冠心病课件(大医英)

冠状动脉粥样硬化性心脏病

(coronaryatheroscleroticheartdisease)

大连医科大学附属二院心内科牛楠精品冠状动脉粥样硬化性心脏病

(coronaryatheros1动脉粥样硬化

atherosclerosis精品动脉粥样硬化

atherosclerosis精品2IntroductionArteriosclerosisThickeningandlossofelasticityofarterialwallsHardeningofthearteriesGreatestmorbidityandmortalityofallhumandiseasesviaNarrowingWeakening精品IntroductionArteriosclerosis精3PlaqueThatHasBeenSurgicallyRemovedfromCoronaryArteryCourtesyRonaldD.GregoryandJohnRiley,MD.精品PlaqueThatHasBeenSurgicall4

NonModifiableRiskFactorsAgeAdominantinfluenceAtherosclerosisbeginsintheyoung,butdoesnotprecipitateorganinjuryuntillaterinlifeGenderMenmorepronethanwomen,butbyage60-70aboutequalfrequencyFamilyHistoryFamilialclusterofriskfactorsGeneticdifferences精品

NonModifiableRiskFactorsAg5

ModifiableRiskFactors

(potentiallycontrollable)

HyperlipidemiaHypertensionCigarettesmokingDiabetesMellitusElevatedHomocysteineFactorsthataffecthemostasisandthrombosisInfections:Herpesvirus;ChlamydiapneumoniaeObesity,sedentarylifestyle,stress精品

ModifiableRiskFactors

(pot6PathogenesisofAtherosclerosisResponsetoinjuryhypothesisInjurytotheendothelium(dysfunctionalendothelium)ChronicinflammatoryresponseMigrationofSMCfrommediatointimaProliferationofSMCinintimaExcessproductionofECMEnhancedlipidaccumulation精品PathogenesisofAtherosclerosi7Responsetoinjury精品Responsetoinjury精品8Endotheliadysfunction精品Endotheliadysfunction精品9InitiationofFattyStreak精品精品10FattyStreak精品精品11Fibro-fattyAtheroma精品精品12AtherosclerosisTimelineFoamCellsFattyStreakIntermediateLesionAtheromaFibrousPlaqueComplicatedLesion/RuptureAdaptedfromPepineCJ.AmJCardiol.1998;82(suppl104).FromFirstDecadeFromThirdDecadeFromFourthDecadeEndothelialDysfunction精品AtherosclerosisTimelineFoamFa13AHAClassificationofatherosclerosis精品AHAClassificationofatherosc14动脉粥样硬化血栓形成:

具共同病理基础的进展性过程正常脂肪条纹纤维斑块粥样硬化斑块斑块破溃/

裂隙和血栓形成心肌梗死

缺血性中风/TIA

严重的下肢缺血临床无症状心血管死亡年龄增长稳定性心绞痛间歇性跛行不稳定性心绞痛}ACS*ACS,急性冠脉综合征;TIA,一过性脑缺血发作缺血性肾病缺血性肠病精品动脉粥样硬化血栓形成:

具共同病理基础的进展性过程正常脂肪15CoronaryArteryDisease冠心病精品CoronaryArteryDisease冠心病精品16Clinicalclassification(1979WHO)AsymptomaticCHD(隐匿型）AnginapectorisCHD（心绞痛型）MyocardialinfarctionCHD(心肌梗死型）IschemiccardiomyopathyCHD（缺血性心肌病型）SuddendeathCHD（猝死型）精品Clinicalclassification(1979W17ClassificationofIHDChronicischemicsyndrome:stableanginaasymptomaticCHDischemiccardiomyopathyCHDAcutecoronarysyndrome:unstableanginaSTEMI/NSTEMI精品ClassificationofIHDChronici18急性冠脉综合症的病理生理学Fusteretal.NEnglJMed.1992;326:310-318.Daviesetal.Circulation.1990;82(SupplII):II-38,II-46.不稳定血栓(UA/NSTEMI)脂肪池巨噬细胞内在的压力，张力外部的剪切力裂缝大裂缝小裂缝闭合血栓

(STEMI)动脉粥样硬化斑块斑块破裂血栓精品急性冠脉综合症的病理生理学Fusteretal.NE19NoSTElevationSTElevationAcuteCoronarySyndromeUnstableAnginaNQMIQwMINSTEMIMyocardialInfarctionDaviesMJ

Heart83:361,2000IschemicDiscomfortPresentationWorkingDxECGBiochem.MarkerFinalDxHammLancet358:1533,2001精品NoSTElevationSTElevationAc20ANGINAPECTORIS精品ANGINAPECTORIS精品21DefinitionofAngina

Apainordiscomfortinthechestoradjacentareascausedbyinsufficientbloodflowtotheheartmuscle.精品DefinitionofAngina 精品22精品精品23ClinicalclassificationandpathologyStableangina:fixedatheromatousstenosisUnstableangina:dynamicobstructionbyplaquerupturewithsuperimposedthrombosisandspasm精品Clinicalclassificationandpa24斑块破裂引起急性严重事件不稳定心绞痛心肌梗死猝死稳定性(劳力性)心绞痛不稳定斑块的进展过程稳定斑块的进展过程NissenSE.AmJCardiol.2000;86(suppl):12H-17H不稳定斑块斑块破裂血栓形成稳定斑块斑块体积增加管腔狭窄精品斑块破裂引起急性严重事件不稳定心肌梗死猝死稳定性不稳定斑块25Stableanginapectoris精品Stableanginapectoris精品26ETIOLOGY.Ischemiaissecondarytocoronaryarterydiseasein95%ofpatients.Theleadingcauseiscertainlyatheroscleroticcoronaryarterydisease.Adecreasedoxygensupplyoranincreaseinoxygendemandcanleadtoaworseningofsymptoms..Ischemiacanoccurinpatientswithnormalcoronaryarteries精品ETIOLOGY.Ischemiaissecondary27Clinicalmenifestation

chestdiscomfortQuality-"squeezing,""griplike,""pressurelike,""suffocating"and"heavy”;ora"discomfort"butnot"pain."Anginaisalmostneversharporstabbing,andusuallydoesnotchangewithpositionorrespiration.Duration-anginalepisodeistypicallyminutesinduration.FleetingdiscomfortoradullachelastingforhoursisrarelyanginaLocation-usuallysubsternal,butradiationtotheneck,jaw,epigastrium,orarmsisnotuncommon.Painabovethemandible,belowtheepigastrium,orlocalizedtoasmallareaovertheleftlateralchestwallisrarelyanginal.Provocation-anginaisgenerallyprecipitatedbyexertionoremotionalstressandcommonlyrelievedbyrest.Sublingualnitroglycerinalsorelievesangina,usuallywithin30secondstoseveralminutes.精品Clinicalmenifestation

chestd28CategorizetheSeverityofAnginaCCSClassificationClass0asymptomaticClassIonstrenuousactivityClassIIonmoderateactivity

2blocksor2flightsofstairsClassIIIonmildactivity

2blocksor2flightsofstairsClassIVrestorminimalactivity精品CategorizetheSeverityofAn29Clinicalfeatures

PhysicalexaminationAnS4gallopmaybetransientlypresentduringanepisode,andthepatientmaybedyspneicordiaphoreticorhaveanewheartmurmur.High-riskfeaturesofanginaincludeheartfailureandhypotension.Acompletephysicalexamiscrucialinmakinganassessmentofrisk.Mostpt:(-)精品ClinicalfeaturesPhysicalexa30AlternativeDiagnosestoAnginaforPatientswithChestPainNon-IschemicCVaorticdissectionpericarditisPulmonarypulmonaryemboluspneumothoraxpneumoniapleuritisChestWallcostochondritisfibrositisribfracturesternoclaviculararthritisherpeszosterGastrointestinalEsophagealesophagitisspasmrefluxBiliarycoliccholecystitischoledocholithiasischolangitisPepticulcerPancreatitisPsychiatricAnxietydisordershyperventilationpanicdisorderprimaryanxietyAffectivedisordersdepressionSomatiformdisordersThoughtdisordersfixedocclusions精品AlternativeDiagnosestoAngin31Investigation12LeadRestingECGshouldberecordedinallpatientswithsymptomssuggestiveofanginapectorisnormalin50%ofpatientsanormalECGdoesnotexcludesevereCAD;however,itdoesimplynormalLVfunctionwithfavorableprognosis精品Investigation12LeadResting32CHDAtrest:

ECG精品CHDAtrest:ECG精品33冠心病Episodeofangina:ST-segmentdepressionECG精品冠心病Episodeofangina:ST-segme34CHDHolter精品CHDHolter精品35Exercisetesting精品Exercisetesting精品36Angina:ExerciseTesting

HighRiskPatientsSignificantST-segmentdepressionatlowlevelsofexerciseand/orheartrate<130FallinsystolicbloodpressureDiminishedexercisecapacityComplexventricularectopyatlowlevelofexercise精品Angina:ExerciseTesting

High37ExerciseTesting

ContraindicationsMI—impendingoracuteUnstableanginaAcutemyocarditis/pericarditisAcutesystemicillnessSevereaorticstenosisCongestiveheartfailureSeverehypertensionUncontrolledcardiacarrhythmias精品ExerciseTesting

Contraindicat38Investigation

Echocardiography.Thestressechocardiogramisawidelyperformedtestusedtoassesspatientsforcoronarydisease.Baselineechocardiographicimagesareobtainedatresttoevaluateleftventricularfunction,wallmotion,andvalvefunction.Imagesarethenacquiredduringpeakstress(thatis,duringaGXTorwithdobutamine)andcomparedwiththoseatrest.Regionalwall-motionabnormalitieswithstressindicateareasofhypoperfusionorischemia.精品InvestigationEchocardiography39InvestigationIsotopescanning:obtainingscintiscansofthemyocardiumatrestandduringstressafteradministrationofanintravenousradioactiveisotopesuchasthallium201精品InvestigationIsotopescanning:40Investigation

Coronaryangiography.

Usedtoidentifyfociofcoronarydisease.Itistheevaluationofchoiceinpatientswithanginathatis(1)poorlyresponsivetomedication,or(2)unstable.ItisalsoindicatedinpatientswithtestresultsconsistentwithahighriskforCAD.精品InvestigationCoronaryangiogr41冠心病Coronaryangiography精品冠心病Coronaryangiography精品42冠心病冠状动脉造影精品冠心病冠状动脉造影精品43冠心病LAD:stenosis LAD:normal精品冠心病LAD:stenosis LAD:44冠心病RCA:stenosis LCX:stenosis精品冠心病RCA:stenosis LCX:stenosi45ChronicStableAngina

TreatmentObjectivesPreventprogressionofcoronaryarterydiseaseandoptimiselifeexpectancyRelievesymptoms精品ChronicStableAngina

Treatme46ManagementAspirinbeta-adrenoreceptorblockingagents(-blockers)calciumantagonistsNitrates精品ManagementAspirin精品47NCEPPrimaryCHDRisk

GoalsforLoweringLDL-CLDL-CGoalNoCHD<2RF<160mg/dLNoCHD2RF<130mg/dLCHD100mg/dLTheNCEPrecommendsloweringLDL-Cevenfurtherthanthesegoals,ifpossible.RiskCategoryNHLBI;September1993精品NCEPPrimaryCHDRisk

Goalsf48CoronaryrevascularisationInvasivetreatment:coronaryangioplasty(PTCA);coronaryarterybypassgrafting(CABG)精品CoronaryrevascularisationInva49冠心病CABG精品冠心病CABG精品50冠心病PTCA精品冠心病PTCA精品51冠心病PTCABeforePTCA afterPTCA精品冠心病PTCABeforePTCA aft52冠心病PTCA/S精品冠心病PTCA/S精品53AcutecoronarysyndromeUnstableanginaNon-STelevationmyocardialinfarction(NSTEMI)STelevationmyocardialinfarction(STEMI)精品AcutecoronarysyndromeUnstabl54UnstableAngina/NSTEMI精品UnstableAngina/NSTEMI精品55UnstableAngina

ClinicalPresentationandClassificationDiagnosisofunstableanginareferstoneworworseningsymptomsofmyocardialischemia:restanginanew-onsetsevereanginaincreasingangina精品UnstableAngina

ClinicalPrese56精品精品57评估住院期间和出院后长期缺血风险评估住院期间死亡风险

(c-index0.83)*及出院后6个月死亡风险(c-index0.81)**多个大型数据库中验证其有效性(c-indices分别为0.84*和0.75**)评价死亡/再发心梗的长期风险网络版可下载

/GRACE *GrangerCB,etal.ArchinternMed.2003;163:2345-2353. **EagleK,atal.JAMA.2004;291:2727-2733.精品评估住院期间和出院后长期缺血风险评估住院期间死亡风险

(c58UnstableAnginaChestpainsyndrome,eithernewonsetorprogressiveanginaTransientST-segmentdepressionontheelectrocardiogram(ECG)WithoutevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponin精品UnstableAnginaChestpainsynd59NSTEMIChestpainsyndrome,eithernewonsetorprogressiveanginaTransientorpersistentST-segmentdepressionontheelectrocardiogram(ECG)WithevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponin精品NSTEMIChestpainsyndrome,eit60UnstableAngina/NSTEMISignificantlikelihoodofoccurrenceofmajorcardiacevents A.IncidenceofMI:8to10% B.Mortality:2to5%精品UnstableAngina/NSTEMISignific61UnstableAngina/NSTEMI:

PathophysiologyAcuteplaquefissuringandruptureSuperimposedthrombusTransientocclusionMediator-inducedvasospasmmaybepresent精品UnstableAngina/NSTEMI:

Pathop62DeterminantsofPlaqueVulnerabilityLipid-richcoresizeCapthicknessCapinflammationandrepair精品DeterminantsofPlaqueVulnera63精品精品64斑块破裂引起急性严重事件不稳定心绞痛心肌梗死猝死稳定性(劳力性)心绞痛不稳定斑块的进展过程稳定斑块的进展过程NissenSE.AmJCardiol.2000;86(suppl):12H-17H不稳定斑块斑块破裂血栓形成稳定斑块斑块体积增加管腔狭窄精品斑块破裂引起急性严重事件不稳定心肌梗死猝死稳定性不稳定斑块65PhysicalExaminatonNotthathelpfulMayhaveevidenceofCHF:JVD,rales,edemaMayhaveS4Mayhavemurmurofmitralregurgitationfrompapillarymuscledysfunction精品PhysicalExaminatonNotthathe66InvestigationECGCardiacEnzymeorTroponinCoronaryangiography精品InvestigationECG精品67精品精品68AcuteCoronarySyndromes精品AcuteCoronarySyndromes精品69评估住院期间和出院后长期缺血风险评估住院期间死亡风险

(c-index0.83)*及出院后6个月死亡风险(c-index0.81)**多个大型数据库中验证其有效性(c-indices分别为0.84*和0.75**)评价死亡/再发心梗的长期风险网络版可下载

/GRACE *GrangerCB,etal.ArchinternMed.2003;163:2345-2353. **EagleK,atal.JAMA.2004;291:2727-2733.精品评估住院期间和出院后长期缺血风险评估住院期间死亡风险

(c70managementAdmittedtohospitalBestrest,OxygenAnti-platelet:asprin,Clopidogrel,GPIIb/IIIainhibitorsAnticoagulant:UFHorLMWHB-blockerNitrates(intravenous)CCBStatinsACEICoronaryrevascularisation精品managementAdmittedtohospital71DefiniteACSPossibleACS(–)ECG;NormalbiomarkersObserve;repeatECG,markersat4-8hrsNorecurrentpain;(–)follow-upstudiesRecurrentpain;(+)follow-upstudiesStresstest;LVfunctionifischemia(–)test:outptfollow-up(+)testAdmit,UseAcuteIschemiaPathwaySTUseMIGuidelinesNoSTST-T’s,chestpain,

markersInitialChestPain

EvaluationSymptomsSuggestiveofACS精品DefiniteACSPossibleACS(–)EC72AcuteCoronarySyndromes精品AcuteCoronarySyndromes精品73PreparationforDischargeAfterUA/NSTEMIAntiplateletRxASA75-162mg/dayClopidogrel75mg/dayBetaBlockerACEI/ARBEspeciallyifDM,HF,EF<40%,HTNStatinLDL<100mg/dL

(ideally<70mg/dL)SecondaryPreventionMeasuresSmokingCessationBP<140/90mmHGor<130/80mmHGforDMorchronickidneydisease

HbA1C<7%BMI18.5-24.9PhysicalExercise30-60minatleast5days/wk

精品PreparationforDischargeAfte74精品精品75NoSTElevationSTElevationAcuteCoronarySyndromeUnstableAnginaNQMIQwMINSTEMIMyocardialInfarctionDaviesMJ

Heart83:361,2000IschemicDiscomfortPresentationWorkingDxECGBiochem.MarkerFinalDxHammLancet358:1533,2001精品NoSTElevationSTElevationAc76Thankyou精品Thankyou精品77冠状动脉粥样硬化性心脏病

(coronaryatheroscleroticheartdisease)

大连医科大学附属二院心内科牛楠精品冠状动脉粥样硬化性心脏病

(coronaryatheros78动脉粥样硬化

atherosclerosis精品动脉粥样硬化

atherosclerosis精品79IntroductionArteriosclerosisThickeningandlossofelasticityofarterialwallsHardeningofthearteriesGreatestmorbidityandmortalityofallhumandiseasesviaNarrowingWeakening精品IntroductionArteriosclerosis精80PlaqueThatHasBeenSurgicallyRemovedfromCoronaryArteryCourtesyRonaldD.GregoryandJohnRiley,MD.精品PlaqueThatHasBeenSurgicall81

NonModifiableRiskFactorsAgeAdominantinfluenceAtherosclerosisbeginsintheyoung,butdoesnotprecipitateorganinjuryuntillaterinlifeGenderMenmorepronethanwomen,butbyage60-70aboutequalfrequencyFamilyHistoryFamilialclusterofriskfactorsGeneticdifferences精品

NonModifiableRiskFactorsAg82

ModifiableRiskFactors

(potentiallycontrollable)

HyperlipidemiaHypertensionCigarettesmokingDiabetesMellitusElevatedHomocysteineFactorsthataffecthemostasisandthrombosisInfections:Herpesvirus;ChlamydiapneumoniaeObesity,sedentarylifestyle,stress精品

ModifiableRiskFactors

(pot83PathogenesisofAtherosclerosisResponsetoinjuryhypothesisInjurytotheendothelium(dysfunctionalendothelium)ChronicinflammatoryresponseMigrationofSMCfrommediatointimaProliferationofSMCinintimaExcessproductionofECMEnhancedlipidaccumulation精品PathogenesisofAtherosclerosi84Responsetoinjury精品Responsetoinjury精品85Endotheliadysfunction精品Endotheliadysfunction精品86InitiationofFattyStreak精品精品87FattyStreak精品精品88Fibro-fattyAtheroma精品精品89AtherosclerosisTimelineFoamCellsFattyStreakIntermediateLesionAtheromaFibrousPlaqueComplicatedLesion/RuptureAdaptedfromPepineCJ.AmJCardiol.1998;82(suppl104).FromFirstDecadeFromThirdDecadeFromFourthDecadeEndothelialDysfunction精品AtherosclerosisTimelineFoamFa90AHAClassificationofatherosclerosis精品AHAClassificationofatherosc91动脉粥样硬化血栓形成:

具共同病理基础的进展性过程正常脂肪条纹纤维斑块粥样硬化斑块斑块破溃/

裂隙和血栓形成心肌梗死

缺血性中风/TIA

严重的下肢缺血临床无症状心血管死亡年龄增长稳定性心绞痛间歇性跛行不稳定性心绞痛}ACS*ACS,急性冠脉综合征;TIA,一过性脑缺血发作缺血性肾病缺血性肠病精品动脉粥样硬化血栓形成:

具共同病理基础的进展性过程正常脂肪92CoronaryArteryDisease冠心病精品CoronaryArteryDisease冠心病精品93Clinicalclassification(1979WHO)AsymptomaticCHD(隐匿型）AnginapectorisCHD（心绞痛型）MyocardialinfarctionCHD(心肌梗死型）IschemiccardiomyopathyCHD（缺血性心肌病型）SuddendeathCHD（猝死型）精品Clinicalclassification(1979W94ClassificationofIHDChronicischemicsyndrome:stableanginaasymptomaticCHDischemiccardiomyopathyCHDAcutecoronarysyndrome:unstableanginaSTEMI/NSTEMI精品ClassificationofIHDChronici95急性冠脉综合症的病理生理学Fusteretal.NEnglJMed.1992;326:310-318.Daviesetal.Circulation.1990;82(SupplII):II-38,II-46.不稳定血栓(UA/NSTEMI)脂肪池巨噬细胞内在的压力，张力外部的剪切力裂缝大裂缝小裂缝闭合血栓

(STEMI)动脉粥样硬化斑块斑块破裂血栓精品急性冠脉综合症的病理生理学Fusteretal.NE96NoSTElevationSTElevationAcuteCoronarySyndromeUnstableAnginaNQMIQwMINSTEMIMyocardialInfarctionDaviesMJ

Heart83:361,2000IschemicDiscomfortPresentationWorkingDxECGBiochem.MarkerFinalDxHammLancet358:1533,2001精品NoSTElevationSTElevationAc97ANGINAPECTORIS精品ANGINAPECTORIS精品98DefinitionofAngina

Apainordiscomfortinthechestoradjacentareascausedbyinsufficientbloodflowtotheheartmuscle.精品DefinitionofAngina 精品99精品精品100ClinicalclassificationandpathologyStableangina:fixedatheromatousstenosisUnstableangina:dynamicobstructionbyplaquerupturewithsuperimposedthrombosisandspasm精品Clinicalclassificationandpa101斑块破裂引起急性严重事件不稳定心绞痛心肌梗死猝死稳定性(劳力性)心绞痛不稳定斑块的进展过程稳定斑块的进展过程NissenSE.AmJCardiol.2000;86(suppl):12H-17H不稳定斑块斑块破裂血栓形成稳定斑块斑块体积增加管腔狭窄精品斑块破裂引起急性严重事件不稳定心肌梗死猝死稳定性不稳定斑块102Stableanginapectoris精品Stableanginapectoris精品103ETIOLOGY.Ischemiaissecondarytocoronaryarterydiseasein95%ofpatients.Theleadingcauseiscertainlyatheroscleroticcoronaryarterydisease.Adecreasedoxygensupplyoranincreaseinoxygendemandcanleadtoaworseningofsymptoms..Ischemiacanoccurinpatientswithnormalcoronaryarteries精品ETIOLOGY.Ischemiaissecondary104Clinicalmenifestation

chestdiscomfortQuality-"squeezing,""griplike,""pressurelike,""suffocating"and"heavy”;ora"discomfort"butnot"pain."Anginaisalmostneversharporstabbing,andusuallydoesnotchangewithpositionorrespiration.Duration-anginalepisodeistypicallyminutesinduration.FleetingdiscomfortoradullachelastingforhoursisrarelyanginaLocation-usuallysubsternal,butradiationtotheneck,jaw,epigastrium,orarmsisnotuncommon.Painabovethemandible,belowtheepigastrium,orlocalizedtoasmallareaovertheleftlateralchestwallisrarelyanginal.Provocation-anginaisgenerallyprecipitatedbyexertionoremotionalstressandcommonlyrelievedbyrest.Sublingualnitroglycerinalsorelievesangina,usuallywithin30secondstoseveralminutes.精品Clinicalmenifestation

chestd105CategorizetheSeverityofAnginaCCSClassificationClass0asymptomaticClassIonstrenuousactivityClassIIonmoderateactivity

2blocksor2flightsofstairsClassIIIonmildactivity

2blocksor2flightsofstairsClassIVrestorminimalactivity精品CategorizetheSeverityofAn106Clinicalfeatures

PhysicalexaminationAnS4gallopmaybetransientlypresentduringanepisode,andthepatientmaybedyspneicordiaphoreticorhaveanewheartmurmur.High-riskfeaturesofanginaincludeheartfailureandhypotension.Acompletephysicalexamiscrucialinmakinganassessmentofrisk.Mostpt:(-)精品ClinicalfeaturesPhysicalexa107AlternativeDiagnosestoAnginaforPatientswithChestPainNon-IschemicCVaorticdissectionpericarditisPulmonarypulmonaryemboluspneumothoraxpneumoniapleuritisChestWallcostochondritisfibrositisribfracturesternoclaviculararthritisherpeszosterGastrointestinalEsophagealesophagitisspasmrefluxBiliarycoliccholecystitischoledocholithiasischolangitisPepticulcerPancreatitisPsychiatricAnxietydisordershyperventilationpanicdisorderprimaryanxietyAffectivedisordersdepressionSomatiformdisordersThoughtdisordersfixedocclusions精品AlternativeDiagnosestoAngin108Investigation12LeadRestingECGshouldberecordedinallpatientswithsymptomssuggestiveofanginapectorisnormalin50%ofpatientsanormalECGdoesnotexcludesevereCAD;however,itdoesimplynormalLVfunctionwithfavorableprognosis精品Investigation12LeadResting109CHDAtrest:

ECG精品CHDAtrest:ECG精品110冠心病Episodeofangina:ST-segmentdepressionECG精品冠心病Episodeofangina:ST-segme111CHDHolter精品CHDHolter精品112Exercisetesting精品Exercisetesting精品113Angina:ExerciseTesting

HighRiskPatientsSignificantST-segmentdepressionatlowlevelsofexerciseand/orheartrate<130FallinsystolicbloodpressureDiminishedexercisecapacityComplexventricularectopyatlowlevelofexercise精品Angina:ExerciseTesting

High114ExerciseTesting

ContraindicationsMI—impendingoracuteUnstableanginaAcutemyocarditis/pericarditisAcutesystemicillnessSevereaorticstenosisCongestiveheartfailureSeverehypertensionUncontrolledcardiacarrhythmias精品ExerciseTesting

Contraindicat115Investigation

Echocardiography.Thestressechocardiogramisawidelyperformedtestusedtoassesspatientsforcoronarydisease.Baselineechocardiographicimagesareobtainedatresttoevaluateleftventricularfunction,wallmotion,andvalvefunction.Imagesarethenacquiredduringpeakstress(thatis,duringaGXTorwithdobutamine)andcomparedwiththoseatrest.Regionalwall-motionabnormalitieswithstressindicateareasofhypoperfusionorischemia.精品InvestigationEchocardiography116InvestigationIsotopescanning:obtainingscintiscansofthemyocardiumatrestandduringstressafteradministrationofanintravenousradioactiveisotopesuchasthallium201精品InvestigationIsotopescanning:117Investigation

Coronaryangiography.

Usedtoidentifyfociofcoronarydisease.Itistheevaluationofchoiceinpatientswithanginathatis(1)poorlyresponsivetomedication,or(2)unstable.ItisalsoindicatedinpatientswithtestresultsconsistentwithahighriskforCAD.精品InvestigationCoronaryangiogr118冠心病Coronaryangiography精品冠心病Coronaryangiography精品119冠心病冠状动脉造影精品冠心病冠状动脉造影精品120冠心病LAD:stenosis LAD:normal精品冠心病LAD:stenosis LAD:121冠心病RCA:stenosis LCX:stenosis精品冠心病RCA:stenosis LCX:stenosi122ChronicStableAngina

TreatmentObjectivesPreventprogressionofcoronaryarterydiseaseandoptimiselifeexpectancyRelievesymptoms精品ChronicStableAngina

Treatme123ManagementAspirinbeta-adrenoreceptorblockingagents(-blockers)calciumantagonistsNitrates精品ManagementAspirin精品124NCEPPrimaryCHDRisk

GoalsforLoweringLDL-CLDL-CGoalNoCHD<2RF<160mg/dLNoCHD2RF<130mg/dLCHD100mg/dLTheNCEPrecommendsloweringLDL-Cevenfurtherthanthesegoals,ifpossible.RiskCategoryNHLBI;September1993精品NCEPPrimaryCHDRisk

Goalsf125CoronaryrevascularisationInvasivetreatment:coronaryangioplasty(PTCA);coronaryarterybypassgrafting(CABG)精品CoronaryrevascularisationInva126冠心病CABG精品冠心病CABG精品127冠心病PTCA精品冠心病PTCA精品128冠心病PTCABeforePTCA afterPTCA精品冠心病PTCABeforePTCA aft129冠心病PTCA/S精品冠心病PTCA/S精品130AcutecoronarysyndromeUnstableanginaNon-STelevationmyocardialinfarction(NSTEMI)STelevationmyocardialinfarction(STEMI)精品AcutecoronarysyndromeUnstabl131UnstableAngina/NSTEMI精品UnstableAngina/NSTEMI精品132UnstableAngina

ClinicalPresentationandClassificationDiagnosisofunstableanginareferstoneworworseningsymptomsofmyocardialischemia:restanginanew-onsetsevereanginaincreasingangina精品UnstableAngina

ClinicalPrese133精品精品134评估住院期间和出院后长期缺血风险评估住院期间死亡风险

(c-index0.83)*及出院后6个月死亡风险(c-index0.81)**多个大型数据库中验证其有效性(c-indices分别为0.84*和0.75**)评价死亡/再发心梗的长期风险网络版可下载

/GRACE *GrangerCB,etal.ArchinternMed.2003;163:2345-2353. **EagleK,atal.JAMA.2004;291:2727-2733.精品评估住院期间和出院后长期缺血风险评估住院期间死亡风险

(c135UnstableAnginaChestpainsyndrome,eithernewonsetorprogressiveanginaTransientST-segmentdepressionontheelectrocardiogram(ECG)WithoutevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponin精品UnstableAnginaChestpainsynd136NSTEMIChestpainsyndrome,eithernewonsetorprogressiveanginaTransientorpersistentST-segmentdepressionontheelectrocardiogram(ECG)WithevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponin精品NSTEMIChestpainsyndrome,eit137UnstableAngina/NSTEMISignificantlikelihoodofoccurrenceofmajorcardiacevents A.IncidenceofMI:8to10% B.