冠心病大医英PPT演示课件

1、1冠状动脉粥样硬化性心脏病(coronary atherosclerotic heart disease) 大连医科大学附属二院心内科 牛 楠2动脉粥样硬化atherosclerosis3introductionarteriosclerosis thickening and loss of elasticity of arterial walls hardening of the arteries greatest morbidity and mortality of all human diseases via narrowing weakening 4plaque that has bee

2、n surgically removed from coronary arterycourtesy ronald d. gregory and john riley, md.5non modifiable risk factorsage a dominant influence atherosclerosis begins in the young, but does not precipitate organ injury until later in lifegender men more prone than women, but by age 60-70 about equal fre

3、quencyfamily history familial cluster of risk factors genetic differences6modifiable risk factors (potentially controllable) hyperlipidemia hypertension cigarette smoking diabetes mellitus elevated homocysteine factors that affect hemostasis and thrombosis infections: herpes virus; chlamydia pneumon

4、iae obesity, sedentary lifestyle, stress 7pathogenesis of atherosclerosisresponse to injury hypothesis injury to the endothelium(dysfunctional endothelium) chronic inflammatory response migration of smc from media to intima proliferation of smc in intima excess production of ecm enhanced lipid accum

5、ulation8response to injury9endothelia dysfunction10initiation of fatty streak11fatty streak12fibro-fatty atheroma13adapted from pepine cj. am j cardiol. 1998;82(suppl 104).from firstdecadefrom thirddecadefrom fourthdecade14aha classification of atherosclerosis15动脉粥样硬化血栓形成动脉粥样硬化血栓形成: : 具具共同病理基础的进展性过程

6、共同病理基础的进展性过程正常正常脂肪条纹脂肪条纹纤维斑块纤维斑块 粥样硬化斑块粥样硬化斑块斑块破溃斑块破溃/ /裂隙和血栓形成裂隙和血栓形成心肌梗死心肌梗死 缺血性中缺血性中风风/ /tiatia 严重的严重的下肢缺血下肢缺血临床无症状临床无症状心血管死亡心血管死亡年龄增长年龄增长稳定性心绞痛稳定性心绞痛间歇性跛行间歇性跛行不稳定性不稳定性心绞痛心绞痛acsacs* *acs, acs, 急性冠脉综合征急性冠脉综合征; tia, ; tia, 一过性脑缺血发作一过性脑缺血发作缺血性肾病缺血性肾病缺血性肠病缺血性肠病16coronary artery disease冠心病冠心病17clinica

7、l classification(1979 who)asymptomatic chd(隐匿型）隐匿型）angina pectoris chd（心绞痛型）（心绞痛型）myocardial infarction chd(心肌梗死型）心肌梗死型）ischemic cardiomyopathy chd（缺血性心肌病型）（缺血性心肌病型）sudden death chd（猝死型）（猝死型）18classification of ihd chronic ischemic syndrome: stable angina asymptomatic chd ischemic cardiomyopathy chd

8、 acute coronary syndrome: unstable angina stemi/nstemi19急性冠脉综合症的病理生理学fuster et al. n engl j med. 1992;326:310-318.davies et al. circulation. 1990;82(suppl ii):ii-38, ii-46.2021angina pectoris22definition of anginaa pain or discomfort in the chest or adjacent areas caused by insufficient blood flow t

9、o the heart muscle.2324clinical classification and pathology stable angina:fixed atheromatous stenosis unstable angina:dynamic obstruction by plaque rupture with superimposed thrombosis and spasm25斑块破裂引起急性严重事件不稳定斑块的进展过程不稳定斑块的进展过程稳定斑块的进展过程稳定斑块的进展过程nissen se. am j cardiol. 2000;86(suppl):12h-17h不稳定斑块不

10、稳定斑块斑块破裂斑块破裂血栓形成血栓形成稳定斑块稳定斑块斑块体积增加斑块体积增加管腔狭窄管腔狭窄26stable angina pectoris27etiology .ischemia is secondary to coronary artery disease in 95% of patients. the leading cause is certainly atherosclerotic coronary artery disease .a decreased oxygen supply or an increase in oxygen demand can lead to a wor

11、sening of symptoms. .ischemia can occur in patients with normal coronary arteries 28clinical menifestationchest discomfortquality - squeezing, griplike, pressurelike, suffocating and heavy”; or a discomfort but not pain. angina is almost never sharp or stabbing, and usually does not change with posi

12、tion or respiration. duration - anginal episode is typically minutes in duration. fleeting discomfort or a dull ache lasting for hours is rarely anginalocation - usually substernal, but radiation to the neck, jaw, epigastrium, or arms is not uncommon. pain above the mandible, below the epigastrium,

13、or localized to a small area over the left lateral chest wall is rarely anginal. provocation - angina is generally precipitated by exertion or emotional stress and commonly relieved by rest. sublingual nitroglycerin also relieves angina, usually within 30 seconds to several minutes. 29categorize the

14、 severity of anginaccs classificationclass 0 asymptomaticclass ion strenuous activityclass iion moderate activity 2 blocks or 2 flights of stairsclass iiion mild activity 2 blocks or 2 flights of stairs class ivrest or minimal activity 30clinical features physical examination an s4 gallop may be tra

15、nsiently present during an episode, and the patient may be dyspneic or diaphoretic or have a new heart murmur. high-risk features of angina include heart failure and hypotension. a complete physical exam is crucial in making an assessment of risk. most pt:(-) 31alternative diagnoses to angina for pa

16、tients with chest painnon-ischemic cvaortic dissectionpericarditispulmonarypulmonary emboluspneumothoraxpneumoniapleuritischest wallcostochondritisfibrositisrib fracturesternoclavicular arthritisherpes zostergastrointestinalesophagealesophagitisspasmrefluxbiliarycoliccholecystitischoledocholithiasis

17、cholangitispeptic ulcerpancreatitispsychiatricanxiety disordershyperventilationpanic disorderprimary anxietyaffective disordersdepressionsomatiform disordersthought disordersfixed occlusions32investigation 12 lead resting ecg should be recorded in all patients with symptoms suggestive of angina pect

18、oris normal in 50% of patients a normal ecg does not exclude severe cad; however, it does imply normal lv function with favorable prognosis33chd chd at rest:at rest: ecgecg34冠心病冠心病 episode of angina:st-segment episode of angina:st-segment depressiondepressionecgecg35chd chd holterholter36exercise te

19、sting 37angina: exercise testinghigh risk patients significant st-segment depression at low levels of exercise and/or heart rate130 fall in systolic blood pressure diminished exercise capacity complex ventricular ectopy at low level of exercise38exercise testingcontraindications miimpending or acute

20、 unstable angina acute myocarditis/pericarditis acute systemic illness severe aortic stenosis congestive heart failure severe hypertension uncontrolled cardiac arrhythmias39investigation echocardiography. the stress echocardiogram is a widely performed test used to assess patients for coronary disea

21、se. baseline echocardiographic images are obtained at rest to evaluate left ventricular function, wall motion, and valve function. images are then acquired during peak stress (that is, during a gxt or with dobutamine) and compared with those at rest. regional wall-motion abnormalities with stress in

22、dicate areas of hypoperfusion or ischemia. 40investigation isotope scanning:obtaining scintiscans of the myocardium at rest and during stress after administration of an intravenous radioactive isotope such as thallium 20141investigation coronary angiography. used to identify foci of coronary disease

23、. it is the evaluation of choice in patients with angina that is (1) poorly responsive to medication, or (2) unstable. it is also indicated in patients with test results consistent with a high risk for cad. 42冠心病冠心病 coronary angiographycoronary angiography43冠心病冠心病 冠状动脉造影冠状动脉造影44冠心病冠心病 lad:stenosis l

24、ad:normal45冠心病冠心病 rca:stenosis lcx:stenosis46chronic stable angina treatment objectives prevent progression of coronary artery disease and optimise life expectancy relieve symptoms47management aspirin beta-adrenoreceptor blocking agents ( -blockers) calcium antagonists nitrates48ncep primary chd ris

25、k goals for lowering ldl-cldl-c goalno chd 2 rf160 mg/dlno chd 2 rf130 mg/dlchd 100 mg/dlthe ncep recommends lowering ldl-c even further than these goals, if possible.risk categorynhlbi; september 199349coronary revascularisation invasive treatment: coronary angioplasty (ptca); coronary artery bypas

26、s grafting (cabg)50冠心病冠心病 cabg51冠心病冠心病 ptca52冠心病冠心病 ptcabefore ptca after ptca53冠心病冠心病 ptca/s54acute coronary syndrome unstable angina non-st elevation myocardial infarction (nstemi) st elevation myocardial infarction(stemi)55unstable angina/nstemi56unstable anginaclinical presentation and classific

27、ation diagnosis of unstable angina refers to new or worsening symptoms of myocardial ischemia: rest angina new-onset severe angina increasing angina5758评估住院期间和出院后长期缺血风险n 评估住院期间死亡风险 (c-index 0.83)* 及出院后6个月死亡风险 (c-index 0.81)* n 多个大型数据库中验证其有效性 (c-indices分别为 0.84*和0.75*)n 评价死亡/再发心梗的长期风险网络版可下载 www.outco

28、/grace*granger cb, et al. arch intern med. 2003;163:2345-2353.*eagle k, at al. jama. 2004;291:2727-2733.59unstable angina chest pain syndrome, either new onset or progressive angina transient st-segment depression on the electrocardiogram (ecg) without evidence of myocardial infarcti

29、on by ck, ck-mb, or troponin60nstemi chest pain syndrome, either new onset or progressive angina transient or persistent st-segment depression on the electrocardiogram (ecg) with evidence of myocardial infarction by ck, ck-mb, or troponin61unstable angina/nstemi significant likelihood of occurrence

30、of major cardiac eventsa. incidence of mi: 8 to 10%b. mortality: 2 to 5%62unstable angina/nstemi:pathophysiology acute plaque fissuring and rupture superimposed thrombus transient occlusion mediator-induced vasospasm may be present63determinants of plaque vulnerability lipid-rich core size cap thick

31、ness cap inflammation and repair6465斑块破裂引起急性严重事件斑块破裂引起急性严重事件不稳定斑块的进展过程不稳定斑块的进展过程稳定斑块的进展过程稳定斑块的进展过程nissen se. am j cardiol. 2000;86(suppl):12h-17h不稳定斑块不稳定斑块斑块破裂斑块破裂血栓形成血栓形成稳定斑块稳定斑块斑块体积增加斑块体积增加管腔狭窄管腔狭窄66physical examinaton not that helpful may have evidence of chf: jvd, rales, edema may have s4 may ha

32、ve murmur of mitral regurgitation from papillary muscle dysfunction67investigation ecg cardiac enzyme or troponin coronary angiography6869acute coronary syndromes70评估住院期间和出院后长期缺血风险n 评估住院期间死亡风险 (c-index 0.83)* 及出院后6个月死亡风险 (c-index 0.81)* n 多个大型数据库中验证其有效性 (c-indices分别为 0.84*和0.75*)n 评价死亡/再发心梗的长期风险网络版可下载 /grace*granger cb, et al. arch intern med. 2003;163:2345-2353.*eagle k, at al. jama. 2004;291:2727-2733.71management admitted to hospital best rest,oxygen anti-platel