冠心病完整版

CoronaryArteryDiseaseDefinitionofCoronaryArteryDiseaseCoronaryArteryDisease(CAD)

ismostcommonlycausedbyobstructionofthecoronaryarteriesbyatheromatousplaqueandsecondarythrombosis.AnatomyofcoronaryarteryAtherosclerosisistheconditioninwhichanarterywallthickensastheresultofabuild-upoffattymaterialssuchascholesterol.Definitionofatherosclerosis

FromendothelialdysfunctiontoatherosclerosisEndothelialDysfunctionFatty-StreakFormationAtheromaUnstableAtheromaABDCAtherosclerosis:fromEgyptianmummies

7HighPrevalenceofCoronaryAtherosclerosisinAsymptomaticTeenagersandYoungAdults.EvidenceFromIntravascularUltrasound.Circulation.2001;103:2705.Prevalenceofcoronaryatherosclerosisbyage

Differentstageofatherosclerosis9

Oxygenrequirements(heartrate;contractility;walltension)Oxygensupply(coronarybloodflowandcoronaryarterialO2content)BalanceThefragilityofbalanceProducemyocardialischemiawithcontractilecardiacdysfunction,arrythmias,infarction,andpossiblydeathStableanginapectorisischaracterizedbyadeep,poorlylocalizedchestorarmdiscomfort(rarelydescribedaspain)thatisreproduciblyassociatedwithphysicalexertionoremotionalstressandrelievedwithin5to15minutesbyrestand/orsublingualnitroglycerin.DefinitionofstableanginaChecklistforhistorytaking•

Location•Radiation•Quality•Whatcausesandrelievesit•Durationandfrequency•AssociatedsymptomsLocationandradiationoftypicalanginaQualityofangina•

Stangling•

pressing•squeezing•constricting

•burning•crushing•heavy15Precipitationandaggravatingfactors

•exertion•walking•inthecold•heavymeal•strongemotionorfright16ReliefofPain•

rest•

nitroglycerin17•

sweating:angina•profusesweating:AMI•nauseaandvomiting:AMI

•shortnessofbreath•palpitation•syncopeAccompanyingSymptomsDifferentialdiagnosisGastroesophagealTypesofchestpain•AAspirinandAnti-ischemia•BBloodpressureandBeta-blocker•CCholesterolandCigarettesmoking•DDiabetesandDiet•EExerciseandEducationThegeneralprinciplesofnon-invasivetherapy21AntiplateletsAspirinCholesterolmodulationStatinsAnti-ischemiaBeta-blocker,CalciumBlockerandNitratesACEI/ARBsDrugtreatments稳定性心绞痛的本质是什么？Thincapfibroatheroma(TCFA)VulnerableandstableplaqueVulnerablePlaqueStableplaque25Differentprogresstypesofvulnerableplaque1Adhesion3Aggregation2Activation4ThrombosisPlateletsCoagulationsystem斑块破裂血小板粘附血小板聚集血管腔部分堵塞-不稳定心绞痛血栓脱落，微血管栓塞-非ST段抬高心梗血管腔因血栓形成，急性闭塞-ST段抬高心梗AcutecoronarysyndromeACSNon-STELEVATIONACSSTELEVATIONACS非ST段抬高心梗（NSTEMI）ST段抬高心梗（STEMI）不稳定心绞痛(UA)Unstableanginaisdefinedasanginapectoris(orequivalenttypeofischemicdiscomfort)withatleastoneoffourfeatures:(1)itoccursatrest(orwithminimalexertion)usuallylastingmorethan20minutes(ifnotinterruptedbynitroglycerin);(2)itissevereanddescribedasfrankpainandofnewonset(i.e.,within1month);(3)itoccurswithacrescendopattern(i.e.,moresevere,prolonged,orfrequentthanpreviously);(4)andpost-MIangina.Typesofunstableangina

severeandintolerable.

prolonged,usuallylastingformorethan30minutesandfrequentlyforanumberofhours.

describedasconstricting,crushing,oppressing,orcompressing;asensationofaheavyweightorasqueezinginthechest.

retrosternalinlocation,radiatesdowntheulnaraspectoftheleftarm

notrelievedbyrestandnitroglycerin.

accompaniedbydiaphoresis,nausea,andvomiting.CharacteristicsofchestpaininACSArrhythmia,evensuddendeath

(About50percentofthedeathsassociatedwithAMIoccurwithin1houroftheeventandareattributabletoarrhythmias,mostoftenventricularfibrillation)

AcuteheartfailureShock(includingcardiogenicshock,hypovolumicshock,etal.)SeverecomplicationsinACSECGinACSThedynamicchangesofECG(especiallyST-T)havetheimportancetoassessischmia.ECGExampleinNon-STEMIACS36ECGExampleinSTEMI37ECGNonSTelevationSTelevationBiomarkerUnstableanginaNon-STEMISTEMIACSBiomarkerThelevelofserumbiomarker(TroponinI,TandCK-MB)isusedtoevaluatetheextentofcardiomyocyteinjuryandnecrosisShort-termmortalityofACSEurHeartJ,2002;23:1190–1201.EuroHeartSurveyACSLong-termmortalityofACSCirculation.2009;119:3110-3117.TreatmentofACSAnti-thrombotictherapyAnti-platelettherapy

AspirinADPreceptorantagonist(Clopidogrel)GPⅡb/Ⅲaantagonist…Anti-coagulationtherapy

unfractionatedheparinlow-molecularweightheparin(LMWH)

ⅩainhibitorDirectthrombosisantagonist…ClassIIntheabsenceofcontraindications,fibrinolytictherapyshouldbeadministeredtoSTEMIpatientswithsymptomonsetwithintheprior12hoursandSTelevationgreaterthan0.1mVinatleast2contiguousprecordialleadsoratleast2adjacentlimbleads.(LevelofEvidence:A)2.Intheabsenceofcontraindications,fibrinolytictherapyshouldbeadministeredtoSTEMIpatientswithsymptomonsetwithintheprior12hoursandneworpresumablynewLBBB.(LevelofEvidence:A)RecommendationsforThrombolysisContraindicationsforThrombolysisThrombolysisforSTEMITheLancet1994;343:311-22.CoronaryArteryBypassSurgery(CABG)47Percut