缺血性心脏病_教学20101216.ppt

1、北京大学人民医院 心脏中心 孙艺红,Coronary (Ischemic) Heart Disease 冠 心 病 缺血性心脏病,CHD,Epidemiology Pathophysiology Risk factors and Prevention Clinical manifestation,Diagnosis and management,Most common form of heart disease Single most important cause of premature death,Epidemiology,Epidemiology - USA,1/2 deaths (1

2、/2million) 1.5 million MI each year 45% MI under age 65 50-100 billion $ per year,One in 4 men/one in 5 women die from CHD 300 000 people have MI each year 1.7 million people have angina,Epidemiology - UK,The incidence of CHD Eastern Europe Many developing countries China India,Epidemiology,Proporti

3、onate Mortality for the Ten Leading Causes of Death in China, 1991-2001,He J 11:1124-34,Pathophysiology,Almost always due to athroma and its complications particularly thrombosis,Occasionally other disorders Congenital anomalies Anomalous origin Fistular/Malformation of a major coronary artery Aorti

4、tis Polyarteritis Connective tissue disorders,Pathophysiology,Pathophysiology Atheroma/Atherosclerosis,Diffused disease of the arterial wall Coronary artery at high risk Cerebral / peripheral vascular disease often coexist Radial / Internal mammary artery largely spared,Plaques begin to appear in 2n

5、d and 3rd decade of life The nature/composition of plaques changes,Pathophysiology Plaque Formation 1,Soldiers died in the korean war,77.3% atherosclerosis 39% occlusive plaque,ENOS JAMA 1953,300 Cases autopsy (age, 22.1y),Tuzcu Circ 1999,5.07mm2,EEM Area13.2 mm2,Atheroma Area 8.13 mm2,Female,32y,In

6、cidence of atherosclerosis in donor heart,Pathophysiology Plaque Formation 2,Fatty streaks develope migrate into intima take-up oxidised LDL from plasma become lipid-laden foam cells,Circulating Monocytes,Pathophysiology Plaque Formation 3,Lipid Pool Foam cells die The contents release,Pathophysiolo

7、gy Plaque Formation 4,Early Atheroma Smooth muscle cells migrate into proliferate within Plaque,Pathophysiology Plaque Formation 5,Lesion Grows Encroaches into lumen Erodes media,Pathophysiology Plaque Formation 6,Mature Fibrolipid Plaque Lipid core Surrounded by SMC Fibrous cap,Pathophysiology Plaq

8、ue Formation 7,Plague Rupture / Fissure Thrombosis + Local spasm Vessel Occlusion ACS,Pathophysiology,Pathophysiology Plaque Rupture,CHDclinical manifestation and pathology,CHD: Risk Factors,Fixed Modifiable Age Lipid disorders Male Smoking Family history Diabetes mellitus Hypertension Obesity Seden

9、tary lifestyle Dietary deficiencies of fruits and vegetables alchole,IMPORTANT RISK FACTORS FOR CORONARY ARTERY DISEASE,Pathophysiology Atherosclerosis,PREVENTABLE AND CONTROLLABLE DISEASE,Every 10 MI pts，9 Predictable Every 6 MI pts，5 Preventable,CHD Prevention,CHD Prevention,Primary Prevention Sec

10、ondary Prevention,Modify Risk Factors Therapeutic Lifestyle Change Evidence-based optimal drug management,CHD Prevention,Population AdviceTLC,Do not smoke Take regular exercise Maintain “ ideal ” body weight Eat a mixed diet rich in fresh fruit and vegetables Aim to get no more than 30% of energy in

11、take from fat Stress control,CHD Prevention,Examples of the benefits of long-term secondary prevention following myocardial infarction,Preventive measure Events prevented per 1000 patient years Smoking cessation 15deaths 46 non-fatal myocardial infarctions(Mls) Aspirin 7 deaths 9 non-fatal Mls 9 non

12、-fatal strokes -adrenoceptor 21 deaths antagonist 21 non-fatal Mls Statins(HMG CoA 7 deaths reductase inhibitors) 12 non-fatal Mls 3 non-fatal strokes 11 revascularisations 4 cases of heart failure N.B. Even in a high-risk rimary prevention (the West of Scotland study), four times as many people nee

13、ded to be treated with a lipid-lowering agent to prevent a cardiac event compared to secondaryprevention.,Optimal evidence-based drug treatment Anti-hypertension drugs Lipid-lower drugstatins Aspirin - blocker ACEI,CHD Prevention,Clinical ManifestationClassification,Myocardial Ischemia Angina Pector

14、is Stable Unstable Myocardial Infarction Q- Wave non-Q-Wave Sudden Death,Clinical Manifestation Angina Pectoris,Discomfort due to transient myocardial ischaemia Clinical syndrome rather than a disease Imbalance: O2 supply and demand,Factors Influecing Myocardial O2 Supply and Demand,Oxygen demand Ox

15、ygen supply Cardiac work Coronary blood flow* Heart rate Duration of diastole Blood pressure Coronary perfusion Myocardial contractility pressure (aortic diastolic coronary sinus or right atrial diastolic pressure) Coronary vasomotor tone Oxygenation Haemoglobin Oxygen saturation *N.B. Coronary bloo

16、d flow occurs mainly in diastole.,Clinical Manifestation Angina Pectoris,Clinical Manifestation Angina Pectoris : Causes,Most Common : Coronary Atheroma Others : Aortic stenosis Hypertrophic Cardiomyopathy,Case 1,Case discussion 1,Clinical features Female, 40 y Atypical chest pain No history of HTN,

17、 dyslipidemia and diabetes ECG: normal Diagnosis decision ?,Case discussion 1,Clinical features Female, 40 y Atypical chest pain No history of HTN, dyslipidemia and diabetes ECG: normal Diagnosis decision Symptom,Clinical Manifestation Symptom,key factor in Diagnosis making (Stable / Unstable Angina

18、),Clinical Manifestation Symptom: Stable Angina,Location : Central Radiation: neck / jaw / arm Characteristics: Worsening factors: “Start-up angina”,CLINICAL SITUATIONS PRECIPITATING ANGINA Common Physical exertion Cold exposure Heavy meals Intense emotion Rare Lying flat (decubitus angina) Vivid dr

19、eams (nocturnal angina),Clinical Manifestation Symptom: Stable Angina,Clinical Manifestation Physical Examination,Frequently Negative But: A careful search for - Important Risk Factors - Contributory Disease (obesity, anemia) - LV dysfunction: gallop rhythm, murmur,Case discussion 1,Clinical feature

20、s Female, 40 y Atypical chest pain No history of HTN, dyslipidemia and diabetes ECG: normal Diagnosis decision Symptom Noncardiac chest pain,Angina PectorisDifferential Diagnosis,Acute myocardial infarction X syndrome Cardiac Neurosis,Clinical ManifestationDifferential Diagnosis,Musculoskeletal Peri

21、cardial Pain Oesophageal,Angina Pectoris Differential Diagnosis,Musculoskeletal Pain Provoked by special movement rather than walking Background pain often persists at rest Associated chest wall tenderness Pain of Pericarditis Provoked by changes in posture or deep inspiration Pain Due to oesophagit

22、is with or without hiatus hernia Burning quality Relieved by antacids,Case discussion 1,Clinical features Female, 40 y Atypical chest pain No history of HTN, dyslipidemia and diabetes ECG: normal Diagnosis decision Symptom Noncardiac chest pain Tests,Diagnosis Special Test - ECG,Resting ECG Evidence

23、 of OMI Normal in most patients T wave flattening / inversion Non-Specific !,Diagnosis Special Test - ECG,The most convincing Evidence REVERSIBLE ST or with/without T inversion During Chest Pain(Spontaneously or by exercise testing),Diagnosis Special Test - ETT,Treadmill/Bicycle ergometer Confirm/Re

24、fute diagnosis Assess Severity of disease Identify high risk patient,Exercise Tolerance Test,Diagnosis Special Test - ETT,Diagnosis Special Test Isotope Scanning,Evaluating Pts with equivocal/uninterpretable ETT Pts unable to exercise Predictive accuracy ETT,Technique Scintiscan of Myocardium At res

25、t and during stress (ETT or Dobutamine) After IV radioactive isotope (201TI),Diagnosis Special Test - Isotope Scanning,Isotope Scanning Technique Thallium - Analogue of potassium Take-up by viable myocardium,Diagnosis Special Test - Isotope Scanning,Ischemia: during stress Perfusion defect Reversibl

26、e not at rest Infarction: Perfusion defect Persistent,Diagnosis Special Test - Isotope Scanning,Diagnosis Special Test,Ventricular Function Radionuclide blood pool scanning ECHO,Diagnosis Special Test - MSCT,Coronary Arteriography,Extent/nature of CAD ? Decide PTCA / CABG Diagnostic - Atypical chest

27、 pain Non-invasive test failed,Diagnosis Special Test,Case discussion 1,Clinical features Female, 40 y Atypical chest pain No history of HTN, dyslipidemia and diabetes ECG: normal Diagnosis decision Symptom Noncardiac chest pain Tests Stress test Angiography CTA,Rapid worsening angina (Crescendo) Se

28、vere angina at rest New-onset angina Post-infarction angina Without evidence of Infarction (ECG / Enzyme),Clinical Manifestation Symptom: Unstable Angina,Clinical Manifestation Risk stratification in Angina,High risk Low risk Unstable angina Predictable exertional angina Post-infarct angina Poor eff

29、ort tolerance Good effort tolerance Ischaemia at low workload (ETT) Ischaemia only at high workload (ETT) Left main or three-vessel disease Single-vessel or minor two-vessel disease Poor LV function Good LV function N.B. Patients may fall between these categories.,Management Angina Pectoris,Risk fac

30、tors control Symptoms Control Life expectancy improvement,ADVICE TO PATIENTS WITH ANGINA Do not smoke Aim at ideal body weight Take regular exercise (Exercise up to, but not beyond, the point of chest pain is beneficial and may promote collateral vessels.) Avoid severe unaccustomed exertion, and vig

31、orous exercise after a heavy meal or in very cold weather Take sublingual nitrate before undertaking exertion that may induce angina,Management Angina Pectoris,Anti - anginal Drug Nitrates -blocker CCB anti-platelet Aspirin 75-100mg Lipid-lowing Statin ACEI,Management Angina Pectoris,baseline Plaque

32、 area 6mm2,Statins for 6months Plaque area 6.4mm2,Shinya Okazaki, et al. Circulation. 2004;110:1061-1068,Regression of Plaque by Statins,Invasive Treatment Revascularization PTCA / CABG,Management Angina Pectoris,Management -PCI,A triple coronary artery bypass graft operation,Management coronary art

33、ery bypass grafting,PTCA CABG Principal use Single-vessel disease; two-vessel Left main stem stenosis;three-vessel disease; unstable angina disease Mortality 1% 1% Incidence of neurological None 5% seldom permanent but stroke complications may occur Hospital stay 24-36 hours 7-10days Return to work

34、2-5days 2-3 months Recurrence of angina 30% in 6 months; PTCA may be 10% in 1 year, then 5% per year repeated Main complications Myocardial infarction; emergency Diffuse left ventricular damage; CABG; vascular damage related to perioperative MI; infection;wound the arterial puncture site pain,Compar

35、ison between PTCA and CABG,Unstable AP LMWH Aspirin + Clopidogrel PTCA / CABG High Risk,Management Angina Pectoris,Unstable angina: risk stratification,High risk Low risk Clinical Post-infarct angina No history of MI Recurrent pain at rest Rapid resolution of Heart failure symptoms ECG ST depression

36、 Minor or no ECG Transient ST elevation changes Persistent deep T wave inversion Biomarkers Troponin T 0.2ug/ml Troponin T0.2ug/ml,Myocardial Infarction,冠状动脉破裂斑块,致命 性血栓,斑块 破裂处,形成血栓 的脂质核心,胶原 纤维帽,Pathophysiology of Acute Coronary Syndrome,UA,No ST Elevation,ST Elevation,NSTEMI,Unstable Angina,QWMI,NQM

37、I,Myocardial Infarction,Working Dx,ECG,Cardiac Biomarker,Final Dx,The Lancet 2001; 358: 1533-1538 and Heart 2000; 83: 361-366.,Presentation,STEMI 的病理生理和治疗原则,病理生理：,斑块破裂,血栓形成,冠脉急性闭塞,心肌坏死,R.B. Jennings et al., Circulation 68-1 (1983) 25-36,Wavefront Phenomenon of Myocardial Necrosis,Pathophysiology MYO

38、CARDIAL INFARCTION,Diagnosis,Clinical presentation Physical examination ECG Biochemical markers Imaging of the coronary anatomy,Case discussion 2,临床表现 男性，65岁， 发作性胸痛8小时 既往史： 吸烟：20支/日，30年； 高血压病史10年 如何问诊？,Symptoms Prolonged cardiac pain Chest, throat, arms, epigastrium or back Anxiety Fear of impending

39、 death Nausea and vomiting Breathlessness Collapse / syncope,Clinical Manifestation MYOCARDIAL INFARCTION,Pallor, sweating, tachycardia Vomiting, bradycardia Hypotension, oliguria, cold peripheries Narrow pulse ressure Raised JVP Third heart sound Quiet first heart sound Diffuse apical impulse Lung

40、crepitations Fever Mitral regurgitation, pericarditis,Signs of sympathetic activation Signs of vagal activation Signs of impaired myocardial function Signs of tissue damage Signs of complications,Physical signs,Clinical Manifestation MYOCARDIAL INFARCTION,Differential Diagnosis,Case discussion 2,临床表

41、现 男性，65岁， 发作性胸痛8小时 既往史： 吸烟：20支/日，30年； 高血压病史10年 需要哪些辅助检查？,辅助检查结果,血液学：血常规、生化、凝血分析 心肌酶学标志物 心电图 运动平板 冠脉CT 冠状动脉造影 超声心动图,1000,100,10,1,0,Relative Marker Increase,Hours After Chest Pain Onset,Upper Reference Interval,Antman EM. In: Braunwald E, ed. Heart Disease: A Textbook in Cardiovascular Medicine, 5th

42、ed. Philadelphia, Pa: WB Saunders; 1997.,DiagnosisCardiac Biomarkers in STEMI,心电图,ECG,特征性改变 高尖T波 ST段抬高 异常Q波或QS波 T波改变 分期和动态演变 超级期 急性期 演变期 陈旧期,冠状动脉造影,Case discussion 2,临床表现 男性，65岁， 发作性胸痛8小时 既往史： 吸烟：20支/日，30年； 高血压病史10年 辅助检查 心电图：V2-V5 st段抬高 心肌标志物：TNI:7.8ng/ml 如何治疗？,治疗原则,冠状动脉血运重建治疗 恢复心肌血流和再灌注 溶栓 PCI CABG

43、,STEMI - Management,Anti-ischemic agents Anticoagulants Provide facilities for defib Antiplatelet agents Coronary revascularization ( Reperfusion Strategy-Reopen IRA) Detect and Treat complications early Long-term management,A triple coronary artery bypass graft operation,Management coronary artery

44、bypass grafting,确诊ST段抬高心肌梗死,一般治疗（抗血小板、抗凝、 B阻断剂）,治疗原则,12小时以内,12小时以上,再灌注治疗,溶栓治疗,冠脉介入治疗,是,否,是,保守治疗,Management -PCI,Case discussion 2,临床表现 男性，65岁 发作性胸痛8小时 既往史： 吸烟：20支/日，30年； 高血压病史10年 辅助检查 心电图：V2-V5 st段抬高 心肌标志物：TNI:7.8ng/ml 治疗 直接PCI 二级预防药物,STEMI Complications,Electronic Arrhythmias Mechanical,COMMON ARRH

45、YTHMIAS IN ACUTE MYOGARDIAL INFARCTION Ventricular fibrillation Ventricular tachycardia Accelerated idioventricular rhythm Ventricular ectopics Atrial fibrillation Atrial tachycardia Sinus bradycardia(particularly after inferior MI) Heart block,STEMI Complications,STEMI Complications Mechanical,Pump

46、 failure Cardiogenic Shock Papillary muscle damage Rupture of ventricular septum Rupture of free wall,Ventricular Septal Rupture,Mitral Regurgitation(Pap. M. dysfunction),Incidence1-2% 1-6%1-2%Timing3-5 d p MI 3-6 d p MI3-5 d p MIPhy Exammurmur 90% JVD, EMDmurmur 50%ThrillCommon NoRareEchoShunt Peri

47、c. EffusionRegurg. JetPA cathO2 step up Diast Press Equal.c-v wave in PCW,Images:Courtesy of W D Edwards (Mayo Foundation)Data: Lavocitz. CV Rev Rpt 1984;5:948; Birnbaum. NEJM 2002;347:1426.,Free WallRupture,STEMI Complications Mechanical,STEMI治疗历程,1960s以前 保守治疗，住院死亡率可高达30 1960s CCU 有效治疗心律失常， 住院死亡率约为15 1980s 冠脉内及随后的静脉溶栓，住院死亡率10%左右 1990s