缺血性心脏病教学

缺血性心脏病教学CHDEpidemiologyPathophysiologyRiskfactorsandPreventionClinicalmanifestation,Diagnosisandmanagement

Mostcommonformofheartdisease

SinglemostimportantcauseofprematuredeathEpidemiologyEpidemiology--USA1/2deaths(1/2million)1.5millionMIeachyear45%MIunderage6550-100billion$peryearOnein4men/onein5womendiefromCHD300000peoplehaveMIeachyear1.7millionpeoplehaveanginaEpidemiology--UK

TheincidenceofCHDEasternEuropeManydevelopingcountriesChinaIndia

EpidemiologyProportionateMortalityfortheTenLeadingCausesofDeathinChina,1991-2001HeJ&GuD,etal,NEnglJMed2005;353;11:1124-34PathophysiologyAlmostalwaysduetoathromaanditscomplicationsparticularlythrombosisOccasionallyotherdisordersCongenitalanomaliesAnomalousoriginFistular/MalformationofamajorcoronaryarteryAortitisPolyarteritisConnectivetissuedisordersPathophysiologyPathophysiology

Atheroma/AtherosclerosisDiffuseddiseaseofthearterialwallCoronaryarteryathighriskCerebral/peripheralvasculardiseaseoftencoexistRadial/InternalmammaryarterylargelysparedPlaquesbegintoappearin2ndand3rddecadeoflifeThenature/compositionofplaqueschangesPathophysiologyPlaqueFormation1Soldiersdiedinthekoreanwar77.3%atherosclerosis39% occlusiveplaqueENOSJAMA1953300Casesautopsy(age,22.1y)TuzcuCirc19995.07

mm2EEMArea

13.2mm2AtheromaArea8.13mm2Female,32y17%37%60%85%71%020406080100<2020-2930-3940-49≥50Incedenceofather(%)age(y)IncidenceofatherosclerosisindonorheartPathophysiologyPlaqueFormation2Fattystreaksdevelope

migrateintointimatake-upoxidisedLDLfromplasmabecomelipid-ladenfoamcellsCirculatingMonocytesPathophysiologyPlaqueFormation3

LipidPoolFoamcellsdieThecontentsreleasePathophysiologyPlaqueFormation4EarlyAtheromaSmoothmusclecellsmigrateintoproliferatewithinPlaquePathophysiologyPlaqueFormation5LesionGrowsEncroachesintolumenErodesmediaPathophysiologyPlaqueFormation6MatureFibrolipidPlaqueLipidcoreSurroundedbySMCFibrouscapPathophysiologyPlaqueFormation7PlagueRupture/FissureThrombosis+LocalspasmVesselOcclusionACSPathophysiology

Pathophysiology

PlaqueRuptureCHD

clinicalmanifestationandpathology

ClinicalproblemPathologyStableanginaIschaemiaduetofixedatheromatous

stenosisofoneormorecoronaryarteriesUnstableanginaIschaemiacausedbydynamicobstructionofacoronaryarteryduetoplaquerupturewithsuperimposedthrombosisandspasmMyocardialinfarctionAcuteocclusionofacoronaryarteryduetoplaqueruptureandthrombosisandresultinginmyocardialnecrosisHeartfailureMyocardialdysfunctionduetoinfarctionorischaemiaArrhythmiaAlteredconductionduetoischaemiaorinfarctionSuddendeathVentriculararrhythmia,asystoleormassivemyocardialinfarction

CHD:RiskFactorsFixedModifiableAge•LipiddisordersMale•SmokingFamilyhistory•Diabetesmellitus•Hypertension•Obesity•Sedentarylifestyle•Dietarydeficienciesoffruitsandvegetables•alcholeIMPORTANTRISKFACTORSFORCORONARYARTERYDISEASEInflammationEndotheliumdysfunctionRiskfactorsGeneticsLifestylePathophysiologyAtherosclerosisPREVENTABLEANDCONTROLLABLEDISEASEEvery10MIpts，9PredictableEvery6MIpts，5PreventableCHDPreventionCHDPreventionPrimaryPreventionSecondaryPrevention

ModifyRiskFactorsTherapeuticLifestyleChangeEvidence-basedoptimaldrugmanagementCHDPreventionPopulationAdvice

TLCDonotsmokeTakeregularexerciseMaintain“ideal”bodyweightEatamixeddietrichinfreshfruitandvegetablesAimtogetnomorethan30%ofenergyintakefromfatStresscontrolCHDPreventionExamplesofthebenefitsoflong-termsecondarypreventionfollowingmyocardialinfarctionPreventivemeasureEventspreventedper1000patientyearsSmokingcessation15deaths46non-fatalmyocardialinfarctions(Mls)Aspirin7deaths9non-fatalMls9non-fatalstrokes-adrenoceptor21deathsantagonist

21non-fatalMlsStatins(HMGCoA7deathsreductaseinhibitors)12non-fatalMls3non-fatalstrokes11revascularisations4casesofheartfailureN.B.Eveninahigh-riskrimaryprevention(theWestofScotlandstudy),fourtimesasmanypeopleneededtobetreatedwithalipid-loweringagenttopreventacardiaceventcomparedtosecondaryprevention.Optimalevidence-baseddrugtreatmentAnti-hypertensiondrugsLipid-lowerdrug—statinsAspirinβ-blockerACEICHDPreventionClinicalManifestation

ClassificationMyocardialIschemia

AnginaPectorisStableUnstable

MyocardialInfarctionQ-Wavenon-Q-Wave

SuddenDeathClinicalManifestation

AnginaPectorisDiscomfortduetotransientmyocardialischaemiaClinicalsyndromeratherthanadiseaseImbalance:O2supplyanddemandFactorsInfluecingMyocardialO2SupplyandDemandOxygendemandOxygensupplyCardiacworkCoronarybloodflow*HeartrateDurationofdiastoleBloodpressureCoronaryperfusionMyocardialcontractilitypressure(aorticdiastoliccoronarysinusorrightatrialdiastolicpressure)

CoronaryvasomotortoneOxygenationHaemoglobinOxygensaturation*N.B.Coronarybloodflowoccursmainlyindiastole.ClinicalManifestation

AnginaPectorisClinicalManifestationAnginaPectoris:CausesMostCommon:CoronaryAtheromaOthers:AorticstenosisHypertrophicCardiomyopathyCase1Casediscussion1ClinicalfeaturesFemale,40yAtypicalchestpainNohistoryofHTN,dyslipidemiaanddiabetesECG:normalDiagnosisdecision?Casediscussion1ClinicalfeaturesFemale,40yAtypicalchestpainNohistoryofHTN,dyslipidemiaanddiabetesECG:normalDiagnosisdecisionSymptomClinicalManifestationSymptom

keyfactorinDiagnosismaking(Stable/UnstableAngina)ClinicalManifestationSymptom:StableAnginaLocation:CentralRadiation:neck/jaw/armCharacteristics:Worseningfactors:“Start-upangina”CLINICALSITUATIONSPRECIPITATINGANGINACommon

PhysicalexertionColdexposureHeavymealsIntenseemotionRare

Lyingflat(decubitusangina)Vividdreams(nocturnalangina)ClinicalManifestationSymptom:StableAnginaClinicalManifestationPhysicalExaminationFrequentlyNegativeBut:Acarefulsearchfor--ImportantRiskFactors--ContributoryDisease(obesity,anemia)--LVdysfunction:galloprhythm,murmurCasediscussion1ClinicalfeaturesFemale,40yAtypicalchestpainNohistoryofHTN,dyslipidemiaanddiabetesECG:normalDiagnosisdecisionSymptomNoncardiacchestpainAnginaPectoris

DifferentialDiagnosisAcutemyocardialinfarctionXsyndromeCardiacNeurosisClinicalManifestation

DifferentialDiagnosisMusculoskeletalPericardialPainOesophagealAnginaPectoris

DifferentialDiagnosisMusculoskeletalPainProvokedbyspecialmovementratherthanwalkingBackgroundpainoftenpersistsatrestAssociatedchestwalltendernessPainofPericarditisProvokedbychangesinpostureordeepinspirationPainDuetooesophagitiswithorwithouthiatusherniaBurningqualityRelievedbyantacidsCasediscussion1ClinicalfeaturesFemale,40yAtypicalchestpainNohistoryofHTN,dyslipidemiaanddiabetesECG:normalDiagnosisdecisionSymptomNoncardiacchestpainTestsDiagnosis

SpecialTest--ECGRestingECGEvidenceofOMINormalinmostpatientsTwaveflattening/inversionNon-Specific!Diagnosis

SpecialTest--ECGThemostconvincingEvidence

REVERSIBLEST

orwith/withoutTinversionDuringChestPain(Spontaneouslyorbyexercisetesting)Diagnosis

SpecialTest-ETTTreadmill/BicycleergometerConfirm/RefutediagnosisAssessSeverityofdiseaseIdentifyhighriskpatientExerciseToleranceTestDiagnosis

SpecialTest-ETTDiagnosis

SpecialTestIsotopeScanningEvaluatingPtswithequivocal/uninterpretableETTPtsunabletoexercisePredictiveaccuracy>ETTTechnique

ScintiscanofMyocardiumAtrestandduringstress(ETTorDobutamine)AfterIVradioactiveisotope(201TI)Diagnosis

SpecialTest--IsotopeScanningIsotopeScanningTechniqueThallium--AnalogueofpotassiumTake-upbyviablemyocardiumDiagnosis

SpecialTest--IsotopeScanningIschemia:duringstressPerfusiondefect

ReversiblenotatrestInfarction:PerfusiondefectPersistentDiagnosis

SpecialTest--IsotopeScanningDiagnosis

SpecialTestVentricularFunctionRadionuclidebloodpoolscanningECHODiagnosis

SpecialTest--MSCTCoronaryArteriographyExtent/natureofCAD?DecidePTCA/CABGDiagnostic-AtypicalchestpainNon-invasivetestfailedDiagnosis

SpecialTestCasediscussion1ClinicalfeaturesFemale,40yAtypicalchestpainNohistoryofHTN,dyslipidemiaanddiabetesECG:normalDiagnosisdecisionSymptomNoncardiacchestpainTestsStresstestAngiographyCTARapidworseningangina(Crescendo)SevereanginaatrestNew-onsetanginaPost-infarctionanginaWithoutevidenceofInfarction(ECG/Enzyme)ClinicalManifestationSymptom:UnstableAnginaClinicalManifestation

RiskstratificationinAnginaHighriskLowriskUnstableanginaPredictableexertionalanginaPost-infarctanginaPoorefforttoleranceGoodefforttoleranceIschaemiaatlowworkload(ETT)Ischaemiaonlyathighworkload(ETT)Leftmainorthree-vesseldiseaseSingle-vesselorminortwo-vesseldiseasePoorLVfunctionGoodLVfunctionN.B.Patientsmayfallbetweenthesecategories.Management

AnginaPectoris

RiskfactorscontrolSymptomsControlLifeexpectancyimprovementADVICETOPATIENTSWITHANGINADonotsmokeAimatidealbodyweightTakeregularexercise(Exerciseupto,butnotbeyond,thepointofchestpainisbeneficialandmaypromotecollateralvessels.)Avoidsevereunaccustomedexertion,andvigorousexerciseafteraheavymealorinverycoldweatherTakesublingualnitratebeforeundertakingexertionthatmayinduceanginaManagement

AnginaPectoris

Anti-anginalDrugNitrates-blockerCCBanti-plateletAspirin75-100mgLipid-lowing–StatinACEIManagement

AnginaPectoris

baselinePlaquearea6mm2Statinsfor6monthsPlaquearea6.4mm2ShinyaOkazaki,etal.Circulation.2004;110:1061-1068RegressionofPlaquebyStatinsInvasiveTreatmentRevascularizationPTCA/CABGManagement

AnginaPectoris

Management--PCIAtriplecoronaryarterybypassgraftoperationManagement

coronaryarterybypassgrafting

PTCACABGPrincipaluseSingle-vesseldisease;two-vesselLeftmainstemstenosis;three-vesseldisease;unstableanginadiseaseMortality<1%<1%IncidenceofneurologicalNone5%seldompermanentbutstrokecomplicationsmayoccurHospitalstay24-36hours7-10daysReturntowork2-5days2-3monthsRecurrenceofangina30%in6months;PTCAmaybe10%in1year,then5%peryearrepeatedMaincomplicationsMyocardialinfarction;emergencyDiffuseleftventriculardamage;CABG;vasculardamagerelatedtoperioperativeMI;infection;woundthearterialpuncturesitepain

ComparisonbetweenPTCAandCABGUnstableAPLMWHAspirin+ClopidogrelPTCA/CABGHighRiskManagement

AnginaPectoris

Unstableangina:riskstratificationHighriskLowriskClinicalPost-infarctanginaNohistoryofMIRecurrentpainatrestRapidresolutionofHeartfailuresymptomsECGSTdepressionMinorornoECGTransientSTelevationchangesPersistentdeepTwaveinversionBiomarkersTroponinT>0.2ug/mlTroponinT<0.2ug/ml

MyocardialInfarction冠状动脉破裂斑块

致命性血栓斑块破裂处

形成血栓的脂质核心

胶原纤维帽PathophysiologyofAcuteCoronarySyndromeUANoSTElevationSTElevationNSTEMIUnstableAnginaQWMINQMIMyocardialInfarctionWorkingDxECGCardiacBiomarkerFinalDxTheLancet2001;358:1533-1538andHeart2000;83:361-366.PresentationSTEMI的病理生理和治疗原则病理生理：斑块破裂血栓形成冠脉急性闭塞心肌坏死R.B.Jenningsetal.,Circulation68-1(1983)25-3640minutes3hours96hoursNonischemicIschemic(viable)NecroticAP=anteriorpapillarymusclePP=posteriorpapillarymuscleAPAPAPPPPPPPWavefrontPhenomenonofMyocardialNecrosis

PathophysiologyMYOCARDIALINFARCTIONDiagnosisClinicalpresentationPhysicalexaminationECGBiochemicalmarkersImagingofthecoronaryanatomyCasediscussion2临床表现男性，65岁，发作性胸痛8小时既往史：吸烟：20支/日，30年；高血压病史10年如何问诊？SymptomsProlongedcardiacpainChest,throat,arms,epigastriumorbackAnxietyFearofimpendingdeathNauseaandvomitingBreathlessnessCollapse/syncopeClinicalManifestation

MYOCARDIALINFARCTION

Pallor,sweating,tachycardiaVomiting,bradycardiaHypotension,oliguria,coldperipheriesNarrowpulseressureRaisedJVPThirdheartsoundQuietfirstheartsoundDiffuseapicalimpulseLungcrepitationsFever

Mitralregurgitation,pericarditisSignsofsympatheticactivationSignsofvagalactivationSignsofimpairedmyocardialfunctionSignsoftissuedamageSignsofcomplicationsPhysicalsignsClinicalManifestation

MYOCARDIALINFARCTIONDifferentialDiagnosiscardiacpulmonaryhematologicalUnstableanginaMyocarditisPericarditisMyopericarditisCardiomyopathyValvulardiseaseApicalballooningPulmonaryembolismPulmonaryinfarctionPneunoniaPleuritisPneumothoraxSicklecellanaemiavascularGastro-intestinalorthopaedicAorticdissectionAorticaneurysmAorticcoarctationCerebrovasculardiseaseOesophagealspasmOesophagitisPepticulcerPancreatitisCholescystitisCervicaldisopathyRibfarctureMuscleinjury/inflammationcostochondritisCasediscussion2临床表现男性，65岁，发作性胸痛8小时既往史：吸烟：20支/日，30年；高血压病史10年需要哪些辅助检查？辅助检查结果血液学：血常规、生化、凝血分析心肌酶学标志物心电图运动平板冠脉CT冠状动脉造影超声心动图10001001010RelativeMarkerIncreaseHoursAfterChestPainOnsetUpperReferenceIntervalAntmanEM.In:BraunwaldE,ed.HeartDisease:ATextbookinCardiovascularMedicine,5thed.Philadelphia,Pa:WBSaunders;1997.Diagnosis

CardiacBiomarkersinSTEMI心电图ECG特征性改变高尖T波ST段抬高异常Q波或QS波T波改变分期和动态演变超级期急性期演变期陈旧期冠状动脉造影Casediscussion2临床表现男性，65岁，发作性胸痛8小时既往史：吸烟：20支/日，30年；高血压病史10年辅助检查心电图：V2-V5st段抬高心肌标志物：TNI:7.8ng/ml如何治疗？治疗原则冠状动脉血运重建治疗恢复心肌血流和再灌注溶栓PCI

CABGSTEMI--ManagementAnti-ischemicagentsAnticoagulantsProvidefacilitiesfordefibAntiplateletagentsCoronaryrevascularization(ReperfusionStrategy-ReopenIRA)DetectandTreatcomplicationsearlyLong-termmanagementAtriplecoronaryarterybypassgraftoperationManagement

coronaryarterybypassgrafting确诊ST段抬高心肌梗死一般治疗（抗血小板、抗凝、

B阻断剂）治疗原则12小时以内12小时以上再灌注治疗溶栓治疗冠脉介入治疗是否是保守治疗Management--PCICasediscussion2临床表现男性，65岁发作性胸痛8小时既往史：吸烟：20支/日，30年；高血压病史10年辅助检查心电图：V2-V5st段抬高心肌标志物：TNI:7.8ng/ml治疗直接PCI二级预防药物STEMIComplicationsElectronic–ArrhythmiasMechanicalCOMMONARRHYTHMIASINACUTEMYOGARDIALINFARCTIONVentricularfibrillationVentriculartachycardiaAcceleratedidioventricularrhythmVentricularectopicsAtrialfibrillationAtrialtachycardiaSinusbradycardia(particularlyafterinferiorMI)HeartblockSTEMIComplicationsSTEMIComplicationsMechanicalPumpfailureCardiogenicShockPapillarymuscledamageRuptureofventricularseptumRuptureoffreewallVentricularSeptalRuptureMitralRegurgitation

(Pap.M.dysfunction)Incidence 1-2% 1-6% 1-2%

Timing 3-5dpMI 3-6dpMI 3-5dpMI

PhyExam murmur90% JVD,EMD murmur50%

Thrill Common No Rare

Echo Shunt Peric.Effusion Regurg.Jet

PAcath