冠心病英文版课件

1、冠心病英文版Atherosclerosis &Coronary heart diseasesZhengzhou University, First affiliated HospitalDept. of CardiologyHaiyu Li, M.D. 第一页，共一百一十五页。冠心病英文版Cardiovascular Diseases第二页，共一百一十五页。冠心病英文版Atherosclerosis第三页，共一百一十五页。冠心病英文版leading cause of death and disabilityCommon location:Coronary circulation: Proxim

2、al left anterior descending coronary artery(LAD)Proximal portion of renal arteriesExtracranial circulation to the brainCarotid bifurcationAtherosclerosis第四页，共一百一十五页。冠心病英文版Coronary heart diseaseatherosclerosisCoronary stenosiscoronary spasmMyocardial ischemia, anoxaemiaCoronary heart disease, CHDIsch

3、emic heart disease第五页，共一百一十五页。冠心病英文版AtherosclerosisStable angina pectoris(SAP)Acute coronary syndromeUnstable angina(UAP) and non-STEMI (UA/NSTEMI)ST elevation myocardial infarction(STEMI)第六页，共一百一十五页。冠心病英文版Three fundamental biological processes of atherosclerosisAccumulation of intimal cells:smooth

4、muscle cells MacrophagesT-lymphocytesProliferated connective tissue matrix: collagenelastic fibersproteoglycans3. Accumulation of lipid:cholesterol estersfree cholesterol第七页，共一百一十五页。冠心病英文版Hypothesis of lipoprotein infiltrationAggregation of platelets and thrombosisClonal theory the response-to-injur

5、y hypothesis Atherosclerosis-Hypothesis第八页，共一百一十五页。冠心病英文版Response-to-injury Atherosclerosis: hypothesisHigh blood pressure,bacterium,virus,toxin,ox-LDL,immune factor,vasoactive substanceendothelium damage and dysfunction(vasoactive substance, adhesion and aggregation of monocytes-foam cell, platelet

6、s)Lipidosis, growth factor, proliferation of smooth mucle cells, collagen, lipolytic enzyme, atherosclerosis第九页，共一百一十五页。冠心病英文版Pathology and pathophysiologyFatty steakFibrous plaqueComplicated lesionAtherosclerosisAtherosclerosis第十页，共一百一十五页。冠心病英文版Initiation of AtherosclerosisFatty steak formation第十一页

7、，共一百一十五页。冠心病英文版Initiation of AtherosclerosisFatty steak formation Lipoprotein oxidation Nonenzymatic glycationLeukocyte recruitmentFoam cell formation第十二页，共一百一十五页。冠心病英文版Atheroma evolution: fibrous plaqueAtheroma evolution and complications第十三页，共一百一十五页。冠心病英文版Atheroma evolution:Involvement of arterial

8、 smooth-muscle cellsBlood coagulationmicrovesselsAtheroma evolution and complications第十四页，共一百一十五页。冠心病英文版Complicated lesion: thrombosisAtheroma evolution and complications第十五页，共一百一十五页。冠心病英文版Atheroma evolution and complications第十六页，共一百一十五页。冠心病英文版Intravascular ultrasound第十七页，共一百一十五页。冠心病英文版Classicificat

9、ion of atherosclerotic lesion using IVUS第十八页，共一百一十五页。冠心病英文版Clinicl stages and classificationAbsence of symptom or stage of delitescenceischemianecrosis(target organ )fibrosisAtherosclerosis第十九页，共一百一十五页。冠心病英文版General manifestationAortic atherosclerosisCoronary artery atherosclerosisCerebral atheroscl

10、erosisMesenteric atherosclerosisPeripheral artery atherosclerosisAtherosclerosisclinical manifestation第二十页，共一百一十五页。冠心病英文版 laboratory examinationLack of sensitive and specific methods for early diagnosisDyslipidemia：X-ray：DSA show severity of stenosisDoppler ultrasound: blood flowradionuclide： detect

11、ion of ischemiaEchocardiogram： CHDECG and stress test: CHDNew techniques: intravascular ultrasound, angioscopeCT, MRIAtherosclerosis第二十一页，共一百一十五页。冠心病英文版Risk factors and prevention1.Lifestyle modification2.Lipid disorders (Dyslipidemia): cholesterol screening in all 20yrsElevated: cholesterol (Tc and

12、 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第二十二页，共一百一十五页。冠心病英文版Diabetes mellitus(DM):RR 1.9 for male, 3.3 for female

13、 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第二十三页，共一百一十五页。冠心病英文版7 years incidence of death/non-fatal MI (East West Study)* These patients had no history of myocardi

14、al 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 infarction occured in patiens 65 yrs8. Male gender/ postmenopausal

15、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第二十五页，共一百一十五页。冠心病英文版 Drug therapy：anti-platelet： aspirin, clopidogrel, GPIIb/IIIa inhitibor, Dipyridamole, cilostazolLipid

16、-lowering Risk factors and prevention第二十六页，共一百一十五页。冠心病英文版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. F

17、ibric acid derivatives（fibrates） Gemifibrozil, clofibrate, Fenofibrate5. Cholesterol absorption inhibitors: ezetimibe6. ProbucolLipid-lowering drugs第二十七页，共一百一十五页。冠心病英文版Prevention of CAD A: aspirin,ACEI B: blood pressure, -blocker, C: cigarette smoking, Cholesterol D: diet, diabetes E: exercise, educ

18、ation第二十八页，共一百一十五页。冠心病英文版Third Report of the National 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第二十九页，共一百一十五页。冠心病英文版Coronary heart di

19、sease(CHD)第三十页，共一百一十五页。冠心病英文版Coronary heart disease (CHD)most common cause: obstruction of atheromatous plaqueother causes: spasm arterial thrombi coronary emboli ostial narrowing due to luetic aortitis congenital abnormalities severe LV hypertrophy 第三十一页，共一百一十五页。冠心病英文版Factors effect myocardial oxyg

20、en supply and demandOxygen supplyOxygen demandHeart rateMyocardial contractilitySystolic wall stressoxygen carryingcapacity of bloodCoronary blood flowVascular resistanceExtravascular compressive forcesautoregulationMetabolic regulationHumoral factorNeural regulationDuration of diastolePressure grad

21、ientEndothelial control第三十二页，共一百一十五页。冠心病英文版Coronary 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

22、failure and arrhythmia)： cardiac enlargement, heart failure, arrhythmia, caused by the myocardial fibrosis as the consequence of chronic mycardial ischemiaSudden death： sudden cardiac arrest caused by ventricular fibrillation/flutter第三十三页，共一百一十五页。冠心病英文版Coronary heart disease (CHD) Type： slient ische

23、mia: delitescenceAngina pectoris： myocardial infarction：Ischemic cardiomyopathy (Heart failure and arrhythmia) Sudden death 第三十四页，共一百一十五页。冠心病英文版Acute Coronary Syndrome(ACS)Resting ischemiaNon-ST elevationSTelevationUnstable anginaNon-Q wave AMIQ wave AMI*positive serum cardiac markers *# occasionall

24、y variant angina第三十五页，共一百一十五页。冠心病英文版Stable angina pectoris(SAP)第三十六页，共一百一十五页。冠心病英文版definition: acute and transient myocardial ischemia and anoxaemia usually caused by coronary insufficiency during exertion or emotional stressCharacteristics: paroxysmal precordial squeezing-like chest pain, behind th

25、e mid sternum，radiated to left shoulder and upper armprecipitated by stress or exertionduration:2-5min typically relieved rapidly by rest or nitrates Stable angina pectoris第三十七页，共一百一十五页。冠心病英文版Coronary stenosis(others:aortic valve disease, HOCM, MB) + Myocardial oxygen demand（HR X SBP）increased myoca

26、rdial hypoxiaacumulation of metabolic product, stimulate C1-5 nerve to cause the sensation of chest pain Stable angina pectorismechanism第三十八页，共一百一十五页。冠心病英文版in angiographySignificant coronary lesion with diameter stenosis 70% in 75% ptsNo significant stenosis in about 5-10% pts, Ischemia may be relat

27、ed to coronary spasm or microvascular dysfunction. PathologyStable angina pectoris第三十九页，共一百一十五页。冠心病英文版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 hemo

28、dynamic situation LV contractility and speed, systolic BP, stroke volume, cardiac output decreased LVED pressure and volume Stunning of myocardiumStable angina pectoris第四十页，共一百一十五页。冠心病英文版symptom：chest pain or oppressionlocation behind or slightly to the left of the mid sternum no definite borderline

29、radiated to the left shoulder and upper armAtypical location: lower jaw, the back of neckClinical manifestationStable angina pectoris第四十一页，共一百一十五页。冠心病英文版chest paincharacteristics：tightness, squeezing, burning, pressing, choking, bursting,rarely sharp, not spasmodic force the patient stop the activit

30、y till the symptom relieved precipitationexertion or emotional agitation。duration：35 minspain relief: within several mins after rest or using nitroglycerin Clinical manifestationStable angina pectoris第四十二页，共一百一十五页。冠心病英文版Physical examinationincreased HR, elevated BP anxiety sweatingoccasionally gallo

31、p rhythm，transient systolic murmurClinical manifestationStable angina pectoris第四十三页，共一百一十五页。冠心病英文版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 OMIcontraindicatio

32、n：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第四十四页，共一百一十五页。冠心病英文版Stress te

33、strestExersciseStable angina pectoris第四十五页，共一百一十五页。冠心病英文版 2.Echocardiography: 3. Radionuclide imaging assessment: TL201，Tc99m-sestamibi myocardial perfusion scintigraphy 4.X-ray of heart 5.coronary angiography：final diagnose 6.others: IVUS、intracoronary Doppler flow 、intracoronary pressureLaboratory

34、Stable angina pectoris第四十六页，共一百一十五页。冠心病英文版Coronary Angiography第四十七页，共一百一十五页。冠心病英文版1.Cardiogenic pain：aortic dissection, HOCM, aortic stenosis2.Respiratory：PE, pneumothorax, pleuritis 3.Gastrointestinal: gastro-esophageal diseases, Hiatal hernia, cholecystitis, peptic ulceration, pancreatitis4.Neurom

35、uscular/skeletal ：Tietze Syndrome (Costochondritis), intercostal neuralgia, Herpes zoster5.Psychologic: anxiety, depression, panic attacks Stable angina pectorisDiagnosisChest pain, risk factors, ECG evidence of ischemia during chest pain, angiographyDifferentiation第四十八页，共一百一十五页。冠心病英文版Functional cla

36、ssification 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, after meals, in cold, in wind. Walking more than 2 blocks,climbing more than stairs of 3rd floor. C

37、CS 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. Stable angina pectoris第四十九页，共一百一十五页。冠心病英文版General consideration：rest，avoid provocative factors , ri

38、sk factors control2. 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第五十页，共一百一十五页。冠心病英文版antianginal and

39、anti-ischemic therapyDrug therapyOxygen supplyOxygen demanda.nitratesb.beta-adrenergic blockersc.Calcium antagonistsd.Drugs improving metabolismStable angina pectoris第五十一页，共一百一十五页。冠心病英文版Drug therapya.nitrateslower oxygen demand: decrease arteriolar and venous tone, reduce preload and afterload incre

40、ase coronary supply: Coronary dilatationNitroglycerinIsosorbide dinitrateisosorbide 5-mononitrate (long-acting nitrates)Stable angina pectoris第五十二页，共一百一十五页。冠心病英文版b. blockers: reduce myocardial oxygen: reduce HR, myocardial contractility, BP,the LV wall stress Abslute contraindications：sever bradycar

41、dia: high-degree A-V block, SSS, severe unstable LV failureRelative contraindications:asthma and bronchospastic disease peripheral vascular disease 1-selective：metoprolol, atenolol, bisoprololDrug therapyStable angina pectoris第五十三页，共一百一十五页。冠心病英文版c.Calcium antagonists：Increase oxygen supply: dilate r

42、esistance 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-酮酰酮酰辅酶辅酶(f mi)A硫解酶），硫解酶），partly inhibit FA oxidation Drug therapyStable

43、 angina pectoris第五十四页，共一百一十五页。冠心病英文版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 therapy

44、Stable angina pectoris第五十五页，共一百一十五页。冠心病英文版stentingStable angina pectoris第五十六页，共一百一十五页。冠心病英文版Unstable angina(UAP) and non-STEMI第五十七页，共一百一十五页。冠心病英文版Resting ischemiaNon-ST elevationSTelevationUnstable anginaNon-Q wave AMIQ wave AMI*positive serum cardiac markers *# occasionally variant anginaAcute Coro

45、nary Syndrome(ACS)第五十八页，共一百一十五页。冠心病英文版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-antithrombin

46、 complexesUAP and non-STEMI第五十九页，共一百一十五页。冠心病英文版Occuring at rest (or with mininal exertion): last 20 minssevere and of new-onset: within 1-2 months, CCS IIIOccuring with a deteriorative pattern: at least CCS IIIvariant angina pectoris (Prinzmetal angina): transient ST elevation, caused by the coronar

47、y spasm Definition UAP and non-STEMI第六十页，共一百一十五页。冠心病英文版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 r

48、est, acute ( within the preceding 48 h) UAP and non-STEMI第六十一页，共一百一十五页。冠心病英文版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, hypotension

49、, tachy-arrhythmiaClass B：Primary unstable anginaClass C：Post-infarction UAP (within 2 weeks of a documented MI)UAP and non-STEMI第六十二页，共一百一十五页。冠心病英文版mechanism： 1.plaque rupture and erosion, with nonocclusive thrombus2.dynamic obstruction: Vasoconstruction 3.progressive mechnial obstruction(rapidly a

50、dvancing or ISR following stenting) 4.secondary UA InflammationThrombogenesisUAP and non-STEMI第六十三页，共一百一十五页。冠心病英文版ECG:Non-STEMI: ST depression last 12 hrCardiac biomarkers of myocardium damage: cTnT, cTnICK-MBUAP and non-STEMI第六十四页，共一百一十五页。冠心病英文版Risk stratification：TIMI Risk ScoreAge =65yrsMore than

51、 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,TACTICS-TIMI18UAP and non-STEMI第六十五页，共一百一十五页

52、。冠心病英文版Treatment 1.Genearl management: rest, oxygen, CCU2. Drug therapy A. Anti-ischemic drug: intravenously, orallynitrates -blocker Calcium antagnoist: first choice for variant anginaMorphineUAP and non-STEMI第六十六页，共一百一十五页。冠心病英文版Treatment 2. Drug therapy: B. antithrombotic therapy a. Anti-platelet

53、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 weight heparin(LMWH)Direct anti-thrombin drug: bivalirudin, hirudin UAP and non-STEMI第六十

54、七页，共一百一十五页。冠心病英文版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 sublingual nitroglycerin, retrosternal in location, sweating, scared, and feeling of impending deathin some patients, AMI is manif

55、ested by shock and acute LV failure, not by chest pain ( the elderly)alert the epigastriumpain and abdominal disordersSTEMIClinical manifestation第八十六页，共一百一十五页。冠心病英文版symptomsGeneral：fever、HR increase、WBC ，ESR fastingGastrointestinal symptom：nausea, vomiting, arrhythmias：VPs、AV block, atrial arrhythmi

56、as occurred more often in patients with HFHeart failure: mainly acute LV failure, may develope RV failure. Initial RV failure occure in patients with RV infarction, associated with hypotensionHypotension and shock：SBP80mmHg after pain release, RV infarctionSTEMIClinical manifestation第八十七页，共一百一十五页。冠心

57、病英文版Pump failureClassification based on clinical examination(Killip)Class I：no HF, rales and S3 absent；Class II: mild HF，rales over 50% of lung, with or without s3；Class III: acute pulmonary edema, rales over 50% of lung fields Class IV: cardiogenic shockClassification based on invasive hemodynamic

58、monitoringClass I：Normal, PCWP pulmonary capillary wedge pressure 2.2；Class II: Pulmonary congestion, PCWP 18. CI 2.2；Class III: peripheral hypoperfusion, PCWP 18, CI 18, CI 0.2mV in at least two contiguous leads; new or presumably new LBBB3.Time from onset of symptoms 12hrs：diminishing benefits but may still be useful in selected patinets 4.age 180/110mmHg on at least two reading2. History of chronic, severe hypertension with or without drug therapy3.active peptic ulcer4. History of cerebrovascular accident5.Known bleeding diathesis or current use of anticoagu