《冠心病英文版》

Atherosclerosis&CoronaryheartdiseasesZhengzhouUniversity,FirstaffiliatedHospitalDept.ofCardiologyHaiyuLi,M.D.1整理课件CardiovascularDiseases2整理课件Atherosclerosis3整理课件leadingcauseofdeathanddisabilityCommonlocation:Coronarycirculation:Proximalleftanteriordescending

coronaryartery(LAD)ProximalportionofrenalarteriesExtracranial

circulationtothebrainCarotidbifurcationAtherosclerosis4整理课件CoronaryheartdiseaseatherosclerosisCoronarystenosiscoronaryspasmMyocardialischemia,anoxaemiaCoronaryheartdisease,CHDIschemicheartdisease5整理课件AtherosclerosisStableanginapectoris(SAP)AcutecoronarysyndromeUnstableangina(UAP)andnon-STEMI(UA/NSTEMI)STelevationmyocardialinfarction(STEMI)6整理课件ThreefundamentalbiologicalprocessesofatherosclerosisAccumulationofintimalcells:smoothmusclecellsMacrophagesT-lymphocytesProliferatedconnectivetissuematrix

:collagenelastic

fibersproteoglycans3.Accumulationoflipid:cholesterolestersfreecholesterol7整理课件HypothesisoflipoproteininfiltrationAggregationofplateletsandthrombosisClonaltheorytheresponse-to-injuryhypothesisAtherosclerosis-Hypothesis8整理课件Response-to-injuryAtherosclerosis:hypothesisHighbloodpressure,bacterium,virus,toxin,ox-LDL,immunefactor,vasoactivesubstanceendotheliumdamageanddysfunction(vasoactivesubstance,adhesionandaggregationofmonocytes-foamcell,platelets)Lipidosis,growthfactor,proliferationofsmoothmuclecells,collagen,lipolyticenzyme,atherosclerosis9整理课件PathologyandpathophysiologyFattysteakFibrousplaqueComplicatedlesionAtherosclerosis10整理课件InitiationofAtherosclerosisFattysteakformation11整理课件InitiationofAtherosclerosisFattysteakformation

Lipoprotein

oxidationNonenzymatic

glycationLeukocyterecruitmentFoamcellformation12整理课件Atheromaevolution:fibrousplaqueAtheromaevolutionandcomplicationsVascularremodeling:compensatoryenlargement13整理课件Atheromaevolution:Involvementofarterialsmooth-musclecellsBloodcoagulationmicrovesselsAtheromaevolutionandcomplications14整理课件炎症细胞少量平滑肌细胞激活的巨噬细胞血栓Complicatedlesion:thrombosisAtheromaevolutionandcomplications15整理课件AtheromaevolutionandcomplicationsVulnerableplaque:ThinfibrouscapRelativelylargelipidcoreHighcontentofmacrophagesInflammatorymediators16整理课件Intravascularultrasound

17整理课件ClassicificationofatheroscleroticlesionusingIVUS18整理课件CliniclstagesandclassificationAbsenceofsymptomorstageofdelitescenceischemianecrosis(targetorgan)fibrosisAtherosclerosis19整理课件GeneralmanifestationAorticatherosclerosisCoronaryarteryatherosclerosisCerebralatherosclerosisMesentericatherosclerosisPeripheralarteryatherosclerosisAtherosclerosisclinicalmanifestation20整理课件

laboratoryexaminationLackofsensitiveandspecificmethodsforearlydiagnosisDyslipidemia：X-ray：DSAshowseverityofstenosisDopplerultrasound:bloodflowradionuclide：detectionofischemiaEchocardiogram：CHDECGandstresstest:CHDNewtechniques:intravascularultrasound,angioscopeCT,MRIAtherosclerosis21整理课件Riskfactorsandprevention1.Lifestylemodification2.Lipiddisorders(Dyslipidemia):cholesterolscreeninginall>20yrsElevated:cholesterol(TcandLDL-c),TG,ApoB/ApoA,Lp(a),Low:HDL-cLDLloweringbyHMG-CoAreductase(statins):cardiovascularevents30%，riskofMI62%3.Hypertension：4.DM,Metabolicsyndromeorinsulinresistancesyndrome:

BP,BMI,TG,seruminsulin

HDL-c

22整理课件Diabetesmellitus(DM):RR1.9formale,3.3forfemalemorediffuselesion.CADequivalent

75-80%causeofdeathinadultDMarevasculardiseases:CAD,cerebrovasculardisease,orperipheralvasculardiseaseRiskfactorsandprevention23整理课件7yearsincidenceofdeath/non-fatalMI

(EastWestStudy)*ThesepatientshadnohistoryofmyocardialinfarctionHaffnerSM,etal.NEnglJMed.1998;339:229–234.05101520253035404550EventsofMIin7yearsNohistoryofMIOMINohistoryofMI*OMInon-diabetics diabetics n=1373 n=1059P<0.001P<0.0014%19%20%45%DM:CADequivalent24整理课件5.

Cigarettesmoking：morethrombogenic6.

Familyhistory：geneticfactor7.

Aging：>40yrsadults，4/5fatalmyocardialinfarctionoccuredinpatiens>65yrs8.Malegender/postmenopausalstate：male:female=2：1,mandevelopCHD10-15yrsearlierthanwoman9.alcohol10.Others:diet,homocysteine,hemostaticfactorsinflammation/infectionRiskfactorsandprevention25整理课件

Drugtherapy：anti-platelet：

aspirin,clopidogrel,GPIIb/IIIainhitibor,Dipyridamole,cilostazolLipid-loweringRiskfactorsandprevention26整理课件HMG-CoAreductaseinhibitors〔statins〕Atorvastatin,Fluvastatin,Lovastatin,Pravastatin,Simvastatin,Cerivastatin,Rosuvastatin：*elevationofaminopherase,rhabdomyolysis2.Bileacid-bindingResinscholestyramine，colestipol3.NicotinicAcid：4.Fibricacidderivatives〔fibrates〕Gemifibrozil,clofibrate,Fenofibrate5.Cholesterolabsorptioninhibitors:ezetimibe6.ProbucolLipid-loweringdrugs27整理课件PreventionofCADA:aspirin,ACEIB:bloodpressure,β-blocker,C:cigarettesmoking,CholesterolD:diet,diabetesE:exercise,education28整理课件ThirdReportoftheNationalCholesterolEducationProgram(NCEP)ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults

ATPIII(adulttreatmentpanelIII)Circulation200217/24:3144-3373Atherosclerosis29整理课件Coronaryheartdisease(CHD)30整理课件Coronaryheartdisease(CHD)mostcommoncause:obstructionofatheromatousplaqueothercauses:spasmarterialthrombicoronaryemboliostialnarrowingduetolueticaortitiscongenitalabnormalitiessevereLVhypertrophy31整理课件FactorseffectmyocardialoxygensupplyanddemandOxygensupplyOxygendemandHeartrateMyocardialcontractilitySystolicwallstressoxygencarryingcapacityofbloodCoronarybloodflowVascularresistanceExtravascularcompressiveforcesautoregulationMetabolicregulationHumoralfactorNeuralregulationDurationofdiastolePressuregradientEndothelialcontrol32整理课件Coronaryheartdisease

Type：slientischemia:delitescence：(ECGchange)Anginapectoris：angina,causedbymyocardialischemia

myocardialinfarction：acutemyocardialischemicnecrosiscausedbytheocclusionofcoronaryarteryIschemiacardiomyopathy(Heartfailureandarrhythmia)：cardiacenlargement,heartfailure,arrhythmia,causedbythemyocardialfibrosisastheconsequenceofchronicmycardialischemiaSuddendeath：suddencardiacarrestcausedbyventricularfibrillation/flutter33整理课件Coronaryheartdisease(CHD)

Type：

slientischemia:delitescenceAnginapectoris：myocardialinfarction：Ischemiccardiomyopathy(Heartfailureandarrhythmia)Suddendeath34整理课件AcuteCoronarySyndrome(ACS)RestingischemiaNon-STelevationSTelevationUnstableanginaNon-QwaveAMIQwaveAMI*positiveserumcardiacmarkers****##occasionallyvariantangina35整理课件Stableanginapectoris(SAP)36整理课件definition:acuteandtransientmyocardialischemiaandanoxaemiausuallycausedbycoronaryinsufficiencyduringexertionoremotionalstressCharacteristics:paroxysmalprecordialsqueezing-likechestpain,behindthemidsternum，radiatedtoleftshoulderandupperarmprecipitatedbystressorexertionduration:2-5mintypically

relievedrapidlybyrestornitratesStableanginapectoris37整理课件Coronarystenosis(others:aorticvalvedisease,HOCM,MB)+Myocardialoxygendemand〔HRXSBP〕increased

myocardialhypoxiaacumulationofmetabolicproduct,stimulateC1-5nervetocausethesensationofchestpain

Stableanginapectorismechanism38整理课件inangiographySignificantcoronarylesionwithdiameterstenosis>70%in75%ptsNosignificantstenosisinabout5-10%pts,Ischemiamayberelatedtocoronaryspasmormicrovasculardysfunction.PathologyStableanginapectoris39整理课件pathophysiology1.MetabolicandelectrophysiologyATPreduced,accumulationofacidsubstancesDysfunctionofironpump(Na+-K+,andNa+-Ca++)Earlydepolarization(STdeviation)2.LVfunctionandhemodynamicsituationLVcontractilityandspeed,systolicBP,strokevolume,cardiacoutputdecreasedLVEDpressureandvolumeStunningofmyocardiumStableanginapectoris40整理课件symptom：chestpainoroppressionlocation

behindorslightlytotheleftofthemidsternumnodefiniteborderlineradiatedtotheleftshoulderandupperarmAtypicallocation:lowerjaw,thebackofneckClinicalmanifestationStableanginapectoris41整理课件chestpaincharacteristics：tightness,squeezing,burning,pressing,choking,bursting,rarelysharp,notspasmodicforcethepatientstoptheactivitytillthesymptomrelievedprecipitationexertionoremotionalagitation。duration：3－5minspainrelief:withinseveralminsafterrestorusingnitroglycerinClinicalmanifestationStableanginapectoris42整理课件PhysicalexaminationincreasedHR,elevatedBPanxietysweatingoccasionallygalloprhythm，transientsystolicmurmurClinicalmanifestationStableanginapectoris43整理课件Laboratory1.ECG：atrestDuringchestpain:ST-Tchangefoundin95%ptsHolter:detectofslientischemiaStresstest:indication：suspectionofCHD,pre-andpost-CABGandPCI,ptswithOMIcontraindication：AMI,UAP,myocarditis,Hypertension,heartfailure,aorticstenosis,HOCM,severarrhythmia,aorticaneurysmEndofthetest：STor≥0.2mV，APattacks，BP>220mmHg，BPdrop，ventriculararrhythmiaCriteriaforpositive:STsegmentdepression

0.1mV，last2minsStableanginapectoris44整理课件StresstestrestExersciseStableanginapectoris45整理课件

2.Echocardiography:3.Radionuclideimagingassessment:TL201，Tc99m-sestamibimyocardialperfusionscintigraphy4.X-rayofheart 5.coronaryangiography：finaldiagnose6.others:IVUS、intracoronaryDopplerflow、intracoronarypressureLaboratoryStableanginapectoris46整理课件CoronaryAngiography47整理课件1.Cardiogenicpain：aorticdissection,HOCM,aorticstenosis2.Respiratory：PE,pneumothorax,pleuritis

3.Gastrointestinal:gastro-esophagealdiseases,Hiatalhernia,cholecystitis,pepticulceration,pancreatitis4.Neuromuscular/skeletal：TietzeSyndrome(Costochondritis),intercostalneuralgia,Herpeszoster5.Psychologic:anxiety,depression,panicattacks

StableanginapectorisDiagnosisChestpain,riskfactors,ECGevidenceofischemiaduringchestpain,angiographyDifferentiation48整理课件FunctionalclassificationofSAP(CCS)CCSI：nochestpainatordinaryactivity.AnginaatstrenuousorrapidorprolongedexertionCCSII：Slightlimitationofordinaryactivity.Walkingorclimbingstairsrapidly,aftermeals,incold,inwind.Walkingmorethan2blocks,climbingmorethanstairsof3rdfloor.CCSIII：Markedlimitationofordinaryactivity.Walking1to2blocks,climbingstairsof3rdfloor

CCSIV：Inabilitytocarryonanyactivitywithoutdiscomfortanginalsymdromemaybepresentatrest.Stableanginapectoris49整理课件Generalconsideration：rest，avoidprovocativefactors,riskfactorscontrol2.Drugtherapy:

preventMIanddeathsymptomreliefandqualityoflifeimprovment3.Coronaryrevascularization:percutaneouscoronaryintervention(PCI)Coronaryarterybypasssurgery(CABG)SVG,LIMAPreventionandtreatmentStableanginapectoris50整理课件antianginalandanti-ischemictherapyDrugtherapyOxygensupplyOxygendemanda.nitratesb.beta-adrenergicblockersc.Calciumantagonistsd.DrugsimprovingmetabolismStableanginapectoris51整理课件Drugtherapya.nitratesloweroxygendemand:decreasearteriolarandvenoustone,reducepreloadandafterloadincreasecoronarysupply:CoronarydilatationNitroglycerinIsosorbidedinitrateisosorbide5-mononitrate(long-actingnitrates)Stableanginapectoris52整理课件b.ß－blockers:reducemyocardialoxygen:reduceHR,myocardialcontractility,BP,theLVwallstressAbslutecontraindications：severbradycardia:high-degreeA-Vblock,SSS,severeunstableLVfailureRelativecontraindications:asthmaandbronchospasticdiseaseperipheralvasculardiseaseß1-selective：metoprolol,atenolol,bisoprololDrugtherapyStableanginapectoris53整理课件c.Calciumantagonists：Increaseoxygensupply:dilateresistancevessels,releasespasm,improvemicrovascularfunctionDecreaseoxygendemand:negativeinotropiceffect,decreaseBPAntiplateleteffectd.Drugsimprovingmetabolism：trimethazine〔vasorel〕，selectivelyinhibit3-KAT〔3-酮酰辅酶A硫解酶〕，partlyinhibitFAoxidationDrugtherapyStableanginapectoris54整理课件preventMIanddeaththerapya.antiplateletangents：ASA，75-325mg/dclopidogrel;ticlopidine:ADPreceptor-antagonists:Cilostazol:phosphodiesteraseinhititor,50-100mgbidb.Lipid-loweringangents:statinsc.Angiotesin-convertingenzymeinhibitor(ACEI)DrugtherapyStableanginapectoris55整理课件stentingStableanginapectoris56整理课件Unstableangina(UAP)andnon-STEMI57整理课件RestingischemiaNon-STelevationSTelevationUnstableanginaNon-QwaveAMIQwaveAMI*positiveserumcardiacmarkers****##occasionallyvariantanginaAcuteCoronarySyndrome(ACS)58整理课件PathophysiologyofACS

stableangina UAP&non-Q-wAMI Q-wAMIAngiographicthrombus

0-1% 75% >90%IncreasedFPA/TAT 0-5% 60-80% 80-90%Activatedplatelets 0-5% 70-80% 80-90%Acutecoronaryocclusion 0-1% 10-25% >90%mortality 1-2% 3-8% 6-15%FPA：fibrinopeptideATAT：thrombin-antithrombincomplexesUAPandnon-STEMI59整理课件Occuringatrest(orwithmininalexertion):last>20minssevereandofnew-onset:within1-2months,CCSIIIOccuringwithadeteriorativepattern:atleastCCSIIIvariantanginapectoris(Prinzmetalangina):transientSTelevation,causedbythecoronaryspasmDefinitionUAPandnon-STEMIAnginapectorisorequivalentischemicdiscomfortwithatleastoneofthethreefeatures60整理课件BraunwaldclassificationofunstableanginaSeverity：ClassI：New-onset,oracceleratedsevereanginanorestpainwithin2monthsClassII：Anginaatrest,subacuteanginaatrest(withintheprecedingmonthbutnotwithin48h)ClassIII：Anginaatrest,acute(withinthepreceding48h)UAPandnon-STEMI61整理课件BraunwaldclassificationofunstableanginaClinicalCircumstancesClassA：SecondaryUAPaclearlyidentifiedconditionextrinsictothecoronaryvascularbedthathasintensifiedmyocardialischemia,e.g.anemia,hypotension,tachy-arrhythmiaClassB：PrimaryunstableanginaClassC：Post-infarctionUAP(within2weeksofadocumentedMI)UAPandnon-STEMI62整理课件mechanism：

1.plaqueruptureanderosion,withnonocclusivethrombus2.dynamicobstruction:Vasoconstruction3.progressivemechnialobstruction(rapidlyadvancingorISRfollowingstenting)4.secondaryUAInflammationThrombogenesisUAPandnon-STEMI63整理课件ECG:Non-STEMI:STdepressionlast>12hrCardiacbiomarkersofmyocardiumdamage:cTnT,cTnICK-MBUAPandnon-STEMICoronaryangiographyAngioscopyandIVUSOtherlaboratorytests64整理课件Riskstratification：TIMIRiskScoreAge>=65yrsMorethan3coronaryriskfactorsPriorangiographiccoronaryobstructionST-segmentdeviation

0.5mmMorethan2anginaeventswithin24hoursDevelopmentofUA/NSTEMIwhileonaspirinElevatedcardiacmarkersAntaman,JAMA2000;284:835-42TIMIIIB,ESSENCE,PRISM-PLUS,TACTICS-TIMI18UAPandnon-STEMI65整理课件Treatment1.Genearlmanagement:rest,oxygen,CCU2.DrugtherapyA.Anti-ischemicdrug:intravenously,orallynitrates

-blockerCalciumantagnoist:firstchoiceforvariantanginaMorphineUAPandnon-STEMI66整理课件Treatment2.Drugtherapy:B.antithrombotictherapya.Anti-plateletAspirin:early,300mgloadingdoseADP-receptorantagonist:clopidogrel300mg-600mgloadingdose,75mg/dGPIIb/IIIareceptorinhibitor:usedinptsplannedtoPCIb.Anticoagulationtherapy:HeparinLowmolecularweightheparin(LMWH)Directanti-thrombindrug:bivalirudin,hirudin

UAPandnon-STEMI67整理课件Treatment2.Drugtherapy:C.othermedicaltherapya.lipid-loweringdrugs:

statins,earlyuse(infirst24hrs)LDL-ctarget:<70mg/dl

b.ACEI:

long-termsecondarypreventionUAPandnon-STEMI68整理课件Treatment3.Invasiveversusconservativestrategyearlyinvasivestrategyindicatedforhighriskpatients:within48-72hrs,Followingbycoronaryrevascularization(PCIorCABG)4.Long-termmanagement

ß-blockers,Statin,ACEI,aspirinclopidegrel(12m)UAPandnon-STEMI69整理课件PatientwithischemictypediscomfortRapidtriageto“urgentcare”roomAspirin160-325mgObtainbaselineserumcardiacmarkerlevelGoal=10minsAssessinitial12-leadsECGECGstronglysuspiciousforischemia(STdepression,T-waveinversion)STelevationNondiagnosticECGyesInitiateantiischemictherapyAssesscontraindicationstothrombolysisInitiatereperfusionstrategyContinueevaluationinEDorshort-termobservationunitObtainfollow-upserumcardiacmarkerConsider2DEchoEvidenceofischemia/infarctionRoutinebloodtesttobeobtainedonadmission:CBCLipidprofileElectrolytelevelsadmitnoadmitInitiatereperfusionstrategyIfSTelevationdevelopsDischargegoal=8-12h70整理课件SYMPTOMSSUGGESTIVEOFACSNoncardiacDiagnosisChronicStableAnginaPossibleACSDefiniteACSTreatmentasindicatedbyalternativediagnosisACC/AHAChronicStableAnginaGuidelinesNoST-ElevationST-ElevationNondiagnosticECGNormalinitialserumcardiacbiomarkersSTand/orTwavechangesOngoingpainPositivecardiacbiomarkersHemodynamicabnormalitiesEvaluateforreperfusiontherapyACC/AHASTEMIGuidelinesObserve≥12hfromsymptomonsetNorecurrentpain;negativefollow-upstudiesRecurrentischemicpainorpositivefollow-upstudiesDiagnosisofACSconfirmedStressstudytoprovokeischemiaConsiderevaluationofLVfunctionifischemiaispresent(testsmaybeperformedeitherpriortodischargeorasoutpatient)NegativePotentialdiagnoses:nonischemicdiscomfort;low-riskACSArrangementsforoutpatientfollow-upPositiveDiagnosisofACSconfirmedorhighlylikelyAdmittohospitalManageviaacuteischemiapathwayAlgorithmforevaluationandmanagementofpatientssuspectedofhavingACS.AndersonJL,etal.JAmCollCardiol2007;50:e1–e157,Figure2.71整理课件STelevationmyocardialinfarctionSTEMI72整理课件AcuteCoronarySyndrome(ACS)RestingischemiaNon-STelevationSTelevationUnstableanginaNon-QwaveAMIQwaveAMI*positiveserumcardiacmarkers****##occasionallyvariantangina73整理课件ischemicnecrosisofmyocardiumresultsfromtheprolongedmyocardialischemiaprecipitated

byanocclusivecoronarythrombusatthesiteofapreexistingatheroscleroticplaque。WithtypicalandserialECGchangesRepresenttheserioussituationofcoronaryarterydiseaseSTEMIDefinition74整理课件1.incidence

：inUSA,71‰inmalebetween35-84yrs,22‰infemale,1attackinabout20second2.mortality：decreasedin30%recent10yearsstill1/3ofthepatientsdied50%ofthedeathoccuredwithin1haftertheonsetMImostdeathes

resultfromventricularfibrillationepidemiologySTEMI75整理课件Causeofthedecreasedmortalitynewdrugtherapyß-blocker,anti-thromboticLMWHnitratesACEIStatinsSTEMI76整理课件Changeofconcept1960-80s:Transmural,non-transmuralorsub-endocardium1980s:QwaveMI，non-QwaveMI1990s:STEMI,non-STEMISTEMI77整理课件Possiblemechanism

ofthechronicCADtoACS炎症细胞少量平滑肌细胞激活的巨噬细胞血栓78整理课件Pathology:CoronarydiseasesOcclusionofLAD:anteriorwallMISTEMI79整理课件Pathology:myocardiummyocardialnecrosis(coagulationnecrosis)coronaryocclusionnecroticmusclefibresdissolvedgranulationtissueremovalofnecrosistissuecollagenzationfirmconnectivetissuescarOMI1-2hr2-3d1-2weeks6－8weeksSTEMI80整理课件STEMIPathology:myocardialdiseases81整理课件Ventricularremodelingconcept:thechangesinLVsize,shape,andthicknessinvolvingboththeinfarctedandnoninfarctedsegmentsDeterminants:thesizeofinfarctionVentricularloadingconditionsInfarctrelatedarterypatencySTEMI82整理课件Infarctexpansion:anincreaseinthesizeoftheinfarctedsegment.“acutedilatationandthinningoftheareaofinfactionnotexplainedbyadditionalmyocardialnecrosis〞..ventriculardilatation：shiftofpressure-volumecurveofLVtotherightlargerLVvolumeatanygivendiastolicpressureCompensatorymechanismsformaintainingstokevolumeAssociatedwithnon-uniformrepolarizationofmyocardium,predisposetolife-threateningventriculararrhythmias.STEMIVentricularremodeling83整理课件Systolicfunction:dyssynchrony:dissociationinthetimecourse

ofcontractionofadjacentsegmenthypokinesis:reductionintheextentofshorteningakinesis:cessationofshorteningdyskinesis:paradoxicalexpansion,systolicbulgingDiastolicfunction:reductioninLVcompliance:decreaseinthepeakrate

ofdeclineinLVpressure(dP/dt)riseinLVend-diastolicpressureandvolumeSTEMIpathophysiologyLVfunction84整理课件Predisposingfactor：heavyexercise,mentalstress:surgicalproceduresfever,tachycardia,respiratoryinfection,hypoxemia,hypoglycemiaPrinzmental’sanginaProdromalsymptoms：weakness,chestdiscomfort,restlessness

,newonsetAPandacceleratingAPCircadianperiodicity

peakincidence:6-12amSTEMIClinicalmanifestation85整理课件SymptomChestpain

severe,sometimesintolerable,prolonged,usuallylastingfor>30mins，lesseffectiveofsublingualnitroglycerin,retrosternalinlocation,sweating,scared,andfeelingofimpendingdeathinsomepatients,AMIismanifestedbyshockandacuteLVfailure,notbychestpain(theelderly)alerttheepigastrium

painandabdominaldisordersSTEMIClinicalmanifestation86整理课件symptomsGeneral：fever、HRincrease、WBC

，ESRfastingGastrointestinalsymptom：nausea,vomiting

,arrhythmias：VPs、AVblock,atrialarrhythmiasoccurredmoreofteninpatientswithHFHeartfailure:mainlyacuteLVfailure,maydevelopeRVfailure.InitialRVfailureoccureinpatientswithRVinfarction,associatedwithhypotensionHypotensionandshock：SBP<80mmHgafterpainrelease,RVinfarctionSTEMIClinicalmanifestation87整理课件PumpfailureClassificationbasedonclinicalexamination(Killip)ClassI：noHF,ralesandS3absent；ClassII:mildHF，ralesover<50%oflung,withorwithouts3；ClassIII:acutepulmonaryedema,ralesover50%oflungfieldsClassIV:cardiogenicshockClassificationbasedoninvasivehemodynamicmonitoringClassI：Normal,PCWPpulmonarycapillarywedgepressure

<18.CI>2.2；ClassII:Pulmonarycongestion,PCWP>18.CI>2.2；ClassIII:peripheralhypoperfusion,PCWP<18,CI<2.2;ClassIV:pulmonarycongestionandperipheralhypoperfusion,PCWP>18,CI<2.2STEMIClinicalmanifestation88整理课件physicalexaminationGeneralappearance:anxious

,distress,coldperspiration,skinpallorCardiacexamination:HR:bradycardia,tachycardia,irregularheartsound:S1muffled,galloprhythmcardiacmurmurs:systolicpericardialfrictionrubsBP:previouslyhypertensivebecomenormotensiveothersSTEMIClinicalmanifestation89整理课件1.ruptureofapapillarymuscle：rarebutfatalcomplicationcauseacutemassivemitralregurgitation,pulmonaryedema2.ruptureofventricularwall：occursmostcommonlywithin1weekfreewallrupture;ruptureofinterventricularseptum3.embolization：LVmural

thrombuscausearterialembolizationDVT(deepveinthrombus)causepulmonaryembolization4.cardiacaneurysm：persistantSTelevationcausemural

thrombus,heartfailure,andarrhythmias5.post-MIsyndrome(Dresslersyndrome)：fever,chestpain,repeatedpericarditis,pleuritis,pneumoniaSTEMIClinicalmanifestationcomplications90整理课件ECG：Typical：pathologicalQwave,STelevation,invertedTwaveSerial：

peakedTwave(hyperacute),STelevation(acute),Qwave,Twaveinversion(old)STEMILaboratorytest91整理课件AnteriorAMISTEMILaboratory92整理课件InferiorAMISTEMILaboratory93整理课件LocalizationLADSTEMILaboratory94整理课件STEMILaboratoryLocalizationLAD95整理课件STEMILaboratoryLocalizationLCX96整理课件STEMILaboratoryLocalizationRCA97整理课件2.vectorcardiography3.radionuclideangiography：4.Echocardiology：distinctregionofdisorderedcontraction,LVfunction,detectioncomplication5.laboratoryexamination:bloodroutineserumcardiacmarkersSTEMILaboratory98整理课件markerRangeoftimestoinitialelevation（h）Meantimetopeakelevations（nonthrombolysis）TimetoreturntonormalrangeMyoglobin1-46-7h24hcTnI*3-624h7-9dcTnT*3-612h-2d7-14dCK-MB3-616-24h3-4dCK-MM1-612h38hLDH8-1024-48h10-14dCardiacmarkers*MostsensitiveandspecificmarkerofmyocardialdamageSTEMILaboratory99整理课件Differentialdiagnosis1.anginapectoris：chestpain,complication,generalsymptoms,elevationofcardiamarkers,ECGchanges2.acutepericarditis：characteristicsofchestpain,timecourseofchestpainandfever,ECGchanges3.acutepulmonaryembolization:chestpain,hemoptysis,dyspnea,increasedloadofRV(SIQIII)STEMIDiagnosis100整理课件4.Acuteabdominalsymptom：acutepancreatitis,cholecystitis,cholelithiasis5.aorticdissection：severchestpainwith(tearing-like),radiatedtoback，withaorticregurgitation,CT、UCG、MRI、chestX-rayDifferentialdiagnosisSTEMIDiagnosis101整理课件Beforeadmission:tranfer,makediagnosiswithin10-20min,initiatereperfusiontherapyassoonaspossibleMonitoringandgeneraltreatment:CCUReperfusionManagementofcomplicationothersSTEMItreatment102整理课件1.CCU:hemodynamicmonitoring,oxygen

2.Painreliefandanti-ischemia:Morphine:2-4mgIVNitrates:notuseininferiorMIorsuspectedRVMIwithhypotensionß-blocker:reduceHR,decreaseBP,decreasemyocardialoxygenconsumption,decreaseVf3.Anti-platelet:aspirin：firstdosage300mg，chewing,100mg/dforeverforpatientswithoutcontraindicationClopidogrel:300mgloading,75mg/dSTEMItreatment103整理课件4.anti-coagulation:anti-thrombin,heparin,LMWH5.limitationofinfarctsize:reperfusion:Fibrinolytictreatment: