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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 Introduction ArteriosclerosisThickeningandlossofelasticityofarterialwallsHardeningofthearteriesGreatestmorbidityandmortalityofallhumandiseasesviaNarrowingWeakening PlaqueThatHasBeenSurgicallyRemovedfromCoronaryAr
2、tery CourtesyRonaldD GregoryandJohnRiley MD NonModifiableRiskFactors AgeAdominantinfluenceAtherosclerosisbeginsintheyoung butdoesnotprecipitateorganinjuryuntillaterinlifeGenderMenmorepronethanwomen butbyage60 70aboutequalfrequencyFamilyHistoryFamilialclusterofriskfactorsGeneticdifferences Modifiable
3、RiskFactors potentiallycontrollable HyperlipidemiaHypertensionCigarettesmokingDiabetesMellitusElevatedHomocysteineFactorsthataffecthemostasisandthrombosisInfections Herpesvirus ChlamydiapneumoniaeObesity sedentarylifestyle stress PathogenesisofAtherosclerosis ResponsetoinjuryhypothesisInjurytotheend
4、othelium dysfunctionalendothelium ChronicinflammatoryresponseMigrationofSMCfrommediatointimaProliferationofSMCinintimaExcessproductionofECMEnhancedlipidaccumulation Responsetoinjury Endotheliadysfunction InitiationofFattyStreak FattyStreak Fibro fattyAtheroma AtherosclerosisTimeline FoamCells FattyS
5、treak IntermediateLesion Atheroma FibrousPlaque ComplicatedLesion Rupture AdaptedfromPepineCJ AmJCardiol 1998 82 suppl104 FromFirstDecade FromThirdDecade FromFourthDecade 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
6、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 MyocardialinfarctionCHD 心肌梗死型 IschemiccardiomyopathyCHD 缺血性心肌病型 SuddendeathCHD 猝死型 ClassificationofIHD Chronicischemicsyndrome stableang
7、inaasymptomaticCHDischemiccardiomyopathyCHDAcutecoronarysyndrome unstableanginaSTEMI NSTEMI 急性冠脉综合症的病理生理学 Fusteretal NEnglJMed 1992 326 310 318 Daviesetal Circulation 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 Ac
8、uteCoronarySyndrome UnstableAngina NQMI QwMI NSTEMI MyocardialInfarction DaviesMJHeart83 361 2000 IschemicDiscomfort Presentation WorkingDx ECG Biochem Marker FinalDx HammLancet358 1533 2001 ANGINAPECTORIS DefinitionofAngina Apainordiscomfortinthechestoradjacentareascausedbyinsufficientbloodflowtoth
9、eheartmuscle Clinicalclassificationandpathology Stableangina fixedatheromatousstenosisUnstableangina dynamicobstructionbyplaquerupturewithsuperimposedthrombosisandspasm 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
10、管腔狭窄 Stableanginapectoris ETIOLOGY Ischemiaissecondarytocoronaryarterydiseasein95 ofpatients Theleadingcauseiscertainlyatheroscleroticcoronaryarterydisease Adecreasedoxygensupplyoranincreaseinoxygendemandcanleadtoaworseningofsymptoms Ischemiacanoccurinpatientswithnormalcoronaryarteries Clinicalmenif
11、estationchestdiscomfort Quality squeezing griplike pressurelike suffocating and heavy ora discomfort butnot pain Anginaisalmostneversharporstabbing andusuallydoesnotchangewithpositionorrespiration Duration anginalepisodeistypicallyminutesinduration Fleetingdiscomfortoradullachelastingforhoursisrarel
12、yanginaLocation usuallysubsternal butradiationtotheneck jaw epigastrium orarmsisnotuncommon Painabovethemandible belowtheepigastrium orlocalizedtoasmallareaovertheleftlateralchestwallisrarelyanginal Provocation anginaisgenerallyprecipitatedbyexertionoremotionalstressandcommonlyrelievedbyrest Subling
13、ualnitroglycerinalsorelievesangina usuallywithin30secondstoseveralminutes CategorizetheSeverityofAngina Clinicalfeatures PhysicalexaminationAnS4gallopmaybetransientlypresentduringanepisode andthepatientmaybedyspneicordiaphoreticorhaveanewheartmurmur High riskfeaturesofanginaincludeheartfailureandhyp
14、otension Acompletephysicalexamiscrucialinmakinganassessmentofrisk Mostpt AlternativeDiagnosestoAnginaforPatientswithChestPain Non IschemicCVaorticdissectionpericarditisPulmonarypulmonaryemboluspneumothoraxpneumoniapleuritisChestWallcostochondritisfibrositisribfracturesternoclaviculararthritisherpesz
15、oster GastrointestinalEsophagealesophagitisspasmrefluxBiliarycoliccholecystitischoledocholithiasischolangitisPepticulcerPancreatitis PsychiatricAnxietydisordershyperventilationpanicdisorderprimaryanxietyAffectivedisordersdepressionSomatiformdisordersThoughtdisordersfixedocclusions Investigation 12Le
16、adRestingECGshouldberecordedinallpatientswithsymptomssuggestiveofanginapectorisnormalin 50 ofpatientsanormalECGdoesnotexcludesevereCAD however itdoesimplynormalLVfunctionwithfavorableprognosis CHD Atrest ECG 冠心病 Episodeofangina ST segmentdepression ECG CHD Holter Exercisetesting Angina ExerciseTestingHighRiskPatients SignificantST segmentdepressionatlowlevelsofexerciseand orheartrate 130FallinsystolicbloodpressureDiminishedexercisecapacityComplexventricularectopyatlowlevelofexercise ExerciseTest
