《冠心病课件(大医英)讲解学习》由会员分享，可在线阅读，更多相关《冠心病课件(大医英)讲解学习（76页珍藏版）》请在金锄头文库上搜索。
1、冠状动脉粥样硬化性心脏病 coronaryatheroscleroticheartdisease 大连医科大学附属二院心内科牛楠 动脉粥样硬化atherosclerosis PlaqueThatHasBeenSurgicallyRemovedfromCoronaryArtery CourtesyRonaldD GregoryandJohnRiley MD NonModifiableRiskFactors AgeAdominantinfluenceAtherosclerosisbeginsintheyoung butdoesnotprecipitateorganinjuryuntillateri
2、nlifeGenderMenmorepronethanwomen butbyage60 70aboutequalfrequencyFamilyHistoryFamilialclusterofriskfactorsGeneticdifferences ModifiableRiskFactors potentiallycontrollable HyperlipidemiaHypertensionCigarettesmokingDiabetesMellitusElevatedHomocysteineFactorsthataffecthemostasisandthrombosisInfections
3、Herpesvirus ChlamydiapneumoniaeObesity sedentarylifestyle stress PathogenesisofAtherosclerosis ResponsetoinjuryhypothesisInjurytotheendothelium dysfunctionalendothelium ChronicinflammatoryresponseMigrationofSMCfrommediatointimaProliferationofSMCinintimaExcessproductionofECMEnhancedlipidaccumulation
4、Responsetoinjury Endotheliadysfunction InitiationofFattyStreak FattyStreak Fibro fattyAtheroma AtherosclerosisTimeline FoamCells FattyStreak IntermediateLesion Atheroma FibrousPlaque ComplicatedLesion Rupture AdaptedfromPepineCJ AmJCardiol 1998 82 suppl104 FromFirstDecade FromThirdDecade FromFourthD
5、ecade AHAClassificationofatherosclerosis 动脉粥样硬化血栓形成 具共同病理基础的进展性过程 正常 脂肪条纹 纤维斑块 粥样硬化斑块 斑块破溃 裂隙和血栓形成 心肌梗死 缺血性中风 TIA 严重的下肢缺血 临床无症状 心血管死亡 年龄增长 稳定性心绞痛间歇性跛行 不稳定性心绞痛 ACS ACS 急性冠脉综合征 TIA 一过性脑缺血发作 缺血性肾病缺血性肠病 CoronaryArteryDisease 冠心病 Clinicalclassification 1979WHO AsymptomaticCHD 隐匿型 AnginapectorisCHD 心绞痛型 M
6、yocardialinfarctionCHD 心肌梗死型 IschemiccardiomyopathyCHD 缺血性心肌病型 SuddendeathCHD 猝死型 ClassificationofIHD Chronicischemicsyndrome stableanginaasymptomaticCHDischemiccardiomyopathyCHDAcutecoronarysyndrome unstableanginaSTEMI NSTEMI 急性冠脉综合症的病理生理学 Fusteretal NEnglJMed 1992 326 310 318 Daviesetal Circulatio
7、n 1990 82 SupplII II 38 II 46 不稳定血栓 UA NSTEMI 脂肪池巨噬细胞内在的压力 张力外部的剪切力 裂缝 大裂缝 小裂缝 闭合血栓 STEMI 动脉粥样硬化斑块 斑块破裂 血栓 NoSTElevation STElevation AcuteCoronarySyndrome UnstableAngina NQMI QwMI NSTEMI MyocardialInfarction DaviesMJHeart83 361 2000 IschemicDiscomfort Presentation WorkingDx ECG Biochem Marker FinalD
8、x HammLancet358 1533 2001 ANGINAPECTORIS DefinitionofAngina Apainordiscomfortinthechestoradjacentareascausedbyinsufficientbloodflowtotheheartmuscle Clinicalclassificationandpathology Stableangina fixedatheromatousstenosisUnstableangina dynamicobstructionbyplaquerupturewithsuperimposedthrombosisandsp
9、asm 斑块破裂引起急性严重事件 不稳定心绞痛 心肌梗死 猝死 稳定性 劳力性 心绞痛 不稳定斑块的进展过程 稳定斑块的进展过程 NissenSE AmJCardiol 2000 86 suppl 12H 17H 不稳定斑块 斑块破裂 血栓形成 稳定斑块 斑块体积增加 管腔狭窄 Stableanginapectoris ETIOLOGY Ischemiaissecondarytocoronaryarterydiseasein95 ofpatients Theleadingcauseiscertainlyatheroscleroticcoronaryarterydisease Adecrease
10、doxygensupplyoranincreaseinoxygendemandcanleadtoaworseningofsymptoms Ischemiacanoccurinpatientswithnormalcoronaryarteries Clinicalmenifestationchestdiscomfort Quality squeezing griplike pressurelike suffocating and heavy ora discomfort butnot pain Anginaisalmostneversharporstabbing andusuallydoesnot
11、changewithpositionorrespiration Duration anginalepisodeistypicallyminutesinduration FleetingdiscomfortoradullachelastingforhoursisrarelyanginaLocation usuallysubsternal butradiationtotheneck jaw epigastrium orarmsisnotuncommon Painabovethemandible belowtheepigastrium orlocalizedtoasmallareaoverthele
12、ftlateralchestwallisrarelyanginal Provocation anginaisgenerallyprecipitatedbyexertionoremotionalstressandcommonlyrelievedbyrest Sublingualnitroglycerinalsorelievesangina usuallywithin30secondstoseveralminutes CategorizetheSeverityofAngina Clinicalfeatures PhysicalexaminationAnS4gallopmaybetransientl
13、ypresentduringanepisode andthepatientmaybedyspneicordiaphoreticorhaveanewheartmurmur High riskfeaturesofanginaincludeheartfailureandhypotension Acompletephysicalexamiscrucialinmakinganassessmentofrisk Mostpt AlternativeDiagnosestoAnginaforPatientswithChestPain Non IschemicCVaorticdissectionpericardi
14、tisPulmonarypulmonaryemboluspneumothoraxpneumoniapleuritisChestWallcostochondritisfibrositisribfracturesternoclaviculararthritisherpeszoster GastrointestinalEsophagealesophagitisspasmrefluxBiliarycoliccholecystitischoledocholithiasischolangitisPepticulcerPancreatitis PsychiatricAnxietydisordershyper
15、ventilationpanicdisorderprimaryanxietyAffectivedisordersdepressionSomatiformdisordersThoughtdisordersfixedocclusions Investigation 12LeadRestingECGshouldberecordedinallpatientswithsymptomssuggestiveofanginapectorisnormalin 50 ofpatientsanormalECGdoesnotexcludesevereCAD however itdoesimplynormalLVfun
16、ctionwithfavorableprognosis CHD Atrest ECG 冠心病 Episodeofangina ST segmentdepression ECG CHD Holter Exercisetesting Angina ExerciseTestingHighRiskPatients SignificantST segmentdepressionatlowlevelsofexerciseand orheartrate 130FallinsystolicbloodpressureDiminishedexercisecapacityComplexventricularectopyatlowlevelofexercise ExerciseTestingContraindications MI impendingoracuteUnstableanginaAcutemyocarditis pericarditisAcutesystemicillnessSevereaorticstenosisCongestiveheartfailureSeverehypertensionUn
