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1、Department of Western Medicine Education Shandong College of Traditional Chinese MedicineDepartment of Western Medicine Education Shandong College of Traditional Chinese Medicine急性心肌梗死西医教学部西医临床教研室 张豪英 张彩坤 宋桂红Department of Western Medicine Education Shandong College of Traditional Chinese Medicine导入新
2、课急性心肌梗死（AMI）是急性心肌缺血性坏死，大多是在冠状动脉病变的基础上发生冠状动脉血供急剧减少或中断，使相应的心肌严重而持久地急性缺血所致。定义Department of Western Medicine Education Shandong College of Traditional Chinese Medicine学习内容诊断与鉴别诊断辅助检查临床表现病理病因与发病机制治疗Department of Western Medicine Education Shandong College of Traditional Chinese Medicine课堂小结 急性心肌梗死的症状 急性心
3、肌梗死的心电图 特点 急性心肌梗死的治疗Department of Western Medicine Education Shandong College of Traditional Chinese Medicine拓展学习-病例分析男，58岁，8小时前无诱因出现胸骨后持续性压榨性疼痛，活动时加重，伴有气促、咳嗽、大汗淋漓，不能平卧，呕吐2次。既往有心前区疼痛史3年。查体：T：36.7，P：106次/分，R：28次/分，BP：120/70mmHg，半卧位，神清，呼吸音稍弱，肺底闻及细湿啰音及少许哮鸣音。心尖搏动位于左第五肋间锁骨中线外侧0.5cm，HR：106次/分，律齐，心音低钝，二尖瓣区
4、可闻及3/6级吹风样杂音，向心前区传导。腹平软，无压痛及反跳痛，肝脾肋下未及。Department of Western Medicine Education Shandong College of Traditional Chinese Medicine拓展学习-病例分析1. 写出最可能的诊断，并列 出鉴别诊断 2. 为明确诊断应进一步进行 哪些检查 3. 治疗原则。Department of Western Medicine Education Shandong College of Traditional Chinese MedicineDepartment of Western Med
5、icine Education Shandong College of Traditional Chinese Medicine病因与发病机制通常是在冠状动脉粥样硬化不稳定斑块病变的基础上继发血栓形成导致冠脉持续、完全阻塞Department of Western Medicine Education Shandong College of Traditional Chinese Medicine病因与发病机制-动画1Department of Western Medicine Education Shandong College of Traditional Chinese Medicine
6、病因与发病机制-动画2Department of Western Medicine Education Shandong College of Traditional Chinese Medicine病因与发病机制-动画3Department of Western Medicine Education Shandong College of Traditional Chinese Medicine病因与发病机制-动画4Department of Western Medicine Education Shandong College of Traditional Chinese Medicine
7、常见诱因CO骤降，冠脉血流量减少：休克、脱水、出血心肌氧耗量增加：劳累、激动、用力大便 血液粘附性增高:饱餐（高脂肪餐） 血脂增高， 血粘度，血小板粘附性增高 血栓形成晨起6-12时交感神经张力增高，易引起冠状动脉痉 挛返回Department of Western Medicine Education Shandong College of Traditional Chinese Medicine病理正常冠状动脉1Department of Western Medicine Education Shandong College of Traditional Chinese Medicine病
8、理正常冠状动脉2Department of Western Medicine Education Shandong College of Traditional Chinese Medicine病理血管病理改变 血管狭窄75%以上，单支或多支LAD：LV前壁、心尖部、下侧壁、前间隔、前 组乳头肌 LCX：LV高侧壁、膈面、LA RCA：LV膈面、后间隔、RV、SAN、AVN 左冠脉主干闭塞：可引起左心室广泛梗塞Department of Western Medicine Education Shandong College of Traditional Chinese Medicine病理重度
9、冠状动脉粥样硬化Department of Western Medicine Education Shandong College of Traditional Chinese Medicine病理冠状动脉斑块内出血Department of Western Medicine Education Shandong College of Traditional Chinese Medicine病理心肌病理改变 2030分钟，心肌即可有少数坏死 12小时，绝大部分心肌呈凝固性坏死 12周后开始溶解吸收，逐渐纤维化 68周形成疤痕而愈合陈旧性心梗全层坏死透壁性心梗Q波梗死1/2全层心内膜下心梗非Q波
10、坏死心壁向外膨出室壁瘤Department of Western Medicine Education Shandong College of Traditional Chinese Medicine病理新近形成血栓的冠状动脉左前降支和心脏Department of Western Medicine Education Shandong College of Traditional Chinese Medicine病理广泛前壁梗死返回Department of Western Medicine Education Shandong College of Traditional Chinese
11、Medicine临床表现先兆 其中不稳定性心绞痛最突出，要特别 注意频发、剧烈、持久、药物无效的 心绞痛 尚可伴有胸闷、心悸、乏力、恶心、 呕吐、BP，ECG等变化Department of Western Medicine Education Shandong College of Traditional Chinese Medicine休克胸骨后 疼痛全身表现心力衰竭心律失常症状临床表现Department of Western Medicine Education Shandong College of Traditional Chinese Medicine心梗症状动画Departme
12、nt of Western Medicine Education Shandong College of Traditional Chinese Medicine乳头肌功能失调心脏体征低血压 休克体征心力衰竭体征心律失常体征临床表现Department of Western Medicine Education Shandong College of Traditional Chinese Medicine乳头肌功能 失调或断裂心肌梗塞 后综合征室壁瘤栓塞心脏破裂并发症临床表现Department of Western Medicine Education Shandong College o
13、f Traditional Chinese Medicine腱索断裂Department of Western Medicine Education Shandong College of Traditional Chinese Medicine乳头肌梗死及断裂Department of Western Medicine Education Shandong College of Traditional Chinese Medicine室间隔破裂穿孔返回Department of Western Medicine Education Shandong College of Traditiona
14、l Chinese M心电图超声心动图实验室检查辅助检查辅助检查返回Department of Western Medicine Education Shandong College of Traditional Chinese MedicineCompany Logo特征性改 变心电图动态性改 变Department of Western Medicine Education Shandong College of Traditional Chinese MedicineCompany L特征性改变坏死损伤缺血宽而 深的 Q波ST段 抬高 呈弓 背向 上型T波 倒置心内膜 下心肌 梗塞无 病
15、理性 Q波Department of Western Medicine Education Shandong College of Traditional Chinese Medicine恢复期亚急性期急性期超急性期动 态 性 改 变Department of Western Medicine Education Shandong College of Traditional Chinese Medicine心电图动态演变动画Department of Western Medicine Education Shandong College of Traditional Chinese Medi
16、cine前壁心梗心电图返回Department of Western Medicine Education Shandong College of Traditional Chinese Medicine辅助检查-超声心动图可检出梗塞部位室壁变薄和运动异常、室 壁瘤，了解左室功能、乳头肌功能返回Department of Western Medicine Education Shandong College of Traditional Chinese Medicine辅助检查-实验室检查血象：中性粒细胞升高，嗜酸粒细胞减少或消失血清酶：肌酸磷酸激酶（CPK）、同功酶（CPKMB）、天门冬氨酸氨基转移酶（AST），谷丙转氨酶（ALT）、乳酸脱氢酶（LDH）升高 心肌标志物：血肌红蛋白、心脏肌凝蛋白及其轻链升高Departme
