内科学概论心脏血管内科.ppt

,內科學概論,高雄醫學大學,LinCC,心臟血管內科,血壓的形成,收縮壓舒張壓,LCC,高血壓分類,原發性高血壓PrimaryHypertension續發性高血壓SecondaryHypertension,LCC,遺傳基因的影響鈉鹽的過度攝取Renin-Angiotensinsystem交感神經系統細胞膜的異常血管的增生肥厚內皮細胞功能異常胰島素抗性,原發性高血壓致病機轉,LCC,續發性高血壓,高血壓的分類JNC7,Normal12080Prehypertetnsion120-139or80-89Stage1hypertension140-159or90-99Stage2hypertension160or100,InitialMeasurements,血壓的測定,基礎血壓隨時血壓休息血壓,LCC,ClinicalpressureAmbulatorypressureHomepressure,血壓的測定,LCC,BloodPressureMeasurement,AmbulatoryMeasurement,AdvantagesofSelf-Measurement,高血壓臨床表現,頭重頭痛耳鳴眼花失眠頭頸部酸痛兩肩酸痛大部分沒有症狀,40歲20%罹患高血壓,隱形殺手,LCC,高血壓自然病程,高血壓前期遺傳-環境因素,惡性高血壓,心臟,大血管,腎,眼,腦,合併症,高血壓,高血壓早期,年齡0-3020-4030-50,LCC,正確測量血壓外觀:脂肪分布皮膚肌肉及神智狀況眼底檢查頸部頚動脈及甲狀腺觸診聽診心臟大小節律及心音異常肺有無囉音腹部腫瘤?動脈雜音股動脈搏動四肢動脈博動水腫神經檢查,高血壓臨床檢查重點,LCC,Laboratorytests,OptimalTests,WhatisthetargetofBPwiththerapy?,General:140/90mmHgDiabetes:3xabovethenormal(99%ofnormal)TotalCK,SGOT,andLDHarenotrecommended(lowspecificity)EmploythefullclinicalpicturetodiagnoseMI,notmerelylabvalues,LCC,NewDefinitionofMI-ECG,Non-STsegmentelevationAMICriteriaarenotadequatetodefineAMISTsegmentelevationAMINewSTelevationin2ormoreleads(0.2InV1-V3)0.1inotherleads,LCC,急性心肌梗塞AcuteMYOCARDIALINFARCTION,STsegmentelevation,PathologicQwave,LCC,NewDefinitionofMI-establishedMI,IntheabsenceofQRSconfounders(BBB,LVH,WPW)AnyQwaveinleadsV1-V3Qwavesmustbe30msecdurationQwavesinotherleadsmusthaveQsin2contiguousleads(eg,IIandIII)Qsmustbe1mmindepth,LCC,NewDefinitionofMI-image,InfarctmanifestsitselfasdecreasedwallmotionbyechoorhypoperfusionbyradionuclideSPECTIschemia,stunning,andhibernationwillproducesimilarchanges,LCC,UseofcardiacmarkersinACS,CardiactroponinafterclassicalAMI,CK-MBafterAMI,Cardiactroponinaftermicroinfarction,DaysafteronsetofAMI,LCC,ChestpainTroponinI/T,CK-MBECGchangesEchocardiographyNuclearcardiologyCardiaccatheterization,急性心肌梗塞-診斷,LCC,急性心肌梗塞AcuteMYOCARDIALINFARCTION,HypokinesiaakinesiaHyperkinesiaLVaneurysmLVsizeEFMRLVthrombus,LCC,急性心肌梗塞AcuteMYOCARDIALINFARCTION,HypoperfusionLVsystolicfunctionLVdiastolicfunction,LCC,急性心肌梗塞-心導管,Fillingdefect,Contrast造影劑,LCC,Myocardialinfarction,arrhythmia,Lossofmuscle,Suddendeath,Ventricularremodeling,Ventriculardilation,Heartfailure,death,LCC,LCC,Thrombin/Fibrin,Platelet,thrombus,Pre-PCIASAStatinACEIClopidogrel,Post-PCIASAStatinACEIClopidogrel,GPIIb/IIIAEmbolicprotectionAnti-inflammatoryCoatedstent,Plaquerupture,thrombus,LCC,Reperfusion,intervension,thrombolysis,LCC,OptimalStrategyUA/NSTEMI,TIMIIIIB,2019,Conservative,Invasive,VANQWISH,MATE,FRISCII,TACTICS-TIMI18,VINO,RITA-3,TRUCS,急性心肌梗塞PrimaryPTCA,InitiatePTCAifavailableandsuitableGoals:PTCAwithin9030min,LCC,氣球擴張術,Stenting,Stenting,LCC,網狀支架置放術,InterventionalCardiology,post,Stenting,SitesofAnti-thromboticDrugAction,Tissuefactor,Plasmaclottingcascade,Prothrombin,Thrombin,Fibrinogen,Fibrin,Thrombus,Plateletaggregation,ConformationalactivationofGPIIb/IIIa,Collagen,ThromboxaneA2,ADP,AT,AT,FactorXa,Coagulationcascade,Plateletcascade,Plaquerupture,thrombus,LCC,Fibrin,Thrombin,Platelet,FibrinolysisAntiplateletAnti-thrombin,THROMBUS,PLATELET,Antiplatelettherapy-aspirin-clopidogrel-GPIIb/IIIainhibitors-persantin-ticlopidine,Thrombin,Antithrombintherapy-heparin,Fibrin,PlasminogenActivators-t-PAR-PASKTNK-tPA,LCC,StreptokinaseUrokinase,急性心肌梗塞Thrombolysis,一般原則胸痛12小時內STsegmentelevation180/110mmHg)HistoryofPRIORCVDorknownINTRACEREBRALPATHOLOGYCurrentuseofANTICOAGULANTS(INR2-3)KnownBLEEDINGDIATHESISRECENTTRAUMA(Within2-4WKS)IncludingheadinjuryNONCOMPRESSIBLEVASCULARPUNCTURES,LCC,Nobenefitharmful,20%40%Decreasedmortality,Non-STsegmentelevationACS,STsegmentelevationACS,Plaquerupture,ACS,Thrombolysis,LCC,THROMBUS,PLATELET,Antiplatelettherapy-aspirin-clopidogrel-GPIIb/IIIainhibitors-persantin-ticlopidine,Thrombin,Antithrombintherapy-heparin,Fibrin,PlasminogenActivators-t-PAR-PASKTNK-tPA,LCC,Adhesion,PlateletsRoleinthrombosis,Aggregation,1,Activation,2,3,GPIIb/IIIaInhibitors,1.PlateletAdhesion,2.PlateletActivation,Platelet,GPIb,Plaquerupture,3.PlateletAggregation,ASA,Clopidogrel/Ticlopidine,TxA2,PlateletsRoleinThrombosis,ActsbyselectiveinhibitionofADPbindingtoitsplateletreceptorandpreventssubsequentplateletaggregation,ADP,ADP,FibrinogenBindingSite,Clopidogrel,Clopidogrel,FibrinogenBindingReduced,Fibrinogen,Platelet,LCC,Clopidogrelmechanismofaction,Plateletaggregation,InhibitionofaggregationbyGPIIb/IIIainhibitors,LCC,ThrombinSerotoninEpinephrineCollagen,Activation,ActivatedPlatelet,COX,Degranulation,GpIIb/IIIafibrinogenreceptor,Toneighboringplatelet,ClopidogrelTiclopidine,THROMBUS,PLATELET,Antiplatelettherapy-aspirin-clopidogrel-GPIIb/IIIainhibitors-persantin-ticlopidine,Thrombin,Antithrombintherapy-heparin,Fibrin,PlasminogenActivators-t-PAR-PASKTNK-tPA,LCC,UnfractionatedheparinLowmolecularweightheparinEnoxaparinDalteparinNadroparinDirectThrombininhibitorsHirudinBivalirudinwarfarin,LCC,AntithromboticTreatment,SitesofAnti-thromboticDrugAction,Tissuefactor,Plasmaclottingcascade,Prothrombin,Thrombin,Fibrinogen,Fibrin,Thrombus,Plateletaggregation,ConformationalactivationofGPIIb/IIIa,Collagen,ThromboxaneA2,ADP,AT,AT,FactorXa,Coagulationcascade,Plateletcascade,MONAMorphine靜脈注射Oxygen4L/minNitroglycerine舌下錠或噴劑Aspirin160-325mg,急性心肌梗塞胸痛,LCC,急性心肌梗塞Morphine,解除胸痛鎮靜減少焦慮每5-10分鐘靜脈注射2-4mg,低血壓病人平躺補充生理食鹽水液呼吸抑制Naloxone0.4mgIV每三分鐘注射一次可重複三劑量,LCC,Managementnon-STsegmentelevationACS,Veryhigh15%,intermediate38%,Veryhigh815%,DeathMI,AspirinheparinGPIIb/IIIaUrgentcathClopidogrelpriorPCI,AspirinLMWHGPIIb/IIIaClopidogrelCoronaryangio,AspirinLMWHIschemia-guidedRx,LCC,ACC/AHAUA/NSTEMIGuidelinesRecommendationsforLong-termMedicalTherapy,ClassIAspirin75to325mg/dayClopidogrel75mgdaily(intheabsenceofcontraindications)whenaspirinisnottoleratedbecauseofhypersensitivityorgastrointestinalintoleranceThecombinationofaspirinandclopidogrelfor9monthsafterUA/NSTEMI-BlockersintheabsenceofcontraindicationsLipid-loweringagentsanddietinpost-ACSandpostrevascularizationpatientswithLDL-C130mg/dLLipid-loweringag