冠心病的知识课件

冠心病的知识课件动脉粥样硬化

atherosclerosisIntroductionArteriosclerosisThickeningandlossofelasticityofarterialwallsHardeningofthearteriesGreatestmorbidityandmortalityofallhumandiseasesviaNarrowingWeakeningPlaqueThatHasBeenSurgicallyRemovedfromCoronaryArteryCourtesyRonaldD.GregoryandJohnRiley,MD.

NonModifiableRiskFactorsAgeAdominantinfluenceAtherosclerosisbeginsintheyoung,butdoesnotprecipitateorganinjuryuntillaterinlifeGenderMenmorepronethanwomen,butbyage60-70aboutequalfrequencyFamilyHistoryFamilialclusterofriskfactorsGeneticdifferences

ModifiableRiskFactors

(potentiallycontrollable)

HyperlipidemiaHypertensionCigarettesmokingDiabetesMellitusElevatedHomocysteineFactorsthataffecthemostasisandthrombosisInfections:Herpesvirus;ChlamydiapneumoniaeObesity,sedentarylifestyle,stressPathogenesisofAtherosclerosisResponsetoinjuryhypothesisInjurytotheendothelium(dysfunctionalendothelium)ChronicinflammatoryresponseMigrationofSMCfrommediatointimaProliferationofSMCinintimaExcessproductionofECMEnhancedlipidaccumulationResponsetoinjuryEndotheliadysfunctionInitiationofFattyStreakFattyStreakFibro-fattyAtheromaAtherosclerosisTimelineFoamCellsFattyStreakIntermediateLesionAtheromaFibrousPlaqueComplicatedLesion/RuptureAdaptedfromPepineCJ.AmJCardiol.1998;82(suppl104).FromFirstDecadeFromThirdDecadeFromFourthDecadeEndothelialDysfunctionAHAClassificationofatherosclerosis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CoronaryArteryDisease冠心病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）ClassificationofIHDChronicischemicsyndrome:stableanginaasymptomaticCHDischemiccardiomyopathyCHDAcutecoronarysyndrome:unstableanginaSTEMI/NSTEMI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NoSTElevationSTElevationAcuteCoronarySyndromeUnstableAnginaNQMIQwMINSTEMIMyocardialInfarctionDaviesMJ

Heart83:361,2000IschemicDiscomfortPresentationWorkingDxECGBiochem.MarkerFinalDxHammLancet358:1533,2001ANGINAPECTORISDefinitionofAngina

Apainordiscomfortinthechestoradjacentareascausedbyinsufficientbloodflowtotheheartmuscle.ClinicalclassificationandpathologyStableangina:fixedatheromatousstenosisUnstableangina:dynamicobstructionbyplaquerupturewithsuperimposedthrombosisandspasm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StableanginapectorisETIOLOGY.Ischemiaissecondarytocoronaryarterydiseasein95%ofpatients.Theleadingcauseiscertainlyatheroscleroticcoronaryarterydisease.Adecreasedoxygensupplyoranincreaseinoxygendemandcanleadtoaworseningofsymptoms..IschemiacanoccurinpatientswithnormalcoronaryarteriesClinicalmenifestation

chestdiscomfortQuality-"squeezing,""griplike,""pressurelike,""suffocating"and"heavy”;ora"discomfort"butnot"pain."Anginaisalmostneversharporstabbing,andusuallydoesnotchangewithpositionorrespiration.Duration-anginalepisodeistypicallyminutesinduration.FleetingdiscomfortoradullachelastingforhoursisrarelyanginaLocation-usuallysubsternal,butradiationtotheneck,jaw,epigastrium,orarmsisnotuncommon.Painabovethemandible,belowtheepigastrium,orlocalizedtoasmallareaovertheleftlateralchestwallisrarelyanginal.Provocation-anginaisgenerallyprecipitatedbyexertionoremotionalstressandcommonlyrelievedbyrest.Sublingualnitroglycerinalsorelievesangina,usuallywithin30secondstoseveralminutes.CategorizetheSeverityofAnginaCCSClassificationClass0asymptomaticClassIonstrenuousactivityClassIIonmoderateactivity

2blocksor2flightsofstairsClassIIIonmildactivity

2blocksor2flightsofstairsClassIVrestorminimalactivityClinicalfeatures

PhysicalexaminationAnS4gallopmaybetransientlypresentduringanepisode,andthepatientmaybedyspneicordiaphoreticorhaveanewheartmurmur.High-riskfeaturesofanginaincludeheartfailureandhypotension.Acompletephysicalexamiscrucialinmakinganassessmentofrisk.Mostpt:(-)AlternativeDiagnosestoAnginaforPatientswithChestPainNon-IschemicCVaorticdissectionpericarditisPulmonarypulmonaryemboluspneumothoraxpneumoniapleuritisChestWallcostochondritisfibrositisribfracturesternoclaviculararthritisherpeszosterGastrointestinalEsophagealesophagitisspasmrefluxBiliarycoliccholecystitischoledocholithiasischolangitisPepticulcerPancreatitisPsychiatricAnxietydisordershyperventilationpanicdisorderprimaryanxietyAffectivedisordersdepressionSomatiformdisordersThoughtdisordersfixedocclusionsInvestigation12LeadRestingECGshouldberecordedinallpatientswithsymptomssuggestiveofanginapectorisnormalin50%ofpatientsanormalECGdoesnotexcludesevereCAD;however,itdoesimplynormalLVfunctionwithfavorableprognosisCHDAtrest:

ECG冠心病Episodeofangina:ST-segmentdepressionECGCHDHolterExercisetestingAngina:ExerciseTesting

HighRiskPatientsSignificantST-segmentdepressionatlowlevelsofexerciseand/orheartrate<130FallinsystolicbloodpressureDiminishedexercisecapacityComplexventricularectopyatlowlevelofexerciseExerciseTesting

ContraindicationsMI—impendingoracuteUnstableanginaAcutemyocarditis/pericarditisAcutesystemicillnessSevereaorticstenosisCongestiveheartfailureSeverehypertensionUncontrolledcardiacarrhythmiasInvestigation

Echocardiography.Thestressechocardiogramisawidelyperformedtestusedtoassesspatientsforcoronarydisease.Baselineechocardiographicimagesareobtainedatresttoevaluateleftventricularfunction,wallmotion,andvalvefunction.Imagesarethenacquiredduringpeakstress(thatis,duringaGXTorwithdobutamine)andcomparedwiththoseatrest.Regionalwall-motionabnormalitieswithstressindicateareasofhypoperfusionorischemia.InvestigationIsotopescanning:obtainingscintiscansofthemyocardiumatrestandduringstressafteradministrationofanintravenousradioactiveisotopesuchasthallium201Investigation

Coronaryangiography.

Usedtoidentifyfociofcoronarydisease.Itistheevaluationofchoiceinpatientswithanginathatis(1)poorlyresponsivetomedication,or(2)unstable.ItisalsoindicatedinpatientswithtestresultsconsistentwithahighriskforCAD.冠心病Coronaryangiography冠心病冠状动脉造影冠心病LAD:stenosis LAD:normal冠心病RCA:stenosis LCX:stenosisChronicStableAngina

TreatmentObjectivesPreventprogressionofcoronaryarterydiseaseandoptimiselifeexpectancyRelievesymptomsManagementAspirinbeta-adrenoreceptorblockingagents(

-blockers)calciumantagonistsNitratesNCEPPrimaryCHDRisk

GoalsforLoweringLDL-CLDL-CGoalNoCHD<2RF<160mg/dLNoCHD

2RF<130mg/dLCHD

100mg/dLTheNCEPrecommendsloweringLDL-Cevenfurtherthanthesegoals,ifpossible.RiskCategoryNHLBI;September1993CoronaryrevascularisationInvasivetreatment:coronaryangioplasty(PTCA);coronaryarterybypassgrafting(CABG)冠心病CABG冠心病PTCA冠心病PTCABeforePTCA afterPTCA冠心病PTCA/SAcutecoronarysyndromeUnstableanginaNon-STelevationmyocardialinfarction(NSTEMI)STelevationmyocardialinfarction(STEMI)UnstableAngina/NSTEMIUnstableAngina

ClinicalPresentationandClassificationDiagnosisofunstableanginareferstoneworworseningsymptomsofmyocardialischemia:restanginanew-onsetsevereanginaincreasingangina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

*GrangerCB,etal.ArchinternMed.2003;163:2345-2353. **EagleK,atal.JAMA.2004;291:2727-2733.UnstableAnginaChestpainsyndrome,eithernewonsetorprogressiveanginaTransientST-segmentdepressionontheelectrocardiogram(ECG)WithoutevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponinNSTEMIChestpainsyndrome,eithernewonsetorprogressiveanginaTransientorpersistentST-segmentdepressionontheelectrocardiogram(ECG)WithevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponinUnstableAngina/NSTEMISignificantlikelihoodofoccurrenceofmajorcardiacevents A.IncidenceofMI:8to10% B.Mortality:2to5%UnstableAngina/NSTEMI:

PathophysiologyAcuteplaquefissuringandruptureSuperimposedthrombusTransientocclusionMediator-inducedvasospasmmaybepresentDeterminantsofPlaqueVulnerabilityLipid-richcoresizeCapthicknessCapinflammationandrepair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PhysicalExaminatonNotthathelpfulMayhaveevidenceofCHF:JVD,rales,edemaMayhaveS4MayhavemurmurofmitralregurgitationfrompapillarymuscledysfunctionInvestigationECGCardiacEnzymeorTroponinCoronaryangiographyAcuteCoronarySyndromes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

*GrangerCB,etal.ArchinternMed.2003;163:2345-2353. **EagleK,atal.JAMA.2004;291:2727-2733.managementAdmittedtohospitalBestrest,OxygenAnti-platelet:asprin,Clopidogrel,GPIIb/IIIainhibitorsAnticoagulant:UFHorLMWHB-blocker