1心血管系统疾病概述2014

INTRODUCTIONofCARDIOVASCULARDISEASE

JiananWangSecondAffiliatedHospital,ZJUSMGeneralityCardiovascularsystem:heart,vessels,nervous-fluidsystem,etal.Function:transportation,neuroendocrineCardiovasculardisease:heartdiseaseandvasculardiseaseClassificationCongenitalheart

&

vasculardiseaseAcongenitalheartdefect(CHD)isadefectinthestructureoftheheartandgreatvesselsofanewborn.Acquiredheart

&

vasculardisease

(AHD):1.

Atherosclerosis；2.

RheumaticHeartdisease；3.

PrimaryHypertension；4.

Pulmonaryheartdisease；5.

Septicheartdisease；6.

Endocriticheartdisease；7.

Hemopathologicalheartdisease；8.Nutritionalandmetabolicheartdisease；9.Cardiovascularneurosis；10.

OthersPathogenicPathoanatomicPathophysiologicalClassificationEndocardicdiseaseMyocardialdiseasePericardialdiseaseVasculardiseaseCongenitalmalformationdiseasePathogenicPathoanatomicPathophysiologicalClassificationHeartfailureShockCononarydysfunctiondiseaseMuscuilpapillaresdysfunctionArrhythmiaHyperdynamiccirculationTemaponadeOthersPathogenicPathoanatomicPathophysiologicalCardiovasculardiseaseistheleadingcause

of

deathWHOStatistics2008TumorPhlmonary

DiseaseDigestive

DiseaseEndocrine

DisorderNueropsychiatric

DisorderUrogenital

DiseaseCongenital

DseaseMusculoskeletal

DisorderOthersCVDImpact

ofcardiovasculardisease

≥70millionAmericansareestimatedtohaveoneormoretypesofCVD

65millionhavehypertension

13millionhaveCHD

5.4millionhavehadastroke

≥8millionhavePAD

Overall,aboutoneinfourAmericanscurrentlyhavesomeformofCVDCVDcontributestoabout1.4milliondeathsannuallyintheUnitedStates,or40%ofalldeaths

Approximately32%ofCVDdeathsoccurprematurely(i.e.,inpersons<75yearsold)

Eachyear,about1.2millionAmericanshaveaneworrecurrentmyocardialinfarction(MI),andmorethan40%oftheseeventsarefatal

Theannualincidenceofneworrecurrentstrokeisabout700,000peryear,andabout275,000AmericansdiefromastrokeeachyearImpact

ofcardiovasculardiseaseEpidemiologyRiskFactorsTRADITIONAL(ESTABLISHED)NOVEL(LESS

ESTABLISHED)ModifiableHypertensionSocioeconomic

statusDiabetesPsychological

factorsDyslipidemiaInflammatory

markersSmokingInfectionObesityHomocysteinePhysical

inactivityThrombotic

factorsKidney

dysfunction/damageNatriuretic

peptideLeft

ventricular

hypertrophyTroponinAlcoholAtrial

fibrillation*NonmodifiableAgeGenetic

polymorphismGenderCoronary

artery

calcificationEthnicityFamily

historyCARDINALSYMPTOMSOFCARDIOVASCULARDISEASEChestpainordiscomfortDyspnea,orthopnea,paroxysmalnocturnaldyspnea,wheezingPalpitations,dizziness,syncopeCough,hemoptysisFatigue,weaknessPaininextremitieswithexertion(claudication)Historymatters!ProvocativeandPalliativefactors:Whatmakesbetterorworse?Quality:VisceralvssomaticRegionandRadiation:Central,left,orright

ToBack,neck,armSeverity:Scaleof1-10Timing:GradualorsuddenonsetAssociatedsymptoms:SOB,sweating,nauseaPotentiallylife-threateningconditionsAcutemyocardialinfarctionUnstableanginaAorticdissectionPulmonaryedemaPulmonaryembolismCAUSESOFCHESTPAINLocation

&

Radiation,Quality,

Duration,AggravatingorRelievingFactors,AssociatedSymptomsorSignsCARCIOVASCULARNONCARDIACAnginaPneumonia

with

pleurisyMyocardial

infarcionSpontaneous

pneumothoraxPericarditisMusculoskeletal

disordersAortic

dissectionHerpes

zosterPulmonary

embolismEsophageal

refluxPeptic

ulcerGallbladder

diseaseAnxiety

statusDyspneaTiming,

position,

quality

of

sensation,

persistent

vs.

intermittentEvidence

of

airways

obstruction?Hyperinflation?Assess

air

movement

and

quality

of

breath

soundsCardiac

exam—volume

overload?Evidence

of

heart

failure?Extremities—DVT?Edema?Oximetry:

evidence

of

desaturation?If

suspicion

of

low

CO:

myocardial

ischimia,

or

pulmonary

vascular

diseaseChest

radiograhAssess

cardiac

size

and

evidence

of

CHFAssess

for

pneumonia,

interstitial

lung

disease,

pleural

effusionsIf

suspicion

of

respiratory

pump

or

gas

exchange

abnomalityIf

suspicion

of

high

cardiac

outputECG

and

echocardiogram

to

assess

left

ventricle

and

pulmonary

artery

pressureABGPulmonary

function

testing

(spirometry,

lung

volumes,

diffusing

capacity)

if

DLCO

reduced:

ABGHCT,

thyroid

function

testsABGHISTORYPHYSICAL

EXAMINATIONNewYorkHeartAssociationFunctionalClassificationIPatientswithcardiacdiseasebutwithoutresultinglimitationsofphysicalactivity.Ordinaryphysicalactivitydoesnotcauseunduefatigue,palpitation,dyspnea,oranginalpain.IISlightlimitationofphysicalactivity.Theyarecomfortableatrest.Ordinaryphysicalactivityresultsinfatigue,palpitations,dyspnea,oranginalpain.IIIMarkedlimitationofphysicalactivity.Theyarecomfortableatrest.Lessthanordinaryphysicalactivitycausesfatigue,palpitations,dyspnea,oranginalpain.IVInabilitytocarryonanyphysicalactivitywithoutdiscomfort.Symptomsofcardiacinsufficiencyoroftheanginalsyndromemaybepresentevenatrest.PalpitationsA

subjectivesensationofanirregularorabnormalheartbeatmaybecausedbyanyarrhythmiawithorwithoutimportantunderlyingstructuralheartdiseaseshouldbedefinedintermsofthedurationandfrequencyoftheepisodestheprecipitatingandrelatedfactorsanyassociatedsymptomsofchestpain,dyspnea,lightheadedness,orsyncopeItiscrucialtousethehistorytodeterminewhetherthepalpitationsarecausedbyanirregularoraregularheartbeatEvaluationbeginswithambulatoryelectrocardiographyLightheadednessorsyncopeCausesanyconditionthatdecreasescardiacoutputArrhythmia

(usuallyoccurswithlittlewarning)obstructionoftheventricularinfloworoutflow

(withexertionorjustafterconclusionofexertion)cardiactamponadeaorticdissectionseverepumpfailurereflex-mediatedvasomotorinstabilityorthostatichypotensionneurologicdiseasesCompletemedicalhistoryAthoroughreviewofsystemsFamilyhistoryprematureatherosclerosisfamilialabnormalities,suchasthelongQTsyndromeorhypertrophiccardiomyopathySocialhistorycigarettesmokingalcoholintakeuseofillicitdrugsPastmedicalhistoryPHYSICALEXAMINATIONcost-effectivenessthepossibilityofmakinginexpensiveserialobservationstheearlydetectionofcriticalfindingstheintelligentandwell-guidedselectionofcostlydiagnostictechnologythetherapeuticvalueofthephysicalcontactbetweenphysicianandpatientImportancePHYSICALEXAMINATIONHeart

failure

increased

respiratoryratelabored

breathingSystemic

diseasesthyriod

disordersrheumaticautoimmunediseases

Congenital

anomaliesGeneralAppearanceOphthalmologicExaminationCarotidPulseJugularVeinsCardiacexaminationAbdomenSkinExtremitiesPHYSICALEXAMINATIONdiabetic

orhypertensiveretinopathyRoth’sspots

—

infectiousendocarditisbeading

oftheretinalarteries

—

hypercholesterolemiaexophthalmosandstare

—

Hyperthyroidism……GeneralAppearanceOphthalmologicExaminationCarotidPulseJugularVeinsCardiacexaminationAbdomenSkinExtremitiesPHYSICALEXAMINATIONthe

heightoftheobservedjugularvenousdistentionabovethesternalangle

ofLouisthejugularvenouspulse

GeneralAppearanceOphthalmologicExaminationCarotidPulseJugularVeinsCardiacexaminationAbdomenSkinExtremitiesdistentionoftheinternaljugularveinPHYSICALEXAMINATIONGeneralAppearanceOphthalmologicExaminationCarotidPulseJugularVeinsCardiacexaminationAbdomenSkinExtremitiesIncreasedandmore

intensewithahigherstrokevolume:aorticregurgitationarteriovenousfistulahyperthyroidismfeveranemia……PHYSICALEXAMINATIONInspection

and

palpationtheleftventricularapexsystolicheavesorliftsthrillsPercussionHeart

borderAusculationheartsoundsmurmurspericardialrubsGeneralAppearanceOphthalmologicExaminationCarotidPulseJugularVeinsCardiacexaminationAbdomenSkinExtremitiesPHYSICALEXAMINATIONhepatomegalyhepatojugularrefluxsplenomegaly

andascitesbeading

oftheretinalarteries

enlargedabdominal

aortaGeneralAppearanceOphthalmologicExaminationCarotidPulseJugularVeinsCardiacexaminationAbdomenSkinExtremitiesPHYSICALEXAMINATIONperipheralpulsesedemacyanosisclubbingGeneralAppearanceOphthalmologicExaminationCarotidPulseJugularVeinsCardiacexaminationAbdomenSkinExtremitiesedemaclubbingcyanosisPHYSICALEXAMINATIONGeneralAppearanceOphthalmologicExaminationCarotidPulseJugularVeinsCardiacexaminationAbdomenSkinExtremitiesColorOsler’s

nodesJaneway’slesionssplinterhemorrhagesXanthomasOsler’s

nodesJaneway’slesionsLABORATORY

STUDIESECGchestradiographEcho-cardiographyBloodtestingraterhythmintervals(PR,QRSduration,QT)QRSaxisPwavemorphology,duration,andaxisQRSprogressionandtransitioninprecordialleadsQRScomplexesinregionalgroupingsSTsegmentsinregionalgroupingsTwavesinregionalgroupingsRadionuclidestudiesStresstestingContinuousECGmonitoringCardiaccatheterizationLABORATORY

STUDIESECGchestradiographEcho-cardiographyBloodtestingchamberenlargementpulmonaryvasculaturethegreatvesselsRadiologicanatomyHeart

sizePulmonaryedemaRadionuclidestudiesStresstestingContinuousECGmonitoringCardiaccatheterizationLABORATORY

STUDIESECGchestradiographEcho-cardiographyBloodtestingcompletebloodcell

countthyroidindiceslipidlevelsarepartofthestandardevaluationPoint-of-carebiomarkermeasurementsRadionuclidestudiesStresstestingContinuousECGmonitoringCardiaccatheterizationLABORATORY

STUDIESECGchestradiographEcho-cardiographyBloodtestingTwo-dimensionalimagingM-modeDopplertransesophageal

echocardiographyTissue

DopplerContrastechocardiographyRadionuclidestudiesStresstestingContinuousECGmonitoringCardiaccatheterizationLABORATORY

STUDIESECGchestradiographEcho-cardiographyBloodtestingCT/CTAMR/MRASPECT/PETRadionuclidestudiesStresstestingContinuousECGmonitoringCardiaccatheterizationLABORATORY

STUDIESECGchestradiographEcho-cardiographyBloodtestingCT/CTAMR/MRASPECT/PETRadionuclidestudiesStresstestingContinuousECGmonitoringCardiaccatheterizationLABORATORY

STUDIESECGchestradiographEcho-cardiographyBloodtestingStressexercisepharmacologicDetective

indexECGabnormalitiesperfusion

abnormalitiesonradionuclidestudiestransientwallmotionabnormalities

onechocardiographyRadionuclidestudiesStresstestingContinuousECGmonitoringCardiaccatheterizationLABORATORY

STUDIESECGchestradiographEcho-cardiographyBloodtestingmeasureprecisegradientsacross

stenoticcardiacvalvesjudgetheseverityofintracardiacshuntsdetermine

intracardiacpressuresevaluate

coronary

arteryCoronary

angiographyIVUSOCTFFRRadionuclidestudiesStresstestingContinuousECGmonitoringCardiaccatheterizationFFR

FFRinLADPoststentFFR

OCT红血栓（急性）DataonfileatLLI

OCT白血栓（陈旧型）DataonfileatLLI第二次OCT+PCILABORATORY

STUDIESECGchestradiographEcho-cardiographyBloodtestingHolter

monitorsEvent

monitorsImplantable

loop

recordersRadionuclidestudiesStresstestingContinuousECGmonitoringCardiaccatheterizationGeneralcardiologistInterventionalcardiologistPCI(percutaneouscoronaryintervention)EP(electrophysiology,pacingandcatheterablation)CongenitalorvalvularheartdiseaseNewTechniquesTranscatheterAortic

Valve

Implatation

(TAVI)

severe

aortic

valve

stenosisNewTechniquesMitra-Clipmoderate/severe

mitral

regurgitationNewTechniquesBioresorbable

stent

1Month6Months12Months18MonthsBVSCohortBPhotostakenbyandonfileatAbbottVascular.TestsperformedbyanddataonfileatAbbottVascular.2years重量降低数据提示，术后2-3年支架材料的重量下降100%尽管2年的物质损失数据表明，BVS已几乎完全吸收，节杆的轮廓还存在节杆周边区域无炎症反应3年后：节杆完全由细胞组织取代4年后：已看不出节杆的痕迹在第2，3及4年血管对BVS的反应:

血管恢复及对植入物的适应TestsperformedbyanddataonfileatAbbottVascular.AlcianBlueStain:Proteoglycan3yearsPhotostakenby