冠状动脉粥样硬化性心脏病英文课件.ppt

1、Coronary Atherosclerotic Heart Diseases,Affiliated Hospital of Jining Medical College Dept.of Cardiac Care Unit Guoxia Dong dong.0321,2,7/2/2020,Contents,Atherosclerosis Stable Angina Pectoris Acute Coronary Syndrome UA and NSTEMI AMI(STEMI),3,7/2/2020,Self-study,Variant Angina Cardiac Syndrome X Si

2、lent Myocardial Ischemia Myocardial Bridging,4,7/2/2020,What Is Atherosclerosis?,Atherosclerosis is the descriptive term for thickened and hardened lesions of the medium and large muscular and elastic arteries.,5,7/2/2020,What Is Coronary Heart Disease?,6,7/2/2020,Coronary heart disease,atherosclero

3、sis,Coronary stenosis,coronary spasm,Myocardial ischemia, necrosis,Ischemic heart disease,7,7/2/2020,8,7/2/2020,Atherosclerosis,9,7/2/2020,Foam cell,Fatty steak,atheromatous plaque,ruptured plaques,Fibrous plaque,Endothelial damage,first decade,Third decade,Forth decade,Adapted from Stary HC et al.

4、Circulation 1995;92:1355-1374.,medium damage,7/2/2020,10,What damage does atherosclerosis cause?,11,7/2/2020,Common location Coronary Heart Disease Carotid Artery Disease Peripheral Arterial Disease Chronic Kidney Disease,12,7/2/2020,How does atherosclerosis start and progress?,13,7/2/2020,Elevated

5、levels of cholesterol and triglycerides in the blood High blood pressure Cigarette smoking,14,7/2/2020,Biological processes,Accumulation of intimal cells smooth muscle cells Macrophages T-lymphocytes,15,7/2/2020,Biological processes,Proliferated connective tissue matrix collagen elastic fibers prote

6、oglycans,16,7/2/2020,Biological processes,3.Accumulation of lipid,17,7/2/2020,Atherosclerosis-Hypothesis,Hypothesis of lipoprotein infiltration Aggregation of platelets and thrombosis Clonal theory The response-to-injury hypothesis,18,7/2/2020,High blood pressure,bacterium,virus,toxin,ox-LDL,immune

7、factor,vasoactive substance. Platelets are activated, adhesion and aggregation of platelets. Lipidoses, growth factor, proliferation of smooth mucle cells, collagen, lipolytic enzyme.,Response-to-injury,19,7/2/2020,Pathology and pathophysiology,Fatty steak Fibrous plaque Complicated lesion,20,7/2/20

8、20,Initiation of Atherosclerosis,Fatty steak formation,21,7/2/2020,Initiation of Atherosclerosis,22,7/2/2020,fibrous plaque,23,7/2/2020,24,7/2/2020,25,7/2/2020,Thin Cap Vulnerable Plaque Thrombus Unstable “ Active Volcano”,Thick Cap Calcified Plaque Flow-limiting Lesion Stable Angina “ Dormant Volca

9、no ”,SAP,ACS,pressure or a squeezing pain !,26,7/2/2020,Unstable and Stable Plaques,薄的纤维帽,炎性细胞,少的平滑 肌细胞,内皮细胞不完整,巨噬细胞,较厚的纤维帽,没有炎性细胞,泡沫细胞,完整的内 皮细胞,较多平滑 肌细胞,Libby P. Circulation. 1995;91:2844-2850.,unstable,stable,7/2/2020,28,Atherosclerosis,Clinical stages Absence of symptom or stage of incubation isc

10、hemia necrosis(target organ ) fibrosis,29,7/2/2020,clinical manifestation,General manifestation Aortic atherosclerosis Coronary artery atherosclerosis Cerebral atherosclerosis RA atherosclerosis Mesenteric atherosclerosis Peripheral artery atherosclerosis,30,7/2/2020,Laboratory Examination,Lack of s

11、ensitive and specific methods for early diagnosis Dyslipidemia X-ray：DSA show severity of stenosis Doppler ultrasound: blood flow,31,7/2/2020,Laboratory Examination,radionuclide： detection of ischemia Echocardiogram： CHD ECG and stress test: CHD Angiography: the most direct way Intravascular ultraso

12、und, angioscope CT, MRI,32,7/2/2020,Risk factors,1.Lipid disorders (Dyslipidemia) Increased cholesterol :Tc and LDL-c, TG, ApoB,Lp(a) Decreased cholesterol: HDL-c apoA 2.Hypertension,33,7/2/2020,Risk factors,3.DM,Metabolic syndrome or insulin resistance syndrome More diffuse lesion CAD equivalent 75

13、-80% cause of death in adult DM are vascular diseases: CAD, cerebrovascular disease, or peripheral vascular disease,34,7/2/2020,7 years incidence of death/non-fatal MI (East West Study),* These patients had no history of myocardial infarction Haffner SM, et al. N Engl J Med. 1998;339:229234.,0,5,10,

14、15,20,25,30,35,40,45,50,Events of MI in 7 years,No history of MI OMI No history of MI* OMI,non-diabetics diabetics n = 1373 n = 1059,P 65 yrs 7. Male gender/ postmenopausal state： male:female = 2：1, men develop CHD 10-15 yrs earlier than women 8. alcohol 9. Others: diet,homocysteine, hemostatic fact

15、ors inflammation/infection,36,7/2/2020,Drug therapy,anti-platelet： aspirin, clopidogrel, GPIIb/IIIa inhitibor, Dipyridamole, cilostazol Lipid-lowering HMG-CoA reductase inhibitors（statins）,37,7/2/2020,Doubts of patients,Quest 1：My blood pressure is only about 100/60 mmHg,Why give me hypotensor loten

16、sin?,38,7/2/2020,Doubts of patients,Question 2：My shape is not fat, lipid is not high, why give me lipid-lowering drugs, made a mistake?,39,7/2/2020,Doubts of patients,Question 3：I have coronary heart disease,then should I do less activities in order to protect the heart?,40,7/2/2020,Coronary Heart

17、Disease (CHD),7/2/2020,41,Clinical Type,Silent myocardial ischemia Angina pectoris Myocardial infarction Ischemic cardiomyopathy Sudden cardiac death,7/2/2020,42,Silent Myocardial Ischemia,Defined as documented episodes of ischemia not associated with any typical or atypical symptoms that among pati

18、ents with obstructive coronary artery disease. Type I: myocardial ischemia is detected on routine ECG, 24h ambulatory ECG monitoring (Holter), etc. but not experience angina at any time; Type II: patients are most frequently encountered in clinical practice. Some episodes of ischemia are associated

19、with chest discomfort and other episodes are asymptomatic.,7/2/2020,43,Ischemic Cardiomyopathy,Symptoms of heart failure, caused by ischemic myocardial dysfunction , diffuse fibrosis, and multiple infarction, alone or in combination. Manifestations: ventricles enlargement (dominant left ventricle),

20、heart failure and arrhythmias.,7/2/2020,44,Sudden Cardiac Death,SCD is natural death due to cardiac causes, heralded by abrupt loss of consciousness within 1 hour of the onset of acute symptoms. The time and mode of death are unexpected. WHO definition: unexpected death within 6 hours. This definiti

21、on incorporates the key elements of natural, rapid and unexpected. One half of SCD due to coronary heart disease，caused by severe arrhythmias, such as ventricular fibrillation and cardiac arrest.,7/2/2020,45,Acute Coronary Syndrome,ACS represents a spectrum of conditions. Acute plaque change charact

22、erized by plaque rupture and exposure of substances that promote platelet activation and thrombin generation.,7/2/2020,46,Stable Angina Pectoris,47,7/2/2020,Definition,Acute and transient myocardial ischemia and anoxaemia. Usually caused by coronary insufficiency during exertion.,48,7/2/2020,Charact

23、eristics,paroxysmal precordial squeezing-like chest pain, behind the mid sternum radiated to left shoulder and upper arm precipitated by stress or exertion relieved rapidly by rest or nitrates,49,7/2/2020,hypoxia,Coronary stenosis (others:aortic valve disease, HOCM) + Myocardial oxygen demand（HRXSBP

24、）increased myocardial hypoxia acumulation of metabolic product, stimulate C1-5 to cause the sensation of chest pain,mechanism,50,7/2/2020,in angiography Significant coronary lesion with diameter stenosis 70% in 75% pts No significant stenosis in about 5-10% pts, Ischemia may be related to coronary s

25、pasm or microvascular dysfunction.,Pathology,Stable angina pectoris,51,7/2/2020,pathophysiology,1.Metabolic and electrophysiology ATP reduced, accumulation of acid substances Dysfunction of ion pump (Na+-K+, and Na+-Ca+) Early depolarization (ST deviation) 2.LV function and hemodynamic situation LV

26、contractility , systolic BP, stroke volume, cardiac output decreased LVED pressure and volume,Stunning of myocardium,Stable angina pectoris,52,7/2/2020,symptom：chest pain location behind or slightly to the left of the mid sternum no definite borderline radiated to the left shoulder and upper arm Aty

27、pical location: lower jaw, the back of neck,Clinical manifestation,Stable angina pectoris,53,7/2/2020,character： tightness, squeezing, burning, pressing, choking, bursting,rarely sharp duration： 35 mins precipitating factor exertion or emotional agitation pain relief: within several mins after rest

28、or using nitroglycerin,Clinical manifestation,Stable angina pectoris,55,7/2/2020,Physical examination increased HR, elevated BP anxiety cool and sweaty skin occasionally gallop rhythm，transient systolic murmur,Clinical manifestation,Stable angina pectoris,56,7/2/2020,Auxiliary examination,Stable ang

29、ina pectoris,57,7/2/2020,Stress test,rest,Exerscise,Stable angina pectoris,58,7/2/2020,2.Echocardiography: 3. Scintigraphy assessment: Can detect filling defect of Infarction area 4.X-ray of heart 5.coronary angiography：final diagnose 6.others: IVUS,Auxiliary examination,Stable angina pectoris,59,7/

30、2/2020,Coronary Angiography,60,7/2/2020,Stable Angina Pectoris,Diagnosis,Chest pain risk factors ECG evidence of ischemia during chest pain angiography,61,7/2/2020,Cardiovascular causes Noncardiac causes,Stable Angina Pectoris,Differential diagnosis,62,7/2/2020,Cardiovascular cause,Myocardial infarc

31、tion Pericarditis Aortic dissection Pulmonary embolism Pulmonary hypertension,63,7/2/2020,Noncardiac cause,Pneumonia with pleurisy Spontaneous pneumothorax Musculoskeletal disorders Herpes zoster Esophageal reflux Peptic ulcer,64,7/2/2020,General treatment： risk factors control 2. Drug therapy 3. Co

32、ronary revascularization: percutaneous coronary intervention (PCI) Coronary artery bypass surgery (CABG) SVG, IMAG,Treatment,Stable Angina Pectoris,65,7/2/2020,Blood and oxygen supply to the heart,Myocardial blood flow,Myocardial oxygen consumption,4% of total cardiac output supplied to the myocardi

33、um,12% of total body oxygen, used at rest by myocardium,7/2/2020,66,Coronary Reserve,Myocardial blood flow increases up to 4 times ., to meet increased myocardial oxygen demand,7/2/2020,67,Myocardial oxygen supply and demand,O2,O2,O2,O2 supply,O2 demand,7/2/2020,68,Aims of medical therapy,Arterial v

34、asodilatation,Reduces arterial resistance,Reduces afterload,Decreases sympathetic drive,Reduce heart rate and contractile force,Reduces cardiac work,LV,RV,Dilatation of coronary arteries,Improves coronary supply,Venodilatation,Reduces venous return,Reduces preload,7/2/2020,69,antianginal and anti-is

35、chemic therapy,Drug therapy,Oxygen supply,Oxygen demand,a.Nitrates b.Beta blockers c.Calcium antagonists d.Drugs improving metabolism,Stable Angina Pectoris,70,7/2/2020,Drug therapy,a.Nitrates lower oxygen demand: decrease arteriolar and venous tone, reduce preload and afterload increase coronary su

36、pply: Coronary dilatation Nitroglycerin Isosorbide dinitrate isosorbide 5-mononitrate (long-acting nitrates),Stable Angina Pectoris,71,7/2/2020,Nitrates in angina,Reduce preload through venodilatation,Reduce afterload by lowering arterial resistance Reduce platelet aggregation,Increase coronary perf

37、usion, including ischaemic areas Reversal of coronary spasm,7/2/2020,72,b. blockers: reduce myocardial oxygen: reduce HR, myocardial contractility, BP,the LV wall stress Abslute contraindications： sever bradycardia: high-degree A-V block, SSS, severe unstable LV failure Relative contraindications: a

38、sthma and bronchospastic disease peripheral vascular disease 1-selective：metoprolol, atenolol, bisoprolol,Drug therapy,Stable Angina Pectoris,73,7/2/2020,c.Calcium antagonists： Increase oxygen supply: dilate conduit and resistance vessels, release spasm, improve microvascular function Decrease oxygen demand: negative inotropic effect, decrease BP Antiplatelet effect,d. Drugs improving metabolism,Drug therapy,Stable Angina P