方全-心绞痛课件

1、病史特点男性，59岁反复胸痛4个月，加重1个月。胸痛呈压榨性与劳力有关。有高血压，吸烟史。有心脑血管病阳性家族史。查体：体胖，无明显其他阳性发现。ECG：V4V6，I，aVL ST 0.5-1mm.思考胸痛的鉴别心绞痛的特点心绞痛的分级心绞痛的分类不同类型心绞痛的病理基础进一步检查冠心病的易患因素心绞痛的鉴别 (1)Non-ischemic CVAortic dissectionPericarditisPulmonaryPulmonary embolusPneumothoraxPneumoniaPleuritisGastrointestinalEsophagealEsophagitis,Spa

2、sm, RefluxBiliaryColicCholecystitisCholedocholithiasisCholangitisPeptic ulcerPancreatitis心绞痛的鉴别 (2)Chest WallCostochondritisFibrositisRib fractureSternoclavicular arthritisHerpes zoster (before the rash)PsychiatricAnxiety disordersHyperventilationPanic disorderPrimary anxietyAffective disorders(e.g.

3、, depression)Somatiform disordersThought disorders(e.g., fixed delusions)心绞痛特点SAVES U：Sudden onset; Anterior chest; Vague sensation; Exercise precipitated; Short duration; Unanimous attack.UAP 的主要临床表现Rest angina: Occurring at rest, usu. 20min, occurring within a week of presentation.New onset angina

4、: At least CCSC III severity, 200mmHg; DBP 110mmHg; Tachy- or Brady-arrhythmias; High degree AVBHCMP or other forms of OT obstruction;Mental or physical impairment; Noninvasive Testing: Exercise ECG(4)(Absolute indication for stopping):SBP drop 10mmHg with ischemia;Moderate to severe angina;Increasi

5、ng ataxia;Dizziness or near syncope;Sign of poor perfusion; Technical difficulties; Sustained VT;ST elevation in leads without Q waves.Noninvasive Testing: Exercise ECG(5)(Relative indication for stopping):SBP drop 10mmHg without ischemia;SBP 250 or DBP 115mmHg;ST depression 2mm;Marked axis deviatio

6、n;Multifocal PVCs, triplets PVCs, SVT, heart block or bradyarrhythmias, BBB or IVCBIncreasing chest pain; Serious symptoms.Noninvasive Testing: Exercise ECG(6)Sensitivity: 68%; Specificity: 77%Influence of other factors on test:Digoxin: 25-40% abnormal ST depression.Beta blockers: Gradually withheld

7、 48hrs.Anti-HBP, vasodilators, nitrates, flacainide.LBBB:RBBB: LV hypertrophy: More false-positive.Rest ST depression: Additional ST significant.Stress Imaging StudiesGood candidates for stress imaging, as opposed to exercise ECG:CLBBB, Paced rhythm, WPW etc.ST 1mm at rest,Unable to exercise,Angina

8、with prior Revascularization.Pharmacologic Modalities (Vasodilators) Used in Stress ImagingDipyridamole(DIP) inhibiting cellular uptake of adenosine (a potent coronary vasodilators). The flow increase by adenosine is of lesser magnitude through stenostic arteries, creating heterogeneous myocardial p

9、erfusion.Side effects of both DIP and ADE are rare, but may cause severe bronchospasm in patients with asthma or COPD. Pharmacologic Modalities (Dobutamine) Used in Stress ImagingIn high doses (20 to 40g /kg /min) increases HR, SBP and myocardial contractility.The flow increase(2-3 times) is less th

10、an that elicited by adenosine or dipyridamole.Side effects are frequent, but the test appears to be safe even in the elderly, including nausea, anxiety, headache, tremor, VPC, APC, SVT, nonsust-VT, chest pain and angina(8%).Invasive Testing - Angiography(Indications)Typical or atypical symptoms and

11、a high clinical probability of sever CAD.Most appropriate for a patient with a high-risk treadmill outcome.Symptoms suggestive but not characteristic, special occupation, eg. Pilots, firefighters etc.A low threshold angiography is appropriate for diabetics.RISK STRATIFICATIONA. Clinical AssessmentB.

12、 ECG/Chest X-RayNoninvasive TestingCoronary Angiography and Left VentriculographyRisk Stratification(Clinical Assessment)Clinical Parameters Predictive of Severe (left main or three vessel) CADAge, Gender, Typical angina, Previous MI,DM and use of insulinRisk Stratification(ECG/Chest X-ray)ECGEviden

13、ce of 1 previous MI, Persistent ST-T inversion,LBBB, LAB+RBBB, II or III AVB, Af, VT,LV hypertrophy,Chest X-rayCardiomegaly, LV aneurysm, PV congestionCoronary calcificationRisk Stratification(Noninvasive Testing)Resting LV FunctionImportance of assessmentGlobal LV FunctionSWMAMR, LV Aneurysm, LV Th

14、rombosisTREATMENTPharmacologic TherapySuccessful and Initiating TreatmentEducation of Patients with CSARisk FactorsRevascularization for CSAOverview of TreatmentStable angina-Two purposes:To prevent MI and death.To reduce symptoms of angina and occurrence of ischemia.稳定心绞痛的A，B，C，D，E治疗A=Aspirin and A

15、ntianginal B=Beta-blocker and Blood pressureC=Cigarette smoking and CholesterolD=Diet and DiabetesE=Education and ExerciseTo Prevent MI and Death（1抗血小板药物阿斯匹林抑制环氧化酶和 TXA2合成。抵克力得 （Ticlopidine a thienopyridine derivative抑制血小板聚集副作用：中心粒细胞减少, TTPClopidogrel: 如上潘生丁 （Dipyridamole口服增加运动性缺血，不能用做抗血小板药。To Preve

16、nt MI and Death（2抗血栓治疗用于稳定型心绞痛的资料极有限。降脂药物胆固醇降低1使心血管事件下降2。抗心绞痛和抗缺血治疗 受体阻滞剂钙拮抗剂硝酸甘油和硝酸盐类UAP的治疗阿斯匹林肝素 阻滞剂硝酸甘油积极治疗24小时无效时需冠状动脉造影PTCA和CABGCABG：左主干病变。三支病变。二支病变，但其中一支病变在前降支近段。一或二支，无前降支病变，但有SCD或持续VT史。PTCA：二或三支病变，包括前降支近端，但病变适合导管治疗，LV功能正常，无需用药的DM。Conditions Provoking or Exacerbating Ischemia (Increased Oxygen Demand)Non-CardiacHyperthermiaHyperthyroidismSympathomimetic toxicity (e.g., cocaine use)HypertensionAnxietyArteriovenous fistulaeCardiacHCMAortic stenosisDilated CMTachycardiaVentricularSuperventricularConditions Provoking or Exacerbating Ischemia (Decrea