qianjy冠心病英文学习课程

1、Coronary heart diseaseatherosclerosisCoronary stenosiscoronary spasmMyocardial ischemia, anoxaemiaCoronary heart disease, CHDIschemic heart disease第1页/共116页第一页，编辑于星期六：十八点 二十二分。AtherosclerosisStable angina pectoris(SAP)Acute coronary syndromeUnstable angina(UAP) and non-STEMI (UA/NSTEMI)ST elevation

2、myocardial infarction(STEMI)elevation .elivein第2页/共116页第二页，编辑于星期六：十八点 二十二分。Atherosclerosis.rusklirusis第3页/共116页第三页，编辑于星期六：十八点 二十二分。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页第四页，编辑于星期六：十八点 二十二分。Three fundamental biological processes of atherosclerosis1. Accumulation of intimalintml cells:smooth muscle cells MacrophagesmkrfeidT-lymphocyteslimfsait2.Prol

4、iferatedprlif.reit connective tissue matrixmeitriks 结缔组织基质增生: collagenkldnelasticilstik fibersproteoglycans.prutiuglaikns3. Accumulation of lipid:cholesteryl estersist free cholesterolklst,rol 第5页/共116页第五页，编辑于星期六：十八点 二十二分。Hypothesis of lipoprotein infiltrationAggregation of platelets and thrombosisC

5、lonal theory克隆(选择)学说 the response-to-injury hypothesis Atherosclerosis-Hypothesis第6页/共116页第六页，编辑于星期六：十八点 二十二分。Response-to-injury Atherosclerosis: hypothesisHigh blood pressure,bacterium,virus,toxin,ox-LDL,immune factor,vasoactive substanceendothelium damage, metergasis(vasoactive substance, adhesion

6、 and aggregation of monocytes-foam cell, platelets)Lipidoses, growth factor, proliferation of smooth mucle cells, collagen, lipolytic enzyme, atherosclerosis第7页/共116页第七页，编辑于星期六：十八点 二十二分。Pathology and pathophysiologyFatty steakFibrous plaqueComplicated lesionli:nAtherosclerosis第8页/共116页第八页，编辑于星期六：十八点

7、 二十二分。Initiation of AtherosclerosisFatty steak formation第9页/共116页第九页，编辑于星期六：十八点 二十二分。Initiation of AtherosclerosisFatty steak formation Lipoprotein.lippruti:n oxidation Nonenzymaticnnenzaimtik glycationLeukocyte recruitmentrikru:tmntFoam cell formation第10页/共116页第十页，编辑于星期六：十八点 二十二分。Atheroma evolution

8、: fibrous plaquepl:kAtheroma evolution and complications第11页/共116页第十一页，编辑于星期六：十八点 二十二分。Atheroma evolution:Involvement of arterial smooth-muscle cellsBlood coagulationkugjuleinmicrovesselsmaikruveslAtheroma evolution and complications第12页/共116页第十二页，编辑于星期六：十八点 二十二分。Complicated lesionli:n: thrombosisAt

9、heroma evolution and complications第13页/共116页第十三页，编辑于星期六：十八点 二十二分。Atheroma evolution and complications第14页/共116页第十四页，编辑于星期六：十八点 二十二分。Intravascular ultrasoundltr.saund第15页/共116页第十五页，编辑于星期六：十八点 二十二分。Classicification of atherosclerotic lesion using IVUS第16页/共116页第十六页，编辑于星期六：十八点 二十二分。Clinicl stages and c

10、lassificationAbsence of symptom or stage of delitescencedeilitesnsischemianecrosis(targett:git organ )fibrosisAtherosclerosis第17页/共116页第十七页，编辑于星期六：十八点 二十二分。General manifestationAortic atherosclerosisCoronary artery atherosclerosisCerebralseribrl atherosclerosisRA atherosclerosisMesentericmesnterik a

11、therosclerosisPeripheralprifrl artery atherosclerosisAtherosclerosisclinical manifestation第18页/共116页第十八页，编辑于星期六：十八点 二十二分。 laboratory lbrtri examinationLack of sensitive and specific methods for early diagnosis.daignusisDyslipidemiadislipidemi：X-ray：DSA show severity of stenosisDoppler ultrasound: bl

12、ood flowradionuclide： detection of ischemiaEchocardiogram： CHDECG and stress test: CHDNew techniques: intravascular ultrasound, angioscopeCT, MRIAtherosclerosis第19页/共116页第十九页，编辑于星期六：十八点 二十二分。Risk factors and prevention1.Lifestyle modification2.Lipid disorders (Dyslipidemia): cholesterol screening in

13、 all 20yrsElevated: cholesterol (Tc and LDL-c), TG, ApoB/ApoA,Lp(a), Low: HDL-c LDL lowering by HMG-CoA reductase(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页第二十页，编辑于星期六：十八点 二十

14、二分。Diabetes mellitus(DM):RR 1.9 for male, 3.3 for female more diffuse lesion.CAD equivalent 75-80% cause of death in adult DM are vascular diseases: CAD, cerebrovascular disease, or peripheral vascular diseaseRisk factors and prevention第21页/共116页第二十一页，编辑于星期六：十八点 二十二分。7 years incidence of death/non-f

15、atal MI (East West Study)* These patients had no history of myocardial infarction Haffner SM, et al. N Engl J Med. 1998;339:229234.05101520253035404550Events 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

16、 infarction occured in patiens 65 yrs8. Male gender/ postmenopausal state：male:female = 2：1, man develop CHD 10-15 yrs earlier than woman9. alcohol10. Others: diet,homocysteine, hemostatic factors inflammation/infectionRisk factors and prevention第23页/共116页第二十三页，编辑于星期六：十八点 二十二分。 Drug therapy：anti-pla

17、telet： aspirin, clopidogrel, GPIIb/IIIa inhitibor, Dipyridamole, cilostazolLipid-lowering Risk factors and prevention第24页/共116页第二十四页，编辑于星期六：十八点 二十二分。1.HMG-CoA reductase inhibitors（statins） Atorvastatin,Fluvastatin,Lovastatin,Pravastatin,Simvastatin,Cerivastatin, Rosuvastatin： *elevation of aminopher

18、ase, rhabdomyolysis2. Bile acid-binding Resins cholestyramine，colestipol3. Nicotinic Acid：4. Fibric acid derivatives（fibrates） Gemifibrozil, clofibrate, Fenofibrate5. Cholesterol absorption inhibitors: ezetimibe6. ProbucolLipid-lowering drugs第25页/共116页第二十五页，编辑于星期六：十八点 二十二分。A: aspirin,ACEIB: blood pr

19、essure, -blocker, C: cigarette smoking, CholesterolD: diet, diabetesE: exercise, educationPrevention of CAD第26页/共116页第二十六页，编辑于星期六：十八点 二十二分。Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults ATP II

20、I (adult treatment panel III)Circulation 2002 17/24: 3144-3373Atherosclerosis第27页/共116页第二十七页，编辑于星期六：十八点 二十二分。Coronary heart disease(CHD)第28页/共116页第二十八页，编辑于星期六：十八点 二十二分。Coronary heart disease (CHD)most common cause: obstruction of atheromatous plaqueother causes: spasm arterial thrombi coronary embol

21、i ostial narrowing due to luetic aortitis congential abnormalitieds severe LV hypertrophy 第29页/共116页第二十九页，编辑于星期六：十八点 二十二分。Factors effect myocardial oxygen supply and demandOxygen supplyOxygen demandHeart rateMyocardial contractilitySystolic wall stressoxygen carryingcapacity of bloodCoronary blood f

22、lowVascular resistanceExtravascular compressive forcesautoregulationMetabolic regulationHumoral factorNeural regulationDuration of diastolePressure gradientEndothelial control第30页/共116页第三十页，编辑于星期六：十八点 二十二分。Coronary heart disease Type： slient ischemia: delitescence： (ECG change)Angina pectoris： angin

23、a, caused by myocardial ischemia myocardial infarction：acute myocardial ischemic necrosis caused by the occlusion of coronary arteryIschemia cardiomyopathy (Heart failure and arrhythmia)： cardiac enlargement, heart failure, arrhythmia, caused by the myocardial fibrosis as the consequence of chronic

24、mycardial ischemiaSudden death： sudden cardiac arrest caused death第31页/共116页第三十一页，编辑于星期六：十八点 二十二分。Coronary heart disease (CHD) Type： slient ischemia: delitescenceAngina pectoris： myocardial infarction：Ischemic cardiomyopathy (Heart failure and arrhythmia) Sudden death 第32页/共116页第三十二页，编辑于星期六：十八点 二十二分

25、。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页第三十三页，编辑于星期六：十八点 二十二分。Stable angina pectoris(SAP)第34页/共116页第三十四页，编辑于星期六：十八点 二十二分。definition: acute and transient myoc

26、ardial 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 exertionrelieved rapidly by rest or nitrates Stable angina p

27、ectoris第35页/共116页第三十五页，编辑于星期六：十八点 二十二分。Factors effect myocardial oxygen supply and demandOxygen supplyOxygen demandHeart rateMyocardial contractilitySystolic wall stressoxygen carryingcapacity of bloodCoronary blood flowVascular resistanceExtravascular compressive forcesautoregulationMetabolic regul

28、ationHumoral factorNeural regulationDuration of diastolePressure gradientEndothelial control第36页/共116页第三十六页，编辑于星期六：十八点 二十二分。 hypoxia Coronary stenosis(others:aortic valve disease, HOCM, MB) +precipitation Myocardial oxygen demand（HRXSBP）increased myocardial hypoxiaacumulation of metabolic product, s

29、timulate C1-5 to cause the sensation of chest pain Stable angina pectorismechanism第37页/共116页第三十七页，编辑于星期六：十八点 二十二分。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 or microvascular dysf

30、unction. PathologyStable angina pectoris第38页/共116页第三十八页，编辑于星期六：十八点 二十二分。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 LV contracti

31、lity and speed, systolic BP, stroke volume, cardiac output decreased LVED pressure and volume Stunning of myocardiumStable angina pectoris第39页/共116页第三十九页，编辑于星期六：十八点 二十二分。symptom：chest pain or oppressionlocation behind or slightly to the left of the mid sternum no definite borderlineradiated to the l

32、eft shoulder and upper armAtypical location: lower jaw, the back of neckClinical manifestationStable angina pectoris第40页/共116页第四十页，编辑于星期六：十八点 二十二分。chest paincharacteristics：tightness, squeezing, burning, pressing, choking, bursting,rarely sharp, not spasmodic force the patient stop the activity till

33、 the symptom 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页第四十一页，编辑于星期六：十八点 二十二分。Physical examinationincreased HR, elevated BP anxiety zaiticrymo-skin, swe

34、atingoccasionallykeinli gallop rhythm，transient systolic murmurClinical manifestationStable angina pectoris第42页/共116页第四十二页，编辑于星期六：十八点 二十二分。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-

35、CABG and PCI, pts with OMIcontraindication：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 ang

36、ina pectoris第43页/共116页第四十三页，编辑于星期六：十八点 二十二分。Stress testrestExersciseStable angina pectoris第44页/共116页第四十四页，编辑于星期六：十八点 二十二分。 2.Echocardiography: 3. Scintigraphy assessment: TL201，Tc99m-sestamibi myocardial perfusion scintigraphy 4.X-ray of heart 5.coronary angiography：final diagnose 6.others: IVUS、int

37、racoronary Doppler flow 、intracoronary pressureLaboratoryStable angina pectoris第45页/共116页第四十五页，编辑于星期六：十八点 二十二分。Coronary Angiography第46页/共116页第四十六页，编辑于星期六：十八点 二十二分。Typing of angina pectoris1.exertional angina：（provocated by the increase of myocardial oxygen demand）stable anginarecent onset anginaprog

38、ressive (deteriorative) angina 2.spontaneous angina：（not related to the increase of myocardial oxygen demand）angina decubitusvariant angina pectoris(Prinzmetal angina)acute coronary insufficiencypostinfarction angina pectoris3.mixed angina： New typing: stable and unstable angian pectorisAngina Pecto

39、ris第47页/共116页第四十七页，编辑于星期六：十八点 二十二分。1.Cardiogenic pain：aortic dissection, HOCM, aortic stenosis2.Throacic- respiratory：PE, pneumothorax, pleuritis 3.Gastrointestinal: gastro-esophageal diseases, Hiatal hernia, cholecystitis, peptic ulceration, pancreatitis4.Neuromuscular/skeletal ：Tietze Syndrome (Co

40、stochondritis), intercostal neuralgia, Herpes zoster5.Psychologic: anxiety, depression, panic attacks Stable angina pectorisDiagnosisChest pain, risk factors, ECG evidence of ischemia during chest pain, angiographyDifferentiation第48页/共116页第四十八页，编辑于星期六：十八点 二十二分。Chest pain, risk factors, ECG, angiogra

41、phyDifferentiation: 1.Cardiogenic pain：aortic dissecion, myocarditis, pericarditis, myocardiopathy, severe valvular diseases (aortic stenosis）2.Throacic- respiratory：pulmonary embolism, infarction, pneumothorax, pleuritis, intrathoracic malignancy, pneumonia3.Gastrointestinal:gastroesophageal reflux

42、, esophagitis, esophageal spasm, Hiatal hernia, cholecystitis, gallstones, peptic ulcer disease, Pancreatitis4.Neuromuscular/skeletal ：Tietze Syndrome(Costochondritis),intercostal neuralgia, Cervical or thoracic degenerative arthristis, cardiac causalgia, Herpes zoster5.Psychologic: anxiety, depress

43、ion, panic attacks DiagnosisStable angina pectoris第49页/共116页第四十九页，编辑于星期六：十八点 二十二分。Functional classification of SAP(CCS )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, aft

44、er meals, in cold, in wind. Walking more than 2 blocks,climbing more than stairs of 3rd floor. CCS III： Marked limitation 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. Sta

45、ble angina pectoris第50页/共116页第五十页，编辑于星期六：十八点 二十二分。1. General consideration： rest，avoid provocative factors , risk factors control2. Drug therapy: prevent MI and death symptom relief and quality of life improvment3. Coronary revascularization:percutaneous coronary intervention (PCI) Coronary artery b

46、ypass surgery (CABG) SVG, LIMAPrevention and treatmentStable angina pectoris第51页/共116页第五十一页，编辑于星期六：十八点 二十二分。antianginal and anti-ischemic therapyDrug therapyOxygen supplyOxygen demanda.nitratesb.beta-adrenergic blockersc.Calcium antagonistsd.Drugs improving metabolismStable angina pectoris第52页/共116页

47、第五十二页，编辑于星期六：十八点 二十二分。Drug therapya.nitrateslower oxygen demand: decrease arteriolar and venous tone, reduce preload and afterload increase coronary supply: Coronary dilatationNitroglycerinIsosorbide dinitrateisosorbide 5-mononitrate (long-acting nitrates)Stable angina pectoris第53页/共116页第五十三页，编辑于星期六

48、：十八点 二十二分。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 failureRelative contraindications:asthma and bronchospastic disease peripheral vascular disease 1-se

49、lective：metoprolol, atenolol, bisoprololDrug therapyStable angina pectoris第54页/共116页第五十四页，编辑于星期六：十八点 二十二分。c.Calcium antagonists：Increase oxygen supply: dilate conduit and resistance vessels, release spasm, improve microvascular functionDecrease oxygen demand: negative inotropic effect, decrease BP A

50、ntiplatelet effect d. Drugs improving metabolism：trimethazine（vasorel），selectively inhibit 3-KAT（3-酮酰辅酶A硫解酶），partly inhibit FA oxidation, Drug therapyStable angina pectoris第55页/共116页第五十五页，编辑于星期六：十八点 二十二分。prevent MI and death therapya.antiplatelet angents：ASA，75-325mg/dclopidogrel; ticlopidine: ADP r

51、eceptor- antagonists:Cilostazol: phosphodiesterase inhititor,50-100mg bidb. Lipid-lowering angents: statins c. Angiotesin-converting enzyme inhibitor (ACEI)Drug therapyStable angina pectoris第56页/共116页第五十六页，编辑于星期六：十八点 二十二分。stentingStable angina pectoris第57页/共116页第五十七页，编辑于星期六：十八点 二十二分。Unstable angina(

52、UAP) and non-STEMI第58页/共116页第五十八页，编辑于星期六：十八点 二十二分。Resting ischemiaNon-ST elevationSTelevationUnstable anginaNon-Q wave AMIQ wave AMI*positive serum cardiac markers *# occasionally variant anginaAcute Coronary Syndrome(ACS)第59页/共116页第五十九页，编辑于星期六：十八点 二十二分。Pathophysiology of ACS stable angina UAP&n

53、on-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 occlusion 0-1%10-25%90%mortality1-2%3-8%6-15%FPA：fibrinopeptide ATAT：thrombin-antithrombin complexesUAP and non-STEMI第60页/共116页第六十页，编辑于星期六：十八点 二十二分。Occuring at rest (or

54、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): transient ST elevation, caused by the coronary spasm Definition (main type)

55、UAP and non-STEMI第61页/共116页第六十一页，编辑于星期六：十八点 二十二分。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 the preceding month but not within 48 h)Class III：Angina at rest, a

56、cute ( within the preceding 48 h) UAP and non-STEMI第62页/共116页第六十二页，编辑于星期六：十八点 二十二分。Braunwald classification of unstable anginaClinical Circumstances Class A：Secondary UAPa clearly identified condition extrinsic to the coronary vascular bed that has intensified myocardial ischemia, e.g. anemia, hypot

57、ension, 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页第六十三页，编辑于星期六：十八点 二十二分。mechanism： 1.plaque rupture and erosion, with nonocclusive thrombus2.dynamic obstruction: Vasoconstruction 3.progressive mechnial obs

58、truction(rapidly advancing or ISR following stenting) 4.secondary UA InflammationThrombogenesisUAP and non-STEMI第64页/共116页第六十四页，编辑于星期六：十八点 二十二分。ECG:Non-STEMI: ST depression last 12 hrCardiac biomarkers of myocardium damage: cTnT, cTnICK-MBUAP and non-STEMI第65页/共116页第六十五页，编辑于星期六：十八点 二十二分。Risk stratif

59、ication：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 IIB, ESSENCE, PRISM-PLUS,TA

60、CTICS-TIMI18UAP and non-STEMI第66页/共116页第六十六页，编辑于星期六：十八点 二十二分。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116页第六十七页，编辑于星期六：十八点