《心绞痛的鉴别-心绞痛ppt培训课件》由会员分享，可在线阅读，更多相关《心绞痛的鉴别-心绞痛ppt培训课件（38页珍藏版）》请在金锄头文库上搜索。
1、病史特点,男性，59岁 反复胸痛4个月，加重1个月。 胸痛呈压榨性与劳力有关。 有高血压，吸烟史。 有心脑血管病阳性家族史。 查体：体胖，无明显其他阳性发现。 ECG：V4V6，I，aVL ST 0.5-1mm.,胸痛的鉴别 心绞痛的特点 心绞痛的分级 心绞痛的分类 不同类型心绞痛的病理基础 进一步检查 冠心病的易患因素,心绞痛的鉴别 (1),Non-ischemic CV Aortic dissection Pericarditis Pulmonary Pulmonary embolus Pneumothorax Pneumonia Pleuritis,Gastrointestinal Es
2、ophageal Esophagitis, Spasm, Reflux Biliary Colic Cholecystitis Choledocholithiasis Cholangitis Peptic ulcer Pancreatitis,心绞痛的鉴别 (2),Chest Wall Costochondritis Fibrositis Rib fracture Sternoclavicular arthritis Herpes zoster (before the rash),Psychiatric Anxiety disorders Hyperventilation Panic diso
3、rder Primary anxiety Affective disorders (e.g., depression) Somatiform disorders Thought disorders (e.g., fixed delusions),心绞痛特点,SAVES U： Sudden onset; Anterior chest; Vague sensation; Exercise precipitated; Short duration; Unanimous attack.,Grading of Angina Pectoris by CCSC,Class I: 日常体力活动不引起心绞痛.C
4、lass II: 日常体力活动轻度受限.Class III: 日常体力活动明显受限.Class IV: 任何体力活动都引起症状，可以有休息时心绞痛。,UAP 的主要临床表现,Rest angina: Occurring at rest, usu. 20min, occurring within a week of presentation. New onset angina: At least CCSC III severity, 200mmHg; DBP 110mmHg; Tachy- or Brady-arrhythmias; High degree AVB HCMP or other f
5、orms of OT obstruction; Mental or physical impairment;,Noninvasive Testing: Exercise ECG(3),Risk: MI and death 1/2500 tests. A standard percentage (often 85%) of age-predicated maximum heart rate is targeted. Reported in estimated METs of exercise (One MET is the standard basal oxygen uptake of 3.5m
6、l/kg per min.) ST depression 1mm for 60-80ms after the end of QRS, during or after exercise.,Noninvasive Testing: Exercise ECG(4) (Absolute indication for stopping):,SBP drop 10mmHg with ischemia; Moderate to severe angina; Increasing ataxia; Dizziness or near syncope; Sign of poor perfusion; Techni
7、cal difficulties; Sustained VT; ST elevation in leads without Q waves.,Noninvasive Testing: Exercise ECG(5) (Relative indication for stopping):,SBP drop 10mmHg without ischemia; SBP 250 or DBP 115mmHg; ST depression 2mm; Marked axis deviation; Multifocal PVCs, triplets PVCs, SVT, heart block or brad
8、yarrhythmias, BBB or IVCB Increasing chest pain; Serious symptoms.,Noninvasive Testing: Exercise ECG(6),Sensitivity: 68%; Specificity: 77% Influence of other factors on test: Digoxin: 25-40% abnormal ST depression. Beta blockers: Gradually withheld 48hrs. Anti-HBP, vasodilators, nitrates, flacainide
9、. LBBB: RBBB: LV hypertrophy: More false-positive. Rest ST depression: Additional ST significant.,Stress Imaging Studies,Good candidates for stress imaging, as opposed to exercise ECG: CLBBB, Paced rhythm, WPW etc. ST 1mm at rest, Unable to exercise, Angina with prior Revascularization.,Pharmacologi
10、c Modalities (Vasodilators) Used in Stress Imaging,Dipyridamole(DIP) inhibiting cellular uptake of adenosine (a potent coronary vasodilators). The flow increase by adenosine is of lesser magnitude through stenostic arteries, creating heterogeneous myocardial perfusion. Side effects of both DIP and A
11、DE are rare, but may cause severe bronchospasm in patients with asthma or COPD.,Pharmacologic Modalities (Dobutamine) Used in Stress Imaging,In high doses (20 to 40g /kg /min) increases HR, SBP and myocardial contractility. The flow increase(2-3 times) is less than that elicited by adenosine or dipyridamole. Side effects are frequent, but the test appears to be safe even in the elderly, including nausea, anxiety, headache, tremor, VPC, APC, SVT, nonsust-VT, chest pain and angina(8%).,Invasive Testing - Angiography (Indications),
