanbecategorizedasunmodifiableandmodifiableUnmodifiablefactors:Age,genderandraceFamilyhistoryandheredityModifiablemajorriskfactorsElevatedserumlipids血脂HypertensionSmokingPhysicalinactivityModifiableminorriskfactorsObesityDiabetesmellitus糖尿病Stressandbehaviorpatterns第10页/共31页Healthpromotionandmaintenance健康促进和维护Identificationofhigh-riskManagementofhigh-riskPhysicalfitnessHealtheducationNutritionalmanagementPharmacologicmanagementDrugsthatincreaselipoproteinremovalDrugsthatrestrictlipoproteinproduction第11页/共31页ClinicalmanifestationofCAD临床表现TherearethreemajorclinicalmanifestationofCAD:angina心绞痛acuteMI心肌梗死suddencardiacdeath猝死第12页/共31页Anginapectoris心绞痛Myocardialischemia心肌缺血isexpressedsymptomaticallyasangina心绞痛.Morespecifically,anginapectorisistransient短暂的chestpaincausedbymyocardialischemia心肌缺血.Anginausuallylastsforonlyafewminutes(3to5minutes)andcommonlysubsides解除whentheprecipitatingfactor(usuallyexertion)isrelieved.第13页/共31页PathophysiologyofAnginapectoris病理生理Myocardialischemiadevelopswhenthedemandformyocardialoxygenexceedstheabilityofthecoronaryarteriestosupplyit.Theprimaryreasonforinsufficientflowisnarrowingofcoronaryarteriesbyatherosclerosis.Forischemiaasaresultofatherosclerosistooccur,thearteryisusually75%ormorestenosed狭窄.第14页/共31页PathophysiologyofAnginapectoris病理生理Withthetotalocclusionofthecoronaryarteries,contractilityceasesafterseveralminutes,deprivingthemyocardialcellsofglucose葡萄糖foraerobicmetabolism有氧代谢.Anaerobicmetabolism无氧代谢beginsandlacticacid乳酸accumulates.Myocardialnervesfibersareirritatedbytheincreasedlacticacidandtransmitapainmessagetothecardiacnervesandupperthoracicposteriorroots上部胸椎神经后根(thereasonforreferredcardiacpaintotheleftshoulderandarm).第15页/共31页Precipitatingfactors激发因素Extracardiacfactorsmyprecipitatemyocardialischemiaandanginalpainincluding:PhysicalexertionStrongemotionConsumptionofaheavymealTemperatureextremesCigarettesmokingSexualactivityStimulantsCircadianrhythmpatterns昼夜节律模式第16页/共31页TypesofanginaStableangina稳定型心绞痛Stableangina(classic)referstochestpainoccurringintermittently间歇性overalongperiodwiththesamepatternofonset,duration,andintensityofsymptoms.Stableanginaisusuallyexerciseinduced.Painatrestisunusual.AnECGusuallyrevealsSTsegmentdepressionST段压低，indicatingsubendocardialischemia.Stableanginacanbecontrolledwithmedicationsonanoutpatientbasis.Medicationcanbetimedtoprovidedpeakeffectsduringthetimeofdaywhenanginaislikingtooccur.第17页/共31页Typesofangina2. Unstableangina不稳定型心绞痛Unstableangina(progressive进展的,cresendo渐强的,orpreinfarctionangina心肌梗死前心绞痛)maybethefirstmanifestationofCAD.Thepatientwithpreviouslydiagnosedstableanginawilldescribeasignificantchangeinthepatternofangina.Itwillbeoccurringwithincreasingfrequency,easilyprovokedbyminimalornoexercise,duringsleeporevenattotalrest.第18页/共31页Typesofangina3. Prinzmetal’sangina

变异型的心绞痛Prinzmetal’sangina(variantangina),isarareformofangina,oftenoccursatrest,usuallyinresponsetospasmofamajorcoronaryartery.Factorsprecipitatecoronaryspasmincludesincreasedmyocardialoxygendemandandincreasedlevelsofavarietyofsubstances(e.g.,histamine组胺,angiotensin血管紧张素,epinephrine肾上腺素,norepinephrine去甲肾上腺素,prostaglandins前列腺素)Whenspasmoccurs,thepatientexperiencepainandmarked,transientSTsegmentelevation.Thepainmayoccurduringrapideyemovement(REM)sleep快速眼动睡眠whenmyocardialoxygenconsumptionincreases.Cyclical周期性的,shortburstsofpainatausualtimeeachdaymayalsooccurwiththistypeofangina.第19页/共31页Clinicalmanifestation临床表现

Themostcommoninitialsymptomischestpainordiscomfort.Patientmayhadavaguesensation,anunpleasantfeeling,oftendescribedasaconstrictive缩窄,squeezing压缩,heavy,choking,orsuffocatingsensation.Althoughmostofthepersonwithanginaexperiencediscomfortsubsternally,thesensationmayoccurintheneckorradiate放射tovariouslocationsincludingjaw下巴,shouldersanddownthearms.Oftenpeoplewillcomplaintofpainbetweentheshoulderblades肩胛骨之间anddismissitasnotbeingheartpain.Associatedsymptomsmayincludes:shortnessofbreath,coolsweat,weakness,orparesthesia感觉异常ofthearm(s).Reliefofclassicanginaisusuallyobtainedwithrestorcessationofactivity.第20页/共31页Diagnosticstudies辅助检查ChestX-raySerumlipidCardiacenzymevaluesECGNuclearimagingAngiographyEchocardiography第21页/共31页EmergencymanagementchestpainEstablishandmaintainairwayAdministeroxygenbynasalcannulaifnotinrespiratorydistress;otherwiseusehighflow(100%)bynonbreathermask.AnticipateneedforintubationifrespiratorydistressevidentStart2IVlineswithlarge-gaugeneedlesRemoveclothing;comfortandreassurepatientMonitorcardiacrateandrhythm;monitorvitalsignsincludinglevelofconsciousnessBepreparedtoperformcardiopulmonaryresuscitation心肺复苏,defirbillation电除颤,externalpacingorcardioversion外部起搏或电复律Assessseverityandlocationofpain,medicateforpainasorderAssessforindicationsandcontraindicationsforthrombolytictherapyPreparetoinitiatethrombolytictherapy溶栓治疗ifindicated第22页/共31页TherapeuticmanagementPharmacologicmanagement药理管理Antiplateletaggregationtherapy抗血小板聚集治疗:isthefirstlineofpharmacologicinterventioninthetreatmentofangina.Aspirin阿司匹林isthedrugofchoice.Nitrates硝酸盐:whicharecommonlyclassifiedasvasodilators,arethenextstepinthetreatmentofangina.Nitroglycerin硝酸甘油:itisgivensublinguallyforacuteanginaattacks,usuallyrelievepaininapproximately3minutesandhasadurationofapproximately20to45minutes.Nitratesproducetheirprincipleeffectsbythefollowing:DilatingperipheralbloodvesselsDilatingcoronaryarteriesandcollateral侧支vessels第23页/共31页PharmacologicmanagementNitrates硝酸盐Theusualrecommendeddoseis1tablettakensublingually(SL)舌下,whichcanbefollowedat5-minuteintervalswithtwomoredoses.Ifrelieffromanginalpainhasnotbeenobtainedafter3tablesand15minutes,thepatientshouldbeinstructedtoseekmedicalattention.Thepredominantsideeffectofnitratedrugsisheadachefromthedilatationofcerebralbloodvessels.Othercomplicationsofthevasodilatordrugsareorthostatichypotension体位性低血压(nitratesyncope硝酸晕厥)andanaggravationofcerebralvascularinsufficiency.Thus,monitorBPandpulsepriortolong-actingnitratesadministration(ifBPis30mmHgbelowbaselineor<90mmHg,withholdmedicationandnotifythedoctors)。第24页/共31页Nitrates硝酸盐ThepatientneedstobeinstructedintheproperuseofsublingualnitroglycerinItshouldbeeasilyaccessibletothepatientatalltime.Forprotectionfromdegradation退化,itshouldbekeptinatightlycloseddarkglassbottlewithmetalcaps.Thepatientshouldbeinstructedtoplaceanitroglycerintablebeneaththetongueandallowittodissolve.Thisshouldcauseafizzingorslightlywarmfeelinglocally.ThepatientshouldbewarnedthatHRmayincreaseandapoundingheadache,dizziness头晕,orflushing脸红mayoccur.Thepatientshouldbecautionedagainstquicklyrisingtoastandingpositionbecauseposturalhypotensionmayoccurafternitroglyceriningestion.ifthepainhasnotbeenrelievedafter5minutes,thepatientshouldbetoldtotakeanothernitroglycerintablet.Thisproceduremayberepeatedforpainreliefevery5minutes,nottoexceedtheingestionof3tablets.Ifpainpersistafterthreedoses,thepatientshouldseekimmediatemedicaltreatment.第25页/共31页TherapeuticmanagementPharmacologicmanagementβ-adrenergicblockingagents:propranolol普奈洛尔,metoprolol美托洛尔,nadolol钠多洛而,atenolol阿替洛尔.Thesedrugsproduceadirectdecreaseinmyocardialcontractility,HR,SVRandBP,allofwhichreducethemyocardialoxygendemand.Sideeffectofthesedrugsincludesbrachycardia心动过缓,hypotension,wheezingandGIcomplaints,weightgain,depressionandsexualdysfunction.Theβ-adrenergicblockersshouldnotbediscontinuedabruptlywithoutmedicalsupervision.第26页/共31页PharmacologicmanagementCalcium-channelblockingagents:nifedipine硝本地平,verapimil维拉帕米,diltiazem地尔硫卓

andnicardipine尼卡地平arethenextstepinthemanagementofangina.Thethreeprimaryeffectsofthesedrugsare:SystemicvascularvasodilatationwithdecreasedSVRDecreasedmyocardialcontractility第27页/共31页Calcium-channelblockersCalcium-channelblockershaveadepressanteffectonthesinoatrial(SA)node窦房结rateofdischargeandtheconductionvelocity传导速度throughAVnode房室结isdecreased,thusslowingtheHR.Calcium-channelblockingagents地高辛potentiatetheactionofdigoxin地高辛byincreasingserumdigoxinlevelsduringtheearlypart(firstweek)oftherapy.Thereforeserumdigoxinlevelsshouldbecloselymonitoreduponinstitutionofthistherapy,andthepatientsh