内科学教学课件：21 心血管系统疾病

心血管系统疾病CardiovascularDiseases教育不是灌输，

而是点燃火焰。——【古希腊】苏格拉底Educationisnotthefillingofavessel,butthekindlingofaflame.——Socrates，BC470~3992005年７月２日晚，成功扮演“毛泽东”的特型演员古月在广东省三水区因突发大面积心肌梗死，抢救无效去世，享年66岁。2005年8月17日晚，著名表演艺术家高秀敏在长春的家中因心脏病突发辞世，享年46岁。名人的意外事件名人的意外事件2006年12月20日上午，著名相声表演艺术家马季因心脏病逝世，享年72岁。2007年著名相声表演艺术家侯耀文因突发心脏病被送往北医三院，经抢救无效去世，享年59岁。Yalta,Febr.1945DiastolicandSystolicArterialPressureofFranklinD.Rooseveltfrom1935untilHisDeathonApril12,1945F.Messerli:NewEnglandJournalofMedicine332:1038-1039,April13,1995选举HeadlinesoftheSt.LouisPost-Dispatch,April13,1945F.Messerli:NewEnglandJournalofMedicine332:1038-1039,April13,1995心血管疾病居我国居民死亡构成比首位冠心病是主要原因，其发生率呈逐年递增《中国心血管病报告2006》卫生部心血管病防治中心2008.04心血管疾病39.1%肿瘤呼吸系统疾病消化系统疾病损伤中毒内分泌疾病泌尿系统疾病传染病其他人心血管病流行状况

——中国心血管病报告20052002年调查估计，我国每年心脑血管病新发及患病的病例数心脏的工作

各部，同时从肺部吸取新鲜血液，以便供左心室下一次收缩使用；右心室吸进从静脉来的、带有大量废物和二氧化碳的血液，这种不新鲜的血通过右心房运送到肺部，在肺部吸收氧气排出二氧化碳后，又变为鲜血流入左心房。心脏和与它相连的大血管组成一个密闭的管道网——血液循环系统。心脏工作起来就像一只泵，收缩时将左心室里富含氧气和营养物质的鲜血“压”到主动脉去，通过动脉输送到身体MyocardiumCoronaryarteriesConductionsystemValvesPericardiumArteriesVeinsCapilariesPreloadAfterloadContractionHeartrateChamberstiffnessOxygenconsumptionCoronarybloodsupply

DeterminantsofNormalCirculation

ClinicalHistoryLocationandradiationTimeanddurationFrequencyExertationoratrestBeforeoraftermealWeather(coldwinter)Relatedmedication......SymptomsChestpainSyncopeFatigueDyspneaPalpitationFeverCyanosisEdemaDizziness......

CharacteristicsRiskfactorsHypertensionDyslipidemiaSmokingPhysicalinactiveDiabetesmellitusInfectionStressFamilyhistory......

PhysicalExaminationInspection:Generalstatus,cyanosis,dyspnea......Palpation:Pulse,frequency,extrasystoli,edema,apical impulse,thrill......Percussion:MarginoftheheartAuscultation:

HeartrateCardiacrhythmCardiacsoundExtracardiacsound(Galloprhythm,openingsnap,pericardialknock)Cardiacmurmur(systolic,diastolic,continuous)

LaboratoryExaminationBloodWBC,RBC,thrombocytesESR,CRP, INR,TPT,CK-MB,Troponin-I,AST,LDHLipidGlucoseElectrolytesBloodgasUrine:Protein,RBC,......

Electrogram(Holter)andElectrophysiology

SurfaceECG

IntracardiacECG

CardiovascularImagingX-Ray,CT,MRIEcho-andDopplercardiographyRadioactiveNuclearimaging,PETCatheterization,angiography

CardiovascularImagingRadioactiveNuclearimaging

IntravascularUltrasoundImaginePreventiveCardiovascularMedicineA:AspirinACEIB:B-blockerBPC:CholesterolCigarettequittingD:DiabetesControlDietE:ExerciseEducation

ConventionalTherapyBehaviorandpsychotherapy(TypeAandTypeBbehavior)MedicationDosagei.v,oral,i.m.TimeFrequencyDruginteractions......AntihypertensiveLipid-loweringAntidiabeticagentsVasodilatorsDiureticsDigitalisAntiarrhythmics......UsageSideeffectsDrugsHypotensionLong-QTProarrhythmiaDisturbanceofelectrolytesDemagingofrenalandliverfunctionTachy-andBradycardia........FirstselectiveX-raycoronaryarteriogramMasonSonesOct301958目前临床诊断冠状动脉病变主要依赖于冠脉造影（金标准），但冠脉造影仅仅显示被造影剂填充的管腔轮廓，不能客观反映血管壁的病变及性质，如果参照节段存在弥漫病变，冠脉造影通常会低估狭窄程度局限性病变弥漫性病变上世纪90年代初，血管内超声问世为客观准确判定血管壁病变性质及其程度提供了可能,多普勒技术为评价冠状动脉功能提供了客观手段评价冠状动脉功能病变形态、性质、狭窄程度多普勒血流测定仅显示管腔轮廓血管内超声冠状动脉造影

InterventionalTherapyAndreasGrüntzig,performedhisfirstcoronaryangioplastyprocedureinZurich,Switzerlandin1977;movedtotheUnitedStatestojointhefacultyofEmoryUniversityin1980,diedinaplanecrashinMonroeCounty,GeorgiaonOctober27,19851984

InterventionalTherapyAMIPTCAStenting术前球囊扩张

InterventionalTherapy植入支架术后

InterventionalTherapyAnnualNumbersofPCICasesinChina

Increase20-25%EachYearinthePast10YearsPhaseI:1985-1996PhaseII:1997-2001PhaseIII:2001-In2014,morethan450,000PCIswereperformedinChina我国冠脉介入治疗数量呈逐年增加

CatheterAblationAblationofVTRFduringVT 3seconds

PacemakertherapyX-ray.MedtronicAttainLVleadinmid-lateralveinwithInSyncdevice.CardiacResynchronization

ICDTherapyICD-Secondaryprevention:Meta-Analysis(AVID,CIDS,CASH)NumberatriskICD:934715467273159104934715467273159104Amio:9326644272481288293266442724812882YearsYearsAmioICDAmioICD5040302010050403020100012345012345ConnollySJ.EurHeartJ2000;21:2071DeathRhythmogenicdeath

ProgressandPerspectivesAngiogenesisImplantationofself(autologous)bonemarrowstemcellsisarelativelysimplemethodforangiogenesiswithoutcausingtoxicityorimmunologicalrejectionIsnerJM,etal.JClinInvest1999;103:1231-6

ProgressandPerspectivesBoneMarrowCellsRegenerateInfarctedMyocardium

Orlicetal.Nature2001;410:701

Lin-c-kitPOSBMCfromtransgenicmiceinjectedintheperi-infarctedleftventricleoffemalemiceaftercoronaryligationNewlyformedmyocardiumoccupied68%oftheinfarctedportionoftheventricle9daysaftertransplantingthebonemarrowcells.DevelopingtissuecomprisedproliferatingmyocytesandvascularstructuresA.BonemarrowcellsandmyocardialregenerationB.Myocardialrepairandconnexin防止动脉粥样硬化控制危险因素:高血脂、高血压、糖尿病、吸烟、肥胖…冠心病的药物和介入治疗药物支架:促进介入治疗后修复、消除内膜过度增生射频消溶是根治快速性心律失常的里程碑对终末期冠心病、心力衰竭Angiogenesis：促进血管新生Myogenesis：Stemcelltransplant，…小结antegrad16.04.2002首例经皮主动脉瓣植入术病史总结患者，男，75岁因“反复胸闷乏力7年”