心脏疾病患者的护理课件

心臟疾病患者的護理邱愛富心臟疾病患者的護理邱愛富1心臟血管系統的解剖

生理功能

邱愛富

心臟血管系統的解剖

生理功能

2一、心臟的構造與功能:

heartsize:拳頭，250-350gmheartlocation:2/3胸骨中線左側；Base:2nd肋骨；Apex:5th肋間&L’t鎖骨中線heartfunction:deliverO2andotheressentialsubstitutetotissueofbodyremoveCO2&代謝產物一、心臟的構造與功能:

heartsize:拳頭，2503心臟壁層:心包膜(pericardium)1)

外層(壁心包膜)：纖維性—防止heart過度擴張、有保護、固定2)

內層(臟心包膜)：漿膜性—兩層間為心包膜腔，含15-50cc心包膜液，可防止收縮時的磨擦

心外膜(epicardium);心肌(myocardium)--不隨意肌，具橫紋及分枝的纖維，有收縮作用心內膜(endocardium)心臟壁層:心包膜(pericardium)4Coronaryvasculature Rightcoronaryartery(RCA）、Leftmain--Leftanteriordescendingartery(LAD)、Leftcircumflex(LCX)Ascendingaorta(75%atdiastolic)RCA(supplyRA,RV,postLV,90%AVnode)LeftmainLAD(supplyAnt.LV,apex)、LCX(supplylateralLV,LA)

Coronaryvasculature Rightcor5TheCardiacCycleBloodCirculationCircuitsPulmonaryCircuit–lungsSystemicCircuit-wholebodyCardiacCycleSystole–contractionDiastole–relaxationAtriarelaxwhenVentriclescontractandviceversa

TheCardiacCycleBloodCircula6StepsinacontractionWhenatriafillpressureopensAVvalvesAtriacontractionfillsventriclescompletelyVentriclesbegintocontractandAVvalvessnapshut(LUB)Increasedcontraction(inc.pressure)forcessemilunarvalvesopenBloodflowsintovesselsleadingaway.PressureincreasesandforcesSLvalvesshut(DUB)Processbeginsagain

StepsinacontractionWhenatr7CardiacOutput心輸出量(CO)=心搏出量(SV)x心跳速率(HR)心搏出量(Strokevolume)：每一次心室收縮時所排出的血量，同時受到前負荷，後負荷及心臟收縮力的影響心輸出量的決定因素前負荷(preload):心室舒張末期,心肌所承受的張力後負荷(Afterload):心室收縮時所遭遇的阻力心臟收縮力(Contractility)心跳速率與節律(heartrate&rhythm)CardiacOutput心輸出量(CO)=心搏出量(8前負荷(Preload)Frank-Starling定律:舒張容積(=前負荷)心室收縮強度輸出容積(myocardiumfiberlength↑preload↑LVEDV↑SV↑)

臨床上：以進入心室的血量多寡為代表（一般用CVP及PAWP估計）前負荷(Preload)Frank-Starling定律:9Contractility收縮力Vpkfortheleftventricleisaround1.1–1.5m/sinhealthypatients.Inpatientswithcardiacfailureorlowcontractility/inotropythisfiguremightwellbeonly0.6or0.7m/sorevenless.Fortherightventriclethefigurewouldbe0.7to1.2inhealthypatients.

Contractility收縮力Vpkforthele10後負荷(Afterload)Ohm’slaw:R=P/QSVR=(MABP–CVP)/CO(systemicvascularresistance)PVR=(MPAP–LAP)/CO(pulmonaryvascularresistance)臨床評估:SVRandPVRAhighBPmeansthattheventricleispushinguphillHighviscosityandvasoconstrictionmeanhardworkfortheventricle後負荷(Afterload)Ohm’slaw:Ahig11CardiacOutputTheamountofbloodejectedbytheleftventricleinoneminuteCO=HRXSVHeartrateis75beatsperminStrokevolumeis70mlperbeatBloodvolume??docalculation

CO=SVxHR=60-130cc/beatX75beat/min=4-8L/minCardiacOutputTheamountofbl12CardiacfunctionindexEjectionFraction心射出分率Is%ofbloodejectedwitheverybeat=SV/LVEDV=2/3=60-75%(Normal>50%)ReflectLVperformanceCardiacindex(CI)心臟指數Cardiacreserve心臟儲備量CardiacfunctionindexEjection13Cardiacindex(CI)心臟指數IsCOcorrectedfordifferencesinbodysize=CO/bodysurfacearea=2.5-4L/min/m2

/hemo/contract.htm

Cardiacindex(CI)心臟指數IsCOco14Cardiacreserve心臟儲備量Cardiacreserve=abilitytorespondtothedemandforincreasedCO(eg.Exercise,stress)Normal:300-400%Cardiacreserve心臟儲備量Cardiacr15ConductionSystemSinoatrialnode(SAnode)-RA,"fastest"autorhythmictissue(pacemaker,60-100bpm)Atrioventricularnode(AVnode)-lastpartofatriatodepolarizesignalhesitatesthenproceedstoventricles(40-60bpm)AVbundle(bundleofHis)-connectsatriatoventriclesRtandLtbundlebranches-sendsignaltoapexofheartPurkinjefibers-actionpotentialsentthroughoutventricletissue(20-40bpm)

ConductionSystemSinoatrialno16

心臟電氣生理特性自律性(Automaticity)—心肌自動去極化的能力，規則自動的激發衝動(Impulses)的能力，主要由SAnode擔任Pacemaker激搏點興奮性(Excitability)--心肌對於刺激產生去極化的能力(被衝動激發產生興奮)傳導性(Conductivity)--心肌經由細胞膜傳送刺激衝動的能力不反應期(Refractoriness)--心肌仍然處於前一刺激之收縮，無法對於新刺激反應的時期心臟電氣生理特性自律性(Automaticity)—心肌自17

NeurologicControloftheHeartAutonomicnervoussystem(自主神經的控制)SympathicNEβ1↑HR,contractility↑CO,BPParasympathicACH↓HR,contractility

NeurologicControloftheHe18壓力接受器(Baroreceptor)與化學接受(Chemoreceptor)壓力接受器(Baroreceptor：位於頸動脈竇、主動脈竇、心房BP↑baroreceptortrasfermassagetovasomotorcenteratmedulastimulateparasymp.inhibitsymp.↓HR,contractility化學接受器(Chemoreceptor)：位於頸動脈體、主動脈體附近PO2,PH,PCO2↓stimulatechemreceptorvasomotorcenter↑cardiacactivity↑PO2壓力接受器(Baroreceptor)與化學接受(Chem19心臟血管疾病的評估及診斷檢查Nursingassessment:history,GoldenPhysicalexaminationDiagnostictestsLaboratoryHemodynamicmonitoringNon-invasivetestsECG,Treadmill,Echo,Nuclearcardiology,CT,MRIInvasivetestsCardiaccatheterization,Coronaryangiography,electrophysiologicstudy(EPS),endomyocardialbiopsy(EMB),TEE,IVUS心臟血管疾病的評估及診斷檢查Nursingasse20NursingassessmentMaincomplaint:chestpain,dyspnea,fatigue,edema,palpitation,syncopeHistoryofpresentillness:onset,signs&symptomsPastmedicalhistory:previousillness,injuries,surgery,medicationRiskfactors:familyhistory,smoking,activity,diet,personalityGolden’s11functionalhealthpatterns

NursingassessmentMaincompla21ChestPainAssessmentAssessment

AnginaPericarditisProvocation/PalliationExercise/restDeepbreath,平躺/前傾、坐起Quality/Quantity壓迫感、沉重、消化不良感尖銳如刀割Region/Radiation胸骨、頸、左手臂、肩↑Severity中度中至重度Time/onset,duration<10minSeveralhrstodaysChestPainAssessmentAssessmen22DyspneaSOB(shortofbreath)呼吸短促DOE(Dyspneaonexercise/exertion)運動時呼吸困難,最常見於walk,crimbstairOrthopnea端坐呼吸,無法平躺，半坐臥緩解PND(paroxysmalnocturnaldyspnea)夜間陣發性呼吸困難,

DyspneaSOB(shortofbreath)呼23Physicalexamination-Inspection

skin:centralcyanosis(lip,mouth,conjundival)poorarterialcirculationperipheralcyanosis(lip,ear,nail)peripheralvasoconstrictionEyes:arcussenitis老人弓,Xanthelasma黃斑瘤

atherosclerosisPhysicalexamination-Inspecti24Physicalexamination-InspectionFingersclubbing杵狀指PO2↓orlungcancerCapillaryrefill(circulation):pressnailtobranches,colorreturn<2secPhysicalexamination-Inspecti25Physicalexamination-InspectionSkintugor(elastrictry):捏起skin,returntime>30secdehydration,BW↓Edema:press5sec,remove(+<1/4”,++1/4”-1/2”,+++1/2”-1”)Physicalexamination-Inspecti26Physicalexam-VitalsignBP:bilateralBP:L’t&R’tSBPdifference>15mmHg↓aortabloodflowinlowerarmPulsepressure:SBP-DBP=30~50,OrthostaticBP:lying-standing>20dehydration,poorHTN,aortadiseasePhysicalexam-VitalsignBP:27Physicalexam-Vitalsignpulse:rate,rhythm,amplitude,bilateralpulsusparadoxus(奇脈):pulsechangewith呼吸,吸氣pulseweaken,BP↓pulsusalternanus(交替脈):pulsechangewithHR,

pulsation:0=none,+=weak,++=normal,+++=strongPhysicalexam-Vitalsignpulse:28PhysicalexaminationCarotidartery:thrill,bruit(vesselmurmur):arterialnarrowing

Jugularveinpressure(JVP)<2cm

Hepatojugularreflux

PhysicalexaminationCarotid29PhysicalexaminationPalpation&AuscultationofprecordiumAreas:aortic,pulmonary,tricuspid,mitral,apex,PMIS1,S2,Abnormalheartsounds:murmur,click,frictionrubPhysicalexaminationPalpation30Diagnosticstudies

Laboratory：CBC,e-,Cholesterol,HDL,LDL,TG,cardiacenzymes(CPK-MB,LDH,troponinT&I,myoglobin)

PT(prothrombintime),(Internationalnormalizedratio;INR)、PTT,BUN,Cre,glucose

HemodynamicmonitoringCVP=4~12cmH2O;reflectRApressureSwan-Ganz:PAWP

Diagnosticstudies

Laboratory：31EKGEKG3212leadEKG雙極肢體導程(縱切面):I,II,III單極肢體導程(縱切面):aVR,aVL,aVF胸導程(橫切面):V1,V2,V3,V4,V5,V6

12leadEKG雙極肢體導程(縱切面):I,II,33NormalEKGNormalEKG34HolterMonitoring

canrecordheartrateandrhythmwhenpatientsfeelchestpainorsymptomsofanarrhythmiaovera24-hourperiodAmbulatoryECG;DynamicECGDevelopedin1960s

HolterMonitoringcanrecordh35

ExerciseStressTests

(Treadmill;運動心電圖)Dx:CAD,functionalcapacity

TargetHR=85%*maxHR

Positive:STdepression>1mmContraindications:UnstableanginawithrecentchestpainCriticalaorticstenosisSeverehypertrophicobstructivecardiomyopathyUntreatedlife-threateningcardiacarrhythmiasUncompensatedcongestiveheartfailureAdvancedAVblockAcutemyocarditisorpericarditisUncontrolledhypertension

ExerciseStressTests(Treadm36Echocardiography超音波usessoundwavestoproduceanimageoftheheartandtoseehowitisfunctioning.Transducerhighfrequency,shortwavereturn示波鏡、描繪圖影像showthesize,shape,andmovementoftheheartmuscle,valvesdisease,bloodflow,arteries.TypesMotion-mode(收縮、活動),2Dimensional-echo(縱、橫向結構),Doppler(血流方向、流速)Echocardiography超音波usessound37TransesophagealEchocardiography

(TEE)Thetestislikestandardechocardiographyexceptthatthepicturesoftheheartcomefrominsidetheesophagusratherthanthroughthechestwall.NPO6-8hourssprayingthroatwithananestheticatube(probe)putdownthethroatGagreflexreturn,theneating

TransesophagealEchocardiograp38IntravascularUltrasound

(IVUS)isacombinationofechocardiographyandcardiaccatheterization.usessoundwaves,whicharesentthroughacathetertoarteryandheart,toproduceanimageofthecoronaryarteriesandtoseetheircondition.israrelydonealoneorasastrictlydiagnosticprocedure.Itisusuallydonewithatranscatheterinterventionlikeangioplasty.

IntravascularUltrasound

(IVU39ChestXrayMostcommonlyperformedimagingtestforCVsystemForevaluationofcardiacchambersizeandgreatvesselsChestXraywithenlargedheartsizeChestXrayMostcommonlyperfo40Nuclearcardiology(心臟核子醫學檢查)Ejectionfraction+wallmotionEvaluationofcardiacperformanceandregionalwallmotionLeftventriculardiastolicphaseindex(MUGA)UsefulforevaluationofdiastolicfunctionPatientswithatrialfibrillationNuclearcardiology(心臟核子醫學檢查)E41NuclearcardiologyTl-201Singlephotonemissioncomputedtomography(SPECT)

MyocardialperfusionimagingTETTl-201,PersantinTl-201Positronemissiontomography(PET)MyocardialbloodflowandmyocardialviabilityNuclearcardiologyTl-201Singl42NuclearCardiologyTc99鎝同位素(hotspot)：與壞死心肌之Ca++結合聚集於受損或梗塞之心肌部位凸顯梗塞之心肌部位

l

MI4hours可發現，24-72hrs最靈敏

Thallium201myocardialimaging鉈(coldspot):測心肌灌注情形

聚集於心肌供血處，灌注好分佈均勻，缺血處無法進入空白冷點(coldspot)NuclearCardiologyTc99鎝同位素(ho43Computedtomography(CTscan)Cardiacdimensions,calcificationsandfunctionIschemicheartdisease,LVaneurysm,etc.PericardialdiseasePericardialeffusion,constrictivepericarditis,pericardialcystParacardiac,pericardialandcardiacmassesCongenitalheartdiseaseDiseaseofthethoracicaortaAorticdissection,aorticaneurysmPulmonaryembolismComputedtomography(CTscan)C44MagneticResonanceImaging(MRI)

Providea2-Dviewoftheheart,includingthechambersandvalves,withouthavingtoinjectadyeorinsertacatheter.InterferewithpacemakerfunctionCan’tusewithprostheticmetallicdevices(valves,prostheticjoints,pacemakeretc.MagneticResonanceImaging(MR45InvasivetestsCardiaccatheterizationCoronaryangiography(CAG)Electrophyiologicstudy(EPS)Endomyocardialbiopsy(EMB)InvasivetestsCardiaccatheter46心導管術的功能有哪些？

在檢查方面可以達到顯影評估心臟功能、血流的情況或是血管阻塞的情形、記錄心臟氧氣變化、測量心臟電位、測量心臟血管各部位的壓力等。在治療方面可以利用氣球擴張術或置入支架撐開阻塞的血管段、將心律不整的原因給予電燒灼，以及放置心律調整器等。心導管術的功能有哪些？在檢查方面可以達到顯影評估心臟功能、47心導管檢查前需注意之事項

由醫師解釋心導管檢查的利弊，並簽寫同意書。禁食4-6小時。檢查部位（穿刺部位）毛髮剔除。檢查四肢末梢動脈循環及做上記號。須換上手術衣，並取下假牙、義眼、眼鏡、及所有飾物等。檢查前先排空膀胱。心導管檢查前需注意之事項由醫師解釋心導管檢查的利弊，並簽寫48施行心導管之禁忌症

絕對禁忌病患拒絕設備或儀器不足相對禁忌控制不良之心臟衰竭,高血壓,心律不整一個月以內之腦中風發燒/感染電解質不平衡急性消化道出血懷孕易出血之體質或情形無法合作之病人腎衰竭施行心導管之禁忌症絕對禁忌49Cardiaccatheterization

post-cath：vitalsign:q15min*4→q30min*2(or4)→q1h股動脈:bedrest6-8hours,compress4-6hrs橈動脈:bedrest1-2hours,compress2hrscheckwound:bleeding？infection？checkP+P(pulsation&perfusion)？complications：bleeding,hemotoma,dyeallergy,arrhythmia,thrombus

Cardiaccatheterization

post-c50EPS(Electrophysiologicstudy)

understandarrhythmiamechanism(eg.Additionalpathway)effectsofdrugsandablationdecidetheneedofpacemakerEPS(Electrophysiologicstudy51EndomyocardialBiopsy(EMB)GradeFindingRejectionSeverity0NoinfiltratesNone1AFocal(perivascularofinterstisialinfiltrateswithoutnecrosisMild1BDiffusebutnotsparseinfiltratewithoutnecrosisMild2Onefocusonlywithaggressiveinfiltrateand/ormyocytedamageFocalModerate3AMultifocaaddressiveinfiltratesand/ormyocytedamageModerate3BDiffuseinflammatoryinfiltrateswithnecrosisBorderlinesevere4DDiffuseaggressivepolymorphousinfiltratewithedema,hemorhageandvasculitis,withnecrosisSevereInternationalSocietyforHeart&LungTransplantationEndomyocardialBiopsyGradingScheme

EndomyocardialBiopsy(EMB)Grad52ReviewAnatomyandphysiologyoftheheartPhysicalexaminationofcardiovascularsystemNursingassessmentNon-invasivetests:Lab.,chestX-ray,EKG,echo,Nuclearcardiology,CT,MRIInvasivetests:Cath,EPS,EMB,TEE,IVUSReviewAnatomyandphysiologyo53心臟疾病患者的護理邱愛富心臟疾病患者的護理邱愛富54心臟血管系統的解剖

生理功能

邱愛富

心臟血管系統的解剖

生理功能

55一、心臟的構造與功能:

heartsize:拳頭，250-350gmheartlocation:2/3胸骨中線左側；Base:2nd肋骨；Apex:5th肋間&L’t鎖骨中線heartfunction:deliverO2andotheressentialsubstitutetotissueofbodyremoveCO2&代謝產物一、心臟的構造與功能:

heartsize:拳頭，25056心臟壁層:心包膜(pericardium)1)

外層(壁心包膜)：纖維性—防止heart過度擴張、有保護、固定2)

內層(臟心包膜)：漿膜性—兩層間為心包膜腔，含15-50cc心包膜液，可防止收縮時的磨擦

心外膜(epicardium);心肌(myocardium)--不隨意肌，具橫紋及分枝的纖維，有收縮作用心內膜(endocardium)心臟壁層:心包膜(pericardium)57Coronaryvasculature Rightcoronaryartery(RCA）、Leftmain--Leftanteriordescendingartery(LAD)、Leftcircumflex(LCX)Ascendingaorta(75%atdiastolic)RCA(supplyRA,RV,postLV,90%AVnode)LeftmainLAD(supplyAnt.LV,apex)、LCX(supplylateralLV,LA)

Coronaryvasculature Rightcor58TheCardiacCycleBloodCirculationCircuitsPulmonaryCircuit–lungsSystemicCircuit-wholebodyCardiacCycleSystole–contractionDiastole–relaxationAtriarelaxwhenVentriclescontractandviceversa

TheCardiacCycleBloodCircula59StepsinacontractionWhenatriafillpressureopensAVvalvesAtriacontractionfillsventriclescompletelyVentriclesbegintocontractandAVvalvessnapshut(LUB)Increasedcontraction(inc.pressure)forcessemilunarvalvesopenBloodflowsintovesselsleadingaway.PressureincreasesandforcesSLvalvesshut(DUB)Processbeginsagain

StepsinacontractionWhenatr60CardiacOutput心輸出量(CO)=心搏出量(SV)x心跳速率(HR)心搏出量(Strokevolume)：每一次心室收縮時所排出的血量，同時受到前負荷，後負荷及心臟收縮力的影響心輸出量的決定因素前負荷(preload):心室舒張末期,心肌所承受的張力後負荷(Afterload):心室收縮時所遭遇的阻力心臟收縮力(Contractility)心跳速率與節律(heartrate&rhythm)CardiacOutput心輸出量(CO)=心搏出量(61前負荷(Preload)Frank-Starling定律:舒張容積(=前負荷)心室收縮強度輸出容積(myocardiumfiberlength↑preload↑LVEDV↑SV↑)

臨床上：以進入心室的血量多寡為代表（一般用CVP及PAWP估計）前負荷(Preload)Frank-Starling定律:62Contractility收縮力Vpkfortheleftventricleisaround1.1–1.5m/sinhealthypatients.Inpatientswithcardiacfailureorlowcontractility/inotropythisfiguremightwellbeonly0.6or0.7m/sorevenless.Fortherightventriclethefigurewouldbe0.7to1.2inhealthypatients.

Contractility收縮力Vpkforthele63後負荷(Afterload)Ohm’slaw:R=P/QSVR=(MABP–CVP)/CO(systemicvascularresistance)PVR=(MPAP–LAP)/CO(pulmonaryvascularresistance)臨床評估:SVRandPVRAhighBPmeansthattheventricleispushinguphillHighviscosityandvasoconstrictionmeanhardworkfortheventricle後負荷(Afterload)Ohm’slaw:Ahig64CardiacOutputTheamountofbloodejectedbytheleftventricleinoneminuteCO=HRXSVHeartrateis75beatsperminStrokevolumeis70mlperbeatBloodvolume??docalculation

CO=SVxHR=60-130cc/beatX75beat/min=4-8L/minCardiacOutputTheamountofbl65CardiacfunctionindexEjectionFraction心射出分率Is%ofbloodejectedwitheverybeat=SV/LVEDV=2/3=60-75%(Normal>50%)ReflectLVperformanceCardiacindex(CI)心臟指數Cardiacreserve心臟儲備量CardiacfunctionindexEjection66Cardiacindex(CI)心臟指數IsCOcorrectedfordifferencesinbodysize=CO/bodysurfacearea=2.5-4L/min/m2

/hemo/contract.htm

Cardiacindex(CI)心臟指數IsCOco67Cardiacreserve心臟儲備量Cardiacreserve=abilitytorespondtothedemandforincreasedCO(eg.Exercise,stress)Normal:300-400%Cardiacreserve心臟儲備量Cardiacr68ConductionSystemSinoatrialnode(SAnode)-RA,"fastest"autorhythmictissue(pacemaker,60-100bpm)Atrioventricularnode(AVnode)-lastpartofatriatodepolarizesignalhesitatesthenproceedstoventricles(40-60bpm)AVbundle(bundleofHis)-connectsatriatoventriclesRtandLtbundlebranches-sendsignaltoapexofheartPurkinjefibers-actionpotentialsentthroughoutventricletissue(20-40bpm)

ConductionSystemSinoatrialno69

心臟電氣生理特性自律性(Automaticity)—心肌自動去極化的能力，規則自動的激發衝動(Impulses)的能力，主要由SAnode擔任Pacemaker激搏點興奮性(Excitability)--心肌對於刺激產生去極化的能力(被衝動激發產生興奮)傳導性(Conductivity)--心肌經由細胞膜傳送刺激衝動的能力不反應期(Refractoriness)--心肌仍然處於前一刺激之收縮，無法對於新刺激反應的時期心臟電氣生理特性自律性(Automaticity)—心肌自70

NeurologicControloftheHeartAutonomicnervoussystem(自主神經的控制)SympathicNEβ1↑HR,contractility↑CO,BPParasympathicACH↓HR,contractility

NeurologicControloftheHe71壓力接受器(Baroreceptor)與化學接受(Chemoreceptor)壓力接受器(Baroreceptor：位於頸動脈竇、主動脈竇、心房BP↑baroreceptortrasfermassagetovasomotorcenteratmedulastimulateparasymp.inhibitsymp.↓HR,contractility化學接受器(Chemoreceptor)：位於頸動脈體、主動脈體附近PO2,PH,PCO2↓stimulatechemreceptorvasomotorcenter↑cardiacactivity↑PO2壓力接受器(Baroreceptor)與化學接受(Chem72心臟血管疾病的評估及診斷檢查Nursingassessment:history,GoldenPhysicalexaminationDiagnostictestsLaboratoryHemodynamicmonitoringNon-invasivetestsECG,Treadmill,Echo,Nuclearcardiology,CT,MRIInvasivetestsCardiaccatheterization,Coronaryangiography,electrophysiologicstudy(EPS),endomyocardialbiopsy(EMB),TEE,IVUS心臟血管疾病的評估及診斷檢查Nursingasse73NursingassessmentMaincomplaint:chestpain,dyspnea,fatigue,edema,palpitation,syncopeHistoryofpresentillness:onset,signs&symptomsPastmedicalhistory:previousillness,injuries,surgery,medicationRiskfactors:familyhistory,smoking,activity,diet,personalityGolden’s11functionalhealthpatterns

NursingassessmentMaincompla74ChestPainAssessmentAssessment

AnginaPericarditisProvocation/PalliationExercise/restDeepbreath,平躺/前傾、坐起Quality/Quantity壓迫感、沉重、消化不良感尖銳如刀割Region/Radiation胸骨、頸、左手臂、肩↑Severity中度中至重度Time/onset,duration<10minSeveralhrstodaysChestPainAssessmentAssessmen75DyspneaSOB(shortofbreath)呼吸短促DOE(Dyspneaonexercise/exertion)運動時呼吸困難,最常見於walk,crimbstairOrthopnea端坐呼吸,無法平躺，半坐臥緩解PND(paroxysmalnocturnaldyspnea)夜間陣發性呼吸困難,

DyspneaSOB(shortofbreath)呼76Physicalexamination-Inspection

skin:centralcyanosis(lip,mouth,conjundival)poorarterialcirculationperipheralcyanosis(lip,ear,nail)peripheralvasoconstrictionEyes:arcussenitis老人弓,Xanthelasma黃斑瘤

atherosclerosisPhysicalexamination-Inspecti77Physicalexamination-InspectionFingersclubbing杵狀指PO2↓orlungcancerCapillaryrefill(circulation):pressnailtobranches,colorreturn<2secPhysicalexamination-Inspecti78Physicalexamination-InspectionSkintugor(elastrictry):捏起skin,returntime>30secdehydration,BW↓Edema:press5sec,remove(+<1/4”,++1/4”-1/2”,+++1/2”-1”)Physicalexamination-Inspecti79Physicalexam-VitalsignBP:bilateralBP:L’t&R’tSBPdifference>15mmHg↓aortabloodflowinlowerarmPulsepressure:SBP-DBP=30~50,OrthostaticBP:lying-standing>20dehydration,poorHTN,aortadiseasePhysicalexam-VitalsignBP:80Physicalexam-Vitalsignpulse:rate,rhythm,amplitude,bilateralpulsusparadoxus(奇脈):pulsechangewith呼吸,吸氣pulseweaken,BP↓pulsusalternanus(交替脈):pulsechangewithHR,

pulsation:0=none,+=weak,++=normal,+++=strongPhysicalexam-Vitalsignpulse:81PhysicalexaminationCarotidartery:thrill,bruit(vesselmurmur):arterialnarrowing

Jugularveinpressure(JVP)<2cm

Hepatojugularreflux

PhysicalexaminationCarotid82PhysicalexaminationPalpation&AuscultationofprecordiumAreas:aortic,pulmonary,tricuspid,mitral,apex,PMIS1,S2,Abnormalheartsounds:murmur,click,frictionrubPhysicalexaminationPalpation83Diagnosticstudies

Laboratory：CBC,e-,Cholesterol,HDL,LDL,TG,cardiacenzymes(CPK-MB,LDH,troponinT&I,myoglobin)

PT(prothrombintime),(Internationalnormalizedratio;INR)、PTT,BUN,Cre,glucose

HemodynamicmonitoringCVP=4~12cmH2O;reflectRApressureSwan-Ganz:PAWP

Diagnosticstudies

Laboratory：84EKGEKG8512leadEKG雙極肢體導程(縱切面):I,II,III單極肢體導程(縱切面):aVR,aVL,aVF胸導程(橫切面):V1,V2,V3,V4,V5,V6

12leadEKG雙極肢體導程(縱切面):I,II,86NormalEKGNormalEKG87HolterMonitoring

canrecordheartrateandrhythmwhenpatientsfeelchestpainorsymptomsofanarrhythmiaovera24-hourperiodAmbulatoryECG;DynamicECGDevelopedin1960s

HolterMonitoringcanrecordh88

ExerciseStressTests

(Treadmill;運動心電圖)Dx:CAD,functionalcapacity

TargetHR=85%*maxHR

Positive:STdepression>1mmContraindications:UnstableanginawithrecentchestpainCriticalaorticstenosisSeverehypertrophicobstructivecardiomyopathyUntreatedlife-threateningcardiacarrhythmiasUncompensatedcongestiveheartfailureAdvancedAVblockAcutemyocarditisorpericarditisUncontrolledhypertension

ExerciseStressTests(Treadm89Echocardiography超音波usessoundwavestoproduceanimageoftheheartandtoseehowitisfunctioning.Transducerhighfrequency,shortwavereturn示波鏡、描繪圖影像showthesize,shape,andmovementoftheheartmuscle,valvesdisease,bloodflow,arteries.TypesMotion-mode(收縮、活動),2Dimensional-echo(縱、橫向結構),Doppler(血流方向、流速)Echocardiography超音波usessound90TransesophagealEchocardiography

(TEE)Thetestislikestandardechocardiographyexceptthatthepicturesoftheheartcomefrominsidetheesophagusratherthanthroughthechestwall.NPO6-8hourssprayingthroatwithananestheticatube(probe)putdownthethroatGagreflexreturn,theneating

TransesophagealEchocardiograp91IntravascularUltrasound

(IVUS)isacombinationofechocardiographyandcardiaccatheterization.usessoundwaves,whicharesentthroughacathetertoarteryandheart,toproduceanimageofthecoronaryarteriesandtoseetheircondition.israrelydonealoneorasastrictlydiagnosticprocedure.Itisusuallydonewithatranscatheterinterventionlikeangioplasty.

IntravascularUltrasound

(IVU92ChestXrayMostcommonlyperformedimagingtestforCVsystemForevaluationofcardiacchambersizeandgreatvesselsChestXraywithenlargedheartsizeChestXrayMostcommonlyperfo93Nuclearcardiology(心臟核子醫學檢查)Ejectionfraction+wallmotionEvaluationofcardiacperformanceandregionalwallmotionLeftventriculardiastolicphaseindex(MUGA)UsefulforevaluationofdiastolicfunctionPatientswithatrialfibrillationNuclearcardiology(心臟核子醫學檢查)E94NuclearcardiologyTl-201Singlephotonemissioncomputedtomography(SPECT)

MyocardialperfusionimagingTETTl-201,PersantinTl-201Positronemissiontomography(PET)MyocardialbloodflowandmyocardialviabilityNuclearcardiologyTl-201Singl95NuclearCardiologyTc99鎝同位素(hotspot)：與壞死心肌之Ca++結合聚集於受損或梗塞之心肌部位凸顯梗塞之心肌部位

l

MI4hours可發現，24-72hrs最靈敏

Thallium201myocardialimaging鉈(coldspot):測心肌灌注情形

聚集於心肌供血處，灌注好分佈均勻，缺血處無法進入空白冷點(coldspot)NuclearCardiologyTc99鎝同位素(ho96Computedtomography(CTscan)Cardiacdimension