心绞痛的鉴别心绞痛

心绞痛的鉴别心绞痛第1页/共39页病史特点男性，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：V4－V6，I，aVLST0.5-1mm.第2页/共39页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第3页/共39页心绞痛的鉴别(1)Non-ischemicCVAorticdissectionPericarditisPulmonaryPulmonaryembolusPneumothoraxPneumoniaPleuritisGastrointestinal EsophagealEsophagitis, Spasm,RefluxBiliaryColicCholecystitisCholedocholithiasisCholangitisPepticulcerPancreatitis第4页/共39页心绞痛的鉴别(2)ChestWallCostochondritisFibrositisRibfractureSternoclaviculararthritisHerpeszoster(beforetherash)PsychiatricAnxietydisordersHyperventilationPanicdisorderPrimaryanxietyAffectivedisorders(e.g.,depression)SomatiformdisordersThoughtdisorders(e.g.,fixeddelusions)第5页/共39页心绞痛特点SAVESU：Suddenonset;Anteriorchest;Vaguesensation;Exerciseprecipitated;Shortduration;Unanimousattack.第6页/共39页GradingofAnginaPectorisbyCCSCClassI:日常体力活动不引起心绞痛.ClassII:日常体力活动轻度受限.ClassIII:日常体力活动明显受限.ClassIV:任何体力活动都引起症状，可以有休息时心绞痛。第7页/共39页UAP的主要临床表现Restangina:Occurringatrest,usu.>20min,occurringwithinaweekofpresentation.Newonsetangina:AtleastCCSCIIIseverity,<2monthsofinitialpresentation.Increasingangina:Distinctlymorefrequent,longerinduration,lowerinThreshold.(ie.IncreasedbyatleastoneCCSCclassin2months,toatleastCCSCIIIseverity)第8页/共39页NoninvasiveTesting:ECG/ChestX-rayECG:Normalin50%stableangina.Abnormalin50%angina(normalrestECG).Equivocal:QIII,QSinV1,V2.PseudonormalizationofSTdepressionorTinversion.ChestX-ray第9页/共39页ECHO本例:左室肥厚，左室舒张功能减低。室间隔增厚：13mm(7-11mm),左室后壁10mm(7-11mm)。室壁运动正常，各瓣膜结构及功能正常，无心包积液。二尖瓣血流频谱示左室功能减低，E/A=0.5第10页/共39页冠状动脉造影本例冠状动脉造影：前降支中段99％狭窄，回旋支近段90％狭窄，远段50％狭窄。DefinitionofSignificantCAD70%diameterstenosisof1majorepicardialarterysegment.50%diameterstenosisofleftmain.Althoughlesionsoflessstenosiscancauseangina,theyhavemuchlessprognosticsignificance.第11页/共39页第12页/共39页第13页/共39页NoninvasiveTesting:UltrafastComputedTomographyUltrafast(electronbeam)computedtomography(EBCT)forthedetectionandquantificationofcoronarycalcification:Sensitivity(detectionofcalcium):85-100%.Specificity:41-76%.Positivepredictivevalue:55-84%.Negativepredictivevalue:84-100%.第14页/共39页NoninvasiveTesting:ExerciseECG(1)Absolutecontraindications:MIin2days;Significantarrhythmias;SevereAS;SymptomaticHF;AcutePE;Acutemyocarditisorpericarditis;Acuteaorticdissection.第15页/共39页NoninvasiveTesting:ExerciseECG(2)Relativecontraindication:Leftmaincoronarystenosis;ModerateAS;Electrolyteabnormalities;SBP>200mmHg;DBP>110mmHg;Tachy-orBrady-arrhythmias;HighdegreeAVBHCMPorotherformsofOTobstruction;Mentalorphysicalimpairment;第16页/共39页NoninvasiveTesting:ExerciseECG(3)Risk:MIanddeath1/2500tests.Astandardpercentage(often85%)ofage-predicatedmaximumheartrateistargeted.ReportedinestimatedMETsofexercise(OneMETisthestandardbasaloxygenuptakeof3.5ml/kgpermin.)STdepression1mmfor60-80msaftertheendofQRS,duringorafterexercise.第17页/共39页NoninvasiveTesting:ExerciseECG(4)

(Absoluteindicationforstopping):SBPdrop>10mmHgwithischemia;Moderatetosevereangina;Increasingataxia;Dizzinessornearsyncope;Signofpoorperfusion;Technicaldifficulties;SustainedVT;STelevationinleadswithoutQwaves.第18页/共39页NoninvasiveTesting:ExerciseECG(5)

(Relativeindicationforstopping):SBPdrop>10mmHgwithoutischemia;SBP>250orDBP>115mmHg;STdepression>2mm;Markedaxisdeviation;MultifocalPVCs,tripletsPVCs,SVT,heartblockorbradyarrhythmias,BBBorIVCBIncreasingchestpain;Serioussymptoms.第19页/共39页NoninvasiveTesting:ExerciseECG(6)Sensitivity:68%;Specificity:77%Influenceofotherfactorsontest:Digoxin:25-40%abnormalSTdepression.Betablockers:Graduallywithheld48hrs.Anti-HBP,vasodilators,nitrates,flacainide.LBBB:RBBB:LVhypertrophy:Morefalse-positive.RestSTdepression:AdditionalSTsignificant.第20页/共39页StressImagingStudiesGoodcandidatesforstressimaging,asopposedtoexerciseECG:CLBBB,Pacedrhythm,WPWetc.ST>1mmatrest,Unabletoexercise,AnginawithpriorRevascularization.第21页/共39页PharmacologicModalities(Vasodilators)UsedinStressImagingDipyridamole(DIP)inhibitingcellularuptakeofadenosine(apotentcoronaryvasodilators).Theflowincreasebyadenosineisoflessermagnitudethroughstenosticarteries,creatingheterogeneousmyocardialperfusion.SideeffectsofbothDIPandADEarerare,butmaycauseseverebronchospasminpatientswithasthmaorCOPD.第22页/共39页PharmacologicModalities(Dobutamine)UsedinStressImagingInhighdoses(20to40g/kg/min)increasesHR,SBPandmyocardialcontractility.Theflowincrease(2-3times)islessthanthatelicitedbyadenosineordipyridamole.Sideeffectsarefrequent,butthetestappearstobesafeevenintheelderly,includingnausea,anxiety,headache,tremor,VPC,APC,SVT,nonsust-VT,chestpainandangina(8%).第23页/共39页InvasiveTesting-Angiography

(Indications)Chestpain,possibleischemic,coexistingCOPDnotacandidateforExercisetestbecauseofdyspnea;Perfusionimagingwithdipyridamoleoradenosinebecauseofbronchospasmandtheophyllinetherapy;StressECHObecauseofpoorimages.第24页/共39页InvasiveTesting-Angiography

(Indications)TypicaloratypicalsymptomsandahighclinicalprobabilityofseverCAD.Mostappropriateforapatientwithahigh-risktreadmilloutcome.Symptomssuggestivebutnotcharacteristic,specialoccupation,eg.Pilots,firefightersetc.Alowthresholdangiographyisappropriatefordiabetics.第25页/共39页RISKSTRATIFICATIONA.ClinicalAssessmentB.ECG/ChestX-RayNoninvasiveTestingCoronaryAngiographyandLeftVentriculography第26页/共39页RiskStratification

(ClinicalAssessment)PrognosisofCADforDeathorNonfatalMI:

LVfunction:thestrongestpredictor,EFisthemostcommonlyused;Anatomicextentandseverityofcoronarytreeinvolvement.Thenumberofdiseasedvessels.Arecentcoronaryplaquerupture:worseningclinicalsymptomswithunstablefeature;Generalhealthandnoncoronarycomorbidity.第27页/共39页RiskStratification

(ClinicalAssessment)ClinicalParametersPredictiveofSevere(leftmainorthreevessel)CADAge,Gender,Typicalangina,PreviousMI,DManduseofinsulin第28页/共39页RiskStratification

(ECG/ChestX-ray)ECGEvidenceof1previousMI,PersistentST-Tinversion,LBBB,LAB+RBBB,IIorIIIAVB,Af,VT,LVhypertrophy,ChestX-rayCardiomegaly,LVaneurysm,PVcongestionCoronarycalcification第29页/共39页RiskStratification

(NoninvasiveTesting)RestingLVFunctionImportanceofassessmentGlobalLVFunctionSWMAMR,LVAneurysm,LVThrombosis第30页/共39页TREATMENTPharmacologicTherapySuccessfulandInitiatingTreatmentEducationofPatientswithCSARiskFactorsRevascularizationforCSA第31页/共39页OverviewofTreatmentStableangina-Twopurposes:TopreventMIanddeath.Toreducesymptomsofanginaandoccurrenceofischemia.第32页/共39页稳定心绞痛的A，B，C，D，E治疗A=AspirinandAntianginalB=Beta-blockerandBloodpressureC=CigarettesmokingandCholesterolD=DietandDiabetesE=EducationandExercise第33页/共39页ToPreve