qianjy冠心病英文学习教案

1、会计学1qianjy冠心病英文冠心病英文第一页，共116页。Coronary heart diseaseatherosclerosisCoronary stenosiscoronary spasmMyocardial ischemia, anoxaemiaCoronary heart disease, CHDIschemic heart disease第1页/共116页第二页，共116页。AtherosclerosisStable angina pectoris(SAP)Acute coronary syndromeUnstable angina(UAP) and non-STEMI (UA/

2、NSTEMI)ST elevation myocardial infarction(STEMI)elevation .elivein第2页/共116页第三页，共116页。Atherosclerosis.rusklirusis第3页/共116页第四页，共116页。leading cause of death and disabilityCommon location:Coronarykr.neri circulation: Proximalprksiml left anteriorntiri descendingdisendi coronary artery(LAD)Proximal porti

3、on of renal arteriesExtracranial.ekstrkreini:lcirculation to the brainCarotid颈动krtid bifurcationAtherosclerosis第4页/共116页第五页，共116页。Three fundamental biological processes of atherosclerosis1.Accumulation of intimalintml cells:2.smooth muscle cells 3.Macrophagesmkrfeid 4.T-lymphocyteslimfsait5.Prolifer

4、atedprlif.reit connective tissue matrixmeitriks 结缔组织(jid-zzh)基质增生 : 6.collagenkldn7.elasticilstik teoglycans.prutiuglaikns蛋白聚糖 9.3. Accumulation of lipid:10. cholesteryl estersist 11. free cholesterolklst,rol 第5页/共116页第六页，共116页。Hypothesis of lipoprotein infiltrationAggregation of platelet

5、s and thrombosisClonal theory克隆(选择(xunz)学说 the response-to-injury hypothesis Atherosclerosis-Hypothesis第6页/共116页第七页，共116页。Response-to-injury Atherosclerosis: hypothesisHigh blood pressure,bacterium,virus,toxin,ox-LDL,immune factor,vasoactive substanceendothelium damage, metergasis(vasoactive substan

6、ce, adhesion and aggregation of monocytes-foam cell, platelets)Lipidoses, growth factor, proliferation of smooth mucle cells, collagen, lipolytic enzyme, atherosclerosis第7页/共116页第八页，共116页。Pathology and pathophysiologyFatty steakFibrous plaqueComplicated lesionli:nAtherosclerosis第8页/共116页第九页，共116页。In

7、itiation of AtherosclerosisFatty steak formation第9页/共116页第十页，共116页。Initiation of AtherosclerosisFatty steak formation Lipoprotein.lippruti:n oxidation Nonenzymaticnnenzaimtik glycationLeukocyte recruitmentrikru:tmntFoam cell formation第10页/共116页第十一页，共116页。Atheroma evolution: fibrous plaquepl:kAtherom

8、a evolution and complications第11页/共116页第十二页，共116页。Atheroma evolution:Involvement of arterial smooth-muscle cellsBlood coagulationkugjuleinmicrovesselsmaikruveslAtheroma evolution and complications第12页/共116页第十三页，共116页。Complicated lesionli:n: thrombosisAtheroma evolution and complications第13页/共116页第十四

9、页，共116页。Atheroma evolution and complications第14页/共116页第十五页，共116页。Intravascular ultrasoundltr.saund第15页/共116页第十六页，共116页。Classicification of atherosclerotic lesion using IVUS第16页/共116页第十七页，共116页。Clinicl stages and classificationAbsence of symptom or stage of delitescencedeilitesns潜伏(qinf)ischemianecro

10、sis(targett:git organ )fibrosisAtherosclerosis第17页/共116页第十八页，共116页。General manifestationAortic atherosclerosisCoronary artery atherosclerosisCerebralseribrl atherosclerosisRA atherosclerosisMesentericmesnterik atherosclerosisPeripheralprifrl artery atherosclerosisAtherosclerosisclinical manifestatio

11、n第18页/共116页第十九页，共116页。 laboratory lbrtri examinationLack of sensitive and specific methods for early diagnosis.daignusisDyslipidemiadislipidemi：X-ray：DSA show severity of stenosisDoppler ultrasound: blood flowradionuclide： detection of ischemiaEchocardiogram： CHDECG and stress test: CHDNew technique

12、s: intravascular ultrasound, angioscopeCT, MRIAtherosclerosis第19页/共116页第二十页，共116页。Risk factors and prevention1.Lifestyle modification2.Lipid disorders (Dyslipidemia): cholesterol screening in all 20yrsElevated: cholesterol (Tc and LDL-c), TG, ApoB/ApoA,Lp(a), Low: HDL-c LDL lowering by HMG-CoA reduc

13、tase(statins):cardiovascular events 30%，risk of MI 62%3.Hypertension：4.DM,Metabolic syndrome or insulin resistance syndrome: BP, BMI ,TG, serum insulin HDL-c, OGTT第20页/共116页第二十一页，共116页。Diabetes mellitus(DM):RR 1.9 for male, 3.3 for female more diffuse lesion.CAD equivalent 75-80% cause of death in a

14、dult DM are vascular diseases: CAD, cerebrovascular disease, or peripheral vascular diseaseRisk factors and prevention第21页/共116页第二十二页，共116页。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;339:2292

15、34.05101520253035404550Events of MI in 7 yearsNo history of MI OMI No history of MI* OMI non-diabetics diabetics n = 1373n = 1059P 0.001P 40yrs adults ，4/5 fatal myocardial infarction occured in patiens 65 yrs8. Male gender/ postmenopausal state：male:female = 2：1, man develop CHD 10-15 yrs earlier t

16、han woman9. alcohol10. Others: diet,homocysteine, hemostatic factors inflammation/infectionRisk factors and prevention第23页/共116页第二十四页，共116页。 Drug therapy：anti-platelet： aspirin, clopidogrel, GPIIb/IIIa inhitibor, Dipyridamole, cilostazolLipid-lowering Risk factors and prevention第24页/共116页第二十五页，共116页

17、。1.HMG-CoA reductase inhibitors（statins） Atorvastatin,Fluvastatin,Lovastatin,Pravastatin,Simvastatin,Cerivastatin, Rosuvastatin： *elevation of aminopherase, rhabdomyolysis2. Bile acid-binding Resins cholestyramine，colestipol3. Nicotinic Acid：4. Fibric acid derivatives（fibrates） Gemifibrozil, clofibr

18、ate, Fenofibrate5. Cholesterol absorption inhibitors: ezetimibe6. ProbucolLipid-lowering drugs第25页/共116页第二十六页，共116页。A: aspirin,ACEIB: blood pressure, -blocker, C: cigarette smoking, CholesterolD: diet, diabetesE: exercise, educationPrevention of CAD第26页/共116页第二十七页，共116页。Third Report of the National

19、Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults ATP III (adult treatment panel III)Circulation 2002 17/24: 3144-3373Atherosclerosis第27页/共116页第二十八页，共116页。Coronary heart disease(CHD)第28页/共116页第二十九页，共116页。Coronary heart disea

20、se (CHD)most common cause: obstruction of atheromatous plaqueother causes: spasm arterial thrombi coronary emboli ostial narrowing due to luetic aortitis congential abnormalitieds severe LV hypertrophy 第29页/共116页第三十页，共116页。Factors effect myocardial oxygen supply and demandOxygen supplyOxygen demandH

21、eart rateMyocardial contractilitySystolic wall stressoxygen carryingcapacity of bloodCoronary blood flowVascular resistanceExtravascular compressive forcesautoregulationMetabolic regulationHumoral factorNeural regulationDuration of diastolePressure gradientEndothelial control第30页/共116页第三十一页，共116页。Co

22、ronary heart disease Type： slient ischemia: delitescence： (ECG change)Angina pectoris： angina, caused by myocardial ischemia myocardial infarction：acute myocardial ischemic necrosis caused by the occlusion of coronary arteryIschemia cardiomyopathy (Heart failure and arrhythmia)： cardiac enlargement,

23、 heart failure, arrhythmia, caused by the myocardial fibrosis as the consequence of chronic mycardial ischemiaSudden death： sudden cardiac arrest caused death第31页/共116页第三十二页，共116页。Coronary heart disease (CHD) Type： slient ischemia: delitescenceAngina pectoris： myocardial infarction：Ischemic cardiomy

24、opathy (Heart failure and arrhythmia) Sudden death 第32页/共116页第三十三页，共116页。Acute Coronary Syndrome(ACS)Resting ischemiaNon-ST elevationSTelevationUnstable anginaNon-Q wave AMIQ wave AMI*positive serum cardiac markers *# occasionally variant angina第33页/共116页第三十四页，共116页。Stable angina pectoris(SAP)第34页/共

25、116页第三十五页，共116页。definition: acute and transient myocardial ischemia and anoxaemia usually caused by coronary insufficiency during exertionCharacteristics: paroxysmal precordial squeezing-like chest pain, behind the mid sternum，radiated to left shoulder and upper armprecipitated by stress or exertion

26、relieved rapidly by rest or nitrates Stable angina pectoris第35页/共116页第三十六页，共116页。Factors effect myocardial oxygen supply and demandOxygen supplyOxygen demandHeart rateMyocardial contractilitySystolic wall stressoxygen carryingcapacity of bloodCoronary blood flowVascular resistanceExtravascular compr

27、essive forcesautoregulationMetabolic regulationHumoral factorNeural regulationDuration of diastolePressure gradientEndothelial control第36页/共116页第三十七页，共116页。 hypoxia Coronary stenosis(others:aortic valve disease, HOCM, MB) +precipitation Myocardial oxygen demand（HRXSBP）increased myocardial hypoxiaacu

28、mulation of metabolic product, stimulate C1-5 to cause the sensation of chest pain Stable angina pectorismechanism第37页/共116页第三十八页，共116页。in angiographySignificant coronary lesion with diameter stenosis 70% in 75% ptsNo significant stenosis in about 5-10% pts, Ischemia may be related to coronary spasm

29、 or microvascular dysfunction. PathologyStable angina pectoris第38页/共116页第三十九页，共116页。pathophysiology1.Metabolic and electrophysiologyATP reduced, accumulation of acid substances Dysfunction of iron pump (Na+-K+, and Na+-Ca+) Early depolarization (ST deviation) 2.LV function and hemodynamic situation

30、LV contractility and speed, systolic BP, stroke volume, cardiac output decreased LVED pressure and volume Stunning of myocardiumStable angina pectoris第39页/共116页第四十页，共116页。symptom：chest pain or oppressionlocation behind or slightly to the left of the mid sternum no definite borderlineradiated to the

31、left shoulder and upper armAtypical location: lower jaw, the back of neckClinical manifestationStable angina pectoris第40页/共116页第四十一页，共116页。chest paincharacteristics：tightness, squeezing, burning, pressing, choking, bursting,rarely sharp, not spasmodic force the patient stop the activity till the sym

32、ptom relieved precipitationexertion or emotional agitation。duration：35 minspain relief: within several mins after rest or using nitroglycerin Clinical manifestationStable angina pectoris第41页/共116页第四十二页，共116页。Physical examinationincreased HR, elevated BP anxiety zaiticrymo-skin, sweatingoccasionallyk

33、einli gallop rhythm，transient systolic murmurClinical manifestationStable angina pectoris第42页/共116页第四十三页，共116页。Laboratory1.ECG：at rest During chest pain: ST-T change found in 95% ptsHolter: detect of slient ischemiaStress test:indication：suspection of CHD, pre- and post- CABG and PCI, pts with OMIco

34、ntraindication：AMI, UAP,myocarditis, Hypertension, heart failure,aortic stenosis, HOCM, sever arrhythmia, aortic aneurysmEnd of the test：ST or 0.2mV，AP attacks，BP220mmHg，BP drop，ventricular arrhythmiaCriteria for positive: ST segment depression 0.1mV，last 2 minsStable angina pectoris第43页/共116页第四十四页，

35、共116页。Stress testrestExersciseStable angina pectoris第44页/共116页第四十五页，共116页。 2.Echocardiography: 3. Scintigraphy assessment: TL201，Tc99m-sestamibi myocardial perfusion scintigraphy 4.X-ray of heart 5.coronary angiography：final diagnose 6.others: IVUS、intracoronary Doppler flow 、intracoronary pressureL

36、aboratoryStable angina pectoris第45页/共116页第四十六页，共116页。第46页/共116页第四十七页，共116页。Typing of angina pectoris1.exertional angina：（provocated by the increase of myocardial oxygen demand）stable anginarecent onset anginaprogressive (deteriorative) angina 2.spontaneous angina：（not related to the increase of myoc

37、ardial oxygen demand）angina decubitusvariant angina pectoris(Prinzmetal angina)acute coronary insufficiencypostinfarction angina pectoris3.mixed angina： New typing: stable and unstable angian pectorisAngina Pectoris第47页/共116页第四十八页，共116页。1.Cardiogenic pain：aortic dissection, HOCM, aortic stenosis2.Th

38、roacic- respiratory：PE, pneumothorax, pleuritis 3.Gastrointestinal: gastro-esophageal diseases, Hiatal hernia, cholecystitis, peptic ulceration, pancreatitis4.Neuromuscular/skeletal ：Tietze Syndrome (Costochondritis), intercostal neuralgia, Herpes zoster5.Psychologic: anxiety, depression, panic atta

39、cks Stable angina pectorisDiagnosisChest pain, risk factors, ECG evidence of ischemia during chest pain, angiographyDifferentiation第48页/共116页第四十九页，共116页。Chest pain, risk factors, ECG, angiographyDifferentiation: 1.Cardiogenic pain：aortic dissecion, myocarditis, pericarditis, myocardiopathy, severe v

40、alvular diseases (aortic stenosis）2.Throacic- respiratory：pulmonary embolism, infarction, pneumothorax, pleuritis, intrathoracic malignancy, pneumonia3.Gastrointestinal:gastroesophageal reflux, esophagitis, esophageal spasm, Hiatal hernia, cholecystitis, gallstones, peptic ulcer disease, Pancreatiti

41、s4.Neuromuscular/skeletal ：Tietze Syndrome(Costochondritis),intercostal neuralgia, Cervical or thoracic degenerative arthristis, cardiac causalgia, Herpes zoster5.Psychologic: anxiety, depression, panic attacks DiagnosisStable angina pectoris第49页/共116页第五十页，共116页。Functional classification of SAP(CCS

42、)CCS I： no chest pain at ordinary activity. Angina at strenuous or rapid or prolonged exertionCCS II： Slight limitation of ordinary activity. Walking or climbing stairs rapidly, after meals, in cold, in wind. Walking more than 2 blocks,climbing more than stairs of 3rd floor. CCS III： Marked limitati

43、on of ordinary activity. Walking 1 to 2 blocks, climbing stairs of 3rd floor CCS IV：Inability to carry on any activity without discomfortanginal symdrome may be present at rest. Stable angina pectoris第50页/共116页第五十一页，共116页。1.General consideration：rest，avoid provocative factors , risk factors control2

44、. Drug therapy: prevent MI and death symptom relief and quality of life improvment3. Coronary revascularization:percutaneous coronary intervention (PCI) Coronary artery bypass surgery (CABG) SVG, LIMAPrevention and treatmentStable angina pectoris第51页/共116页第五十二页，共116页。antianginal and anti-ischemic th

45、erapyDrug therapyOxygen supplyOxygen demanda.nitratesb.beta-adrenergic blockersc.Calcium antagonistsd.Drugs improving metabolismStable angina pectoris第52页/共116页第五十三页，共116页。Drug therapya.nitrateslower oxygen demand: decrease arteriolar and venous tone, reduce preload and afterload increase coronary s

46、upply: Coronary dilatationNitroglycerinIsosorbide dinitrateisosorbide 5-mononitrate (long-acting nitrates)Stable angina pectoris第53页/共116页第五十四页，共116页。b. blockers: reduce myocardial oxygen: reduce HR, myocardial contractility, BP,the LV wall stress Abslute contraindications：sever bradycardia: high-de

47、gree A-V block, SSS, severe unstable LV failureRelative contraindications:asthma and bronchospastic disease peripheral vascular disease 1-selective：metoprolol, atenolol, bisoprololDrug therapyStable angina pectoris第54页/共116页第五十五页，共116页。c.Calcium antagonists：Increase oxygen supply: dilate conduit and

48、 resistance vessels, release spasm, improve microvascular functionDecrease oxygen demand: negative inotropic effect, decrease BP Antiplatelet effect d. Drugs improving metabolism：trimethazine（vasorel），selectively inhibit 3-KAT（3-酮酰辅酶(f mi)A硫解酶），partly inhibit FA oxidation, Drug therapyStable angina

49、pectoris第55页/共116页第五十六页，共116页。prevent MI and death therapya.antiplatelet angents：ASA，75-325mg/dclopidogrel; ticlopidine: ADP receptor- antagonists:Cilostazol: phosphodiesterase inhititor,50-100mg bidb. Lipid-lowering angents: statins c. Angiotesin-converting enzyme inhibitor (ACEI)Drug therapyStable

50、 angina pectoris第56页/共116页第五十七页，共116页。stentingStable angina pectoris第57页/共116页第五十八页，共116页。Unstable angina(UAP) and non-STEMI第58页/共116页第五十九页，共116页。Resting ischemiaNon-ST elevationSTelevationUnstable anginaNon-Q wave AMIQ wave AMI*positive serum cardiac markers *# occasionally variant anginaAcute Coro

51、nary Syndrome(ACS)第59页/共116页第六十页，共116页。Pathophysiology of ACS stable angina UAP&non-Q-w AMIQ-w AMIAngiographic thrombus0-1%75%90%Increased FPA/TAT0-5%60-80%80-90%Activated platelets0-5%70-80%80-90%Acute coronary occlusion0-1%10-25%90%mortality1-2%3-8%6-15%FPA：fibrinopeptide ATAT：thrombin-antithr

52、ombin complexesUAP and non-STEMI第60页/共116页第六十一页，共116页。Occuring at rest (or with mininal exertion)ectoris: last 20 minssever and of new-onset: within 1-2 months, CCS IIIOccuring with a crescendo pattern: Deterioration of CCS classfication, at least CCS IIIvariant angina pectoris (Prinzmetal angina):

53、transient ST elevation, caused by the coronary spasm Definition (main type)UAP and non-STEMI第61页/共116页第六十二页，共116页。Braunwald classification of unstable anginaSeverity：Class I：New-onset, or accelerated severe anginano rest pain within 2 monthsClass II：Angina at rest, subacute angina at rest (within th

54、e preceding month but not within 48 h)Class III：Angina at rest, acute ( within the preceding 48 h) UAP and non-STEMI第62页/共116页第六十三页，共116页。Braunwald classification of unstable anginaClinical Circumstances Class A：Secondary UAPa clearly identified condition extrinsic to the coronary vascular bed that

55、has intensified myocardial ischemia, e.g. anemia, hypotension, tachy-arrhythmiaClass B：Primary unstable anginaClass C：Post-infarction UAP (within 2 weeks of a documented MI)UAP and non-STEMI第63页/共116页第六十四页，共116页。mechanism： 1.plaque rupture and erosion, with nonocclusive thrombus2.dynamic obstruction

56、: Vasoconstruction 3.progressive mechnial obstruction(rapidly advancing or ISR following stenting) 4.secondary UA InflammationThrombogenesisUAP and non-STEMI第64页/共116页第六十五页，共116页。ECG:Non-STEMI: ST depression last 12 hrCardiac biomarkers of myocardium damage: cTnT, cTnICK-MBUAP and non-STEMI第65页/共116

57、页第六十六页，共116页。Risk stratification：TIMI Risk ScoreAge =65yrsMore than 3 coronary risk factorsPrior angiographic coronary obstructionST-segment deviation 0.5 mmMore than 2 angina events within 24 hoursDevelopment of UA/NSTEMI while on aspirinElevated cardiac markersAntaman, JAMA 2000; 284:835-42TIMI II

58、B, ESSENCE, PRISM-PLUS,TACTICS-TIMI18UAP and non-STEMI第66页/共116页第六十七页，共116页。Treatment 1.Genearl management: rest, oxygen, CCU2. Drug therapy A. Anti-ischemic drug: intravenously, orallynitrates -blocker calciumklsim antagnoist: first choice for variant anginaMorphine sulfateUAP and non-STEMI第67页/共11

59、6页第六十八页，共116页。Treatment 2. Drug therapy: B. antithrombotic therapy a. Anti-platelet Aspirin: early, 300mg loading dose ADP-receptor antagonist: clopidogrel 300mg-600mg loading dose, 75 mg/dGP IIb/IIIa receptor inhibitor: used in pts planned to PCI b. Anticoagulation therapy:HeparinLow molecular weig

60、ht heparin(LMWH)Direct anti-thrombin drug: bivalirudin, hirudin UAP and non-STEMI第68页/共116页第六十九页，共116页。Treatment 2. Drug therapy: C. other medical therapy a. lipid-lowering drugs: statins, early use(in first 24 hrs) LDL-c target: 30 mins，less effective of sublingualsbligwl nitroglycerin, retrosternalret