《coronaryheartdisease课件》由会员分享，可在线阅读，更多相关《coronaryheartdisease课件（73页珍藏版）》请在金锄头文库上搜索。
1、Coronary Atherosclerotic Coronary Atherosclerotic Heart Disease (CHD)Heart Disease (CHD) coronaryheartdisease Definition Coronary atherosclerotic heart disease: Coronary heart disease: Ischemic heart disease:coronaryheartdiseaseClinical TypeSilent myocardial ischemiaAngina pectorisMyocardial infarct
2、ionIschemic cardiomyopathySudden cardiac death coronaryheartdiseaseSilent Myocardial IschemiaDefined as documented episodes of ischemia not Defined as documented episodes of ischemia not associated with any typical or atypical symptoms that among associated with any typical or atypical symptoms that
3、 among patients with obstructive coronary artery disease.patients with obstructive coronary artery disease.Type I:Type I: myocardial ischemia is detected on routine ECG, myocardial ischemia is detected on routine ECG, 24h ambulatory ECG monitoring (Holter), etc. but not 24h ambulatory ECG monitoring
4、 (Holter), etc. but not experience angina at any time;experience angina at any time;Type II:Type II: patients are most frequently encountered in patients are most frequently encountered in clinical practice. Some episodes of ischemia are associated with clinical practice. Some episodes of ischemia a
5、re associated with chest discomfort and other episodes are asymptomatic.chest discomfort and other episodes are asymptomatic.coronaryheartdiseaseIschemic CardiomyopathySymptoms of heart failure, caused by ischemic myocardial dysfunction (hibernation), diffuse fibrosis, and multiple infarction, alone
6、 or in combination.Manifestations: ventricles enlargement (dominant left ventricle), heart failure and arrhythmias.coronaryheartdiseaseSudden Cardiac DeathSCD is natural death due to cardiac causes, heralded by SCD is natural death due to cardiac causes, heralded by abrupt loss of consciousness with
7、in 1 hours of the onset of abrupt loss of consciousness within 1 hours of the onset of acute symptoms.acute symptoms.The time and mode of death are unexpected. The time and mode of death are unexpected. WHO definition: unexpected death within 6 hours.WHO definition: unexpected death within 6 hours.T
8、his definition incorporates the key elements of This definition incorporates the key elements of natural,natural, rapidrapid and and unexpectedunexpected. .One half of SCD due to coronary heart diseaseOne half of SCD due to coronary heart disease，caused by caused by severe arrhythmias, such as ventr
9、icular fibrillation and severe arrhythmias, such as ventricular fibrillation and cardiac arrest.cardiac arrest.coronaryheartdiseaseAcute Coronary Syndromes（ACS）ACS represents a spectrum of conditions: including: acute MI, unstable angina and sudden cardiac death. Acute plaque change characterized by
10、 plaque rupture and exposure of substances that promote platelet activation and thrombin generation.coronaryheartdiseaseRiskFactorAge, gender and family history HypertensionDislipidmiaDiabetes mellitusTobacco useObesitycoronaryheartdiseaseCandidate Risk FactorHomocystein Homocystein Fibrinogen Fibri
11、nogen LP(a) LP(a) Fibrinolytic activityFibrinolytic activity（tPAtPA） Plasminogen activator inhibitorPlasminogen activator inhibitor（PAIPAI） C C reactive protein reactive protein Coagulation factor Coagulation factor Estrogens Estrogens AlcoholAlcoholType A personality and stressType A personality an
12、d stresscoronaryheartdiseaseAngina PectorisDefinition： A clinical syndrome due to myocardial ischemia characterized by episodes of precordial discomfort or pressure, typically precipitated by exertion and relieved by rest or sublingual nitroglycerin. coronaryheartdiseaseCoronary arterial stenosisCor
13、onary arterial stenosisCoronary arterial spasm Coronary arterial spasm Myocardial oxygen consumption Myocardial oxygen consumption Mechanism and Pathophysiologycoronaryheartdisease心绞痛发生机制心绞痛发生机制心肌缺血心肌缺血缺氧缺氧酸性或肽类酸性或肽类物质物质 刺激心脏刺激心脏植物神经植物神经传入纤维传入纤维1515胸交感神胸交感神经节及相应脊经节及相应脊髓段髓段大脑大脑疼疼 痛痛coronaryheartdisea
14、se牵涉痛发生机制胸骨后、两前臂内侧及胸骨后、两前臂内侧及小指（左侧多见）疼痛小指（左侧多见）疼痛反映在反映在1-5胸交感神经胸交感神经节相应脊髓段脊神经节相应脊髓段脊神经coronaryheartdiseaseClinical Presentation:Clinical Presentation:Episodes of chest pain：LocationLocationCharacterCharacterTriggerTriggerDurationDurationRelieve Relieve Symptom:Symptom:coronaryheartdiseaseIn general,
15、 no abnormal signHR 、BP S3、S4 gallopApical systolic murmurClinical Presentation:Clinical Presentation:Signs:Signs:coronaryheartdisease ElectrocardiogramElectrocardiogramECG at restECG at restECG at episodes of chest painECG at episodes of chest painExercise ECGExercise ECGAmbulatory Ambulatory ECG E
16、CG monitoring monitoring (Holter)(Holter)coronaryheartdiseaseECG at ECG at Episodes of chest paincoronaryheartdiseasecoronaryheartdiseaseCoronary Angiography1、 心绞痛无法确诊者。 2、对内科治疗中心绞痛仍较重者，明确动脉病变情况以考虑介入治疗或旁路移植手术。 3 、冠脉痉挛行麦角新碱试验。coronaryheartdiseasecoronaryheartdiseaseOther Diagnostic Testing心脏X线检查放射性核素
17、检查二维超声心动图血管镜coronaryheartdiseaseClinicalTypeofAngina劳累性心绞痛劳累性心绞痛劳累性心绞痛劳累性心绞痛stable angina pectorisstable angina pectorisstable angina pectorisstable angina pectoris initial onset angina pectorisinitial onset angina pectorisinitial onset angina pectorisinitial onset angina pectoris acceleratedanginaa
18、cceleratedanginapectorispectorispectorispectoris自发性心绞痛自发性心绞痛自发性心绞痛自发性心绞痛anginadecubitusanginadecubitus PrinzmetalPrinzmetalPrinzmetalPrinzmetal s variant angina pectoriss variant angina pectoriss variant angina pectoriss variant angina pectoris acute coronary insufficiency acute coronary insufficien
19、cy acute coronary insufficiency acute coronary insufficiency postinfarction angina pectorispostinfarction angina pectorispostinfarction angina pectorispostinfarction angina pectoris混合型心绞痛混合型心绞痛混合型心绞痛混合型心绞痛coronaryheartdiseaseStable angina pectorisUnstable angina pectorisTyping by stability or quiesc
20、ence Typing by stability or quiescence of an atherosclerotic plaque:of an atherosclerotic plaque:ClinicalTypeofAnginacoronaryheartdiseaseClassification of Angina Classification of Angina ClassClassClassClass：ordinary physical activityordinary physical activityordinary physical activityordinary physi
21、cal activity does not cause angina does not cause angina does not cause angina does not cause anginaClass Class Class Class ： slight limitation of ordinaryslight limitation of ordinaryslight limitation of ordinaryslight limitation of ordinary physical activity physical activity physical activity phy
22、sical activity Class Class Class Class ：marked limitation of ordinarymarked limitation of ordinarymarked limitation of ordinarymarked limitation of ordinary physical activity physical activity physical activity physical activity ClassClassClassClass ：inability to carry on anyinability to carry on an
23、yinability to carry on anyinability to carry on any activity without discomfort activity without discomfort activity without discomfort activity without discomfortCanadian Class:Canadian Class:coronaryheartdiseaseDifferential DiagnosisDifferential Diagnosis心脏神经官能症心脏神经官能症急性心肌梗塞急性心肌梗塞其它疾病引起的心绞痛其它疾病引起的
24、心绞痛消化道疾病消化道疾病呼吸系统引起的胸痛呼吸系统引起的胸痛心包疾病心包疾病coronaryheartdiseaseTherapy of AnginaTherapy of AnginaMedical therapyMedical therapyPercutaneous Percutaneous transluminal transluminal coronary coronary angioplasty (PTCA)angioplasty (PTCA)Coronary Coronary artery artery bypass bypass grafting grafting （CABGCA
25、BG）coronaryheartdiseasePlatelet inhibitorsPlatelet inhibitors： AspirinAspirin、ticlipidineticlipidine、clopidogrelclopidogrelNitratesNitrates- -blockersblockersCalcium channel blockersCalcium channel blockersLipid-lowering agentsLipid-lowering agents 3-hydroxy-3-methylglutaryl coenzyme A 3-hydroxy-3-m
26、ethylglutaryl coenzyme A (HMG-CoA) (HMG-CoA) ( (statin)statin) fibratefibrateTherapy of AnginaTherapy of AnginaPharmacologic therapy:Pharmacologic therapy:coronaryheartdisease阿司匹林阿司匹林抑制环氧酶，阻止花生四烯酸转化为前列腺素抑制环氧酶，阻止花生四烯酸转化为前列腺素G G2 2、前列腺素、前列腺素H H2 2，使血小板合成血栓素，使血小板合成血栓素A A2 2(TXA(TXA2 2) )减减少，抑制血小板的聚集和释放
27、。剂量：少，抑制血小板的聚集和释放。剂量：0.050.3/0.050.3/天，天，长期服用。长期服用。噻氯匹啶噻氯匹啶(Ticlopidine,(Ticlopidine,抵克力得抵克力得) )机制不清，可能与机制不清，可能与ADPADP介导的血小板聚集有关。介导的血小板聚集有关。剂量：剂量：0.250.5/0.250.5/天，长期服用。天，长期服用。氯吡格雷氯吡格雷(Chlopidogrel)(Chlopidogrel)与抵克力得类似，但起效快、作用更强，没有与抵克力得类似，但起效快、作用更强，没有降低白细胞之副作用。剂量：降低白细胞之副作用。剂量：75mg/75mg/天，长期服用。天，长期服
28、用。Pharmacologic therapyPharmacologic therapycoronaryheartdisease硝酸酯类硝酸酯类机理：扩张冠脉。机理：扩张冠脉。 扩张周围血管，特别是静脉，减少回流及缩扩张周围血管，特别是静脉，减少回流及缩小心脏。同时降低血压，从而降低心肌耗氧小心脏。同时降低血压，从而降低心肌耗氧量。量。制剂及用法：制剂及用法： 硝酸甘油片（硝酸甘油片（0.6mg/0.6mg/片）、消心痛（片）、消心痛（10mg/10mg/片）、片）、5 5单硝酸异山梨醇酯（单硝酸异山梨醇酯（20mg20mg、50mg50mg、60mg/60mg/片），含化或口服（片），含化或
29、口服（1313次次/ /日）。尚有气雾剂、贴日）。尚有气雾剂、贴剂及注射剂。剂及注射剂。副作用：头痛、颜面潮红、血压下降。副作用：头痛、颜面潮红、血压下降。 Pharmacologic therapyPharmacologic therapycoronaryheartdisease 阻滞剂阻滞剂机理：降低心率及心肌收缩力，而减低心肌耗氧量。机理：降低心率及心肌收缩力，而减低心肌耗氧量。因可诱发冠脉痉挛，仅适用于劳累型心绞痛。因可诱发冠脉痉挛，仅适用于劳累型心绞痛。剂型及用法：普奈洛尔（心得安，剂型及用法：普奈洛尔（心得安，Propranolol),10mg/Propranolol),10mg/
30、片，片，1040mg.tid.1040mg.tid.。 心脏心脏 1 1受体选择性阻滞剂：受体选择性阻滞剂： 美托洛尔（美托洛尔（Betaloc,Betaloc,倍它乐克），倍它乐克），2525、50mg/50mg/片，片，2550mg2550mg，tid.tid.。 阿替洛尔（阿替洛尔（Atenolol,Atenolol,氨酰心安），氨酰心安），25mg/25mg/片，片，25mg,bid.25mg,bid.。副作用：心动过缓、诱发或加重心衰、支气管痉挛、副作用：心动过缓、诱发或加重心衰、支气管痉挛、血压下降。血压下降。Pharmacologic therapyPharmacologic t
31、herapycoronaryheartdisease钙拮抗剂钙拮抗剂: :主要用于自发型心绞痛（变异型）主要用于自发型心绞痛（变异型）机理：抑制机理：抑制CaCa+进入细胞内，也抑制心肌细胞兴奋进入细胞内，也抑制心肌细胞兴奋收缩耦联中收缩耦联中CaCa+的利用。的利用。作用：扩张冠脉、抑制心肌收缩力、扩张周围血管作用：扩张冠脉、抑制心肌收缩力、扩张周围血管（动脉）、降低血液粘度、抗血小板聚集、改善心（动脉）、降低血液粘度、抗血小板聚集、改善心肌微循环。肌微循环。剂型及用法：剂型及用法：地尔硫卓（地尔硫卓（Diltiazem,Diltiazem,合心爽、合贝爽），合心爽、合贝爽），3030、90
32、mg/90mg/片，片，30mg,tid.30mg,tid.，90mg,qd.90mg,qd.，亦有注射剂。，亦有注射剂。韦拉帕米及硝苯吡啶很少使用。韦拉帕米及硝苯吡啶很少使用。副作用：抑制房室传导、诱发及加重心衰。副作用：抑制房室传导、诱发及加重心衰。Pharmacologic therapyPharmacologic therapycoronaryheartdiseaseTherapy of AnginaTherapy of AnginaPTCA and stentCABGRevascularization:coronaryheartdiseaseAcuteMyocardialInfarc
33、tionDefinition：The The rupture rupture of of plaque plaque leads leads to to the the coronary coronary occlusion occlusion and and blood blood flow flow interruption, interruption, the the persistent persistent ischemia ischemia results in myocardial necrosis . results in myocardial necrosis . coron
34、aryheartdiseasePathologyThe role of acute plaque changesThe role of acute plaque changescoronaryheartdiseasecoronaryheartdiseasecoronaryheartdiseasePathologycoronaryheartdiseasePathologyOcclusive coronary thrombosis:Occlusive coronary thrombosis:20-3020-3020-3020-30min necrosis min necrosis min necr
35、osis min necrosis 1-2h coagulation necrosis and myocytolysis1-2h coagulation necrosis and myocytolysis1-2h coagulation necrosis and myocytolysis1-2h coagulation necrosis and myocytolysis1-2w fibrosis1-2w fibrosis1-2w fibrosis1-2w fibrosis6-86-86-86-8w connective tissue scarw connective tissue scarw
36、connective tissue scarw connective tissue scarTransmural infarction,subendocardial infarctionTransmural infarction,subendocardial infarctionTransmural infarction,subendocardial infarctionTransmural infarction,subendocardial infarctionQ-waveQ-waveQ-waveQ-wave and non-Q-wave infarctionand non-Q-wave i
37、nfarctionand non-Q-wave infarctionand non-Q-wave infarctionrupture rupture rupture rupture of of of of free free free free wall, wall, wall, wall, interventricular interventricular interventricular interventricular septum, septum, septum, septum, papillary muscle, aneurysmpapillary muscle, aneurysmp
38、apillary muscle, aneurysmpapillary muscle, aneurysmcoronaryheartdiseasePathophysiologyLeft ventricular function:Left ventricular function: dyssynchronydyssynchrony hypokinesishypokinesis akinesisakinesis dyskinesis(paradoxical expansion)dyskinesis(paradoxical expansion)Ventricular remodeling:Ventric
39、ular remodeling: infarct expansion infarct expansion ventricular dilation ventricular dilationcoronaryheartdiseasePathophysiologycoronaryheartdiseasePathophysiologycoronaryheartdiseaseSymptomsProdromal symptomsProdromal symptomsProdromal symptomsProdromal symptomsChest painChest painChest painChest
40、painGeneral symptomsGeneral symptomsGeneral symptomsGeneral symptomsArrhythmiasArrhythmiasArrhythmiasArrhythmiasHypotension and cardiac shockHypotension and cardiac shockHypotension and cardiac shockHypotension and cardiac shockGastrointestinalGastrointestinalGastrointestinalGastrointestinal symptom
41、ssymptomssymptomssymptoms Heart failureHeart failureHeart failureHeart failurecoronaryheartdiseaseSignsCardiac signs： HR increase or decrease S1 1 S4 4 or S3 3 gallop Apical SM or/and mid and late systolic click， pericardial friction sound， hypotensionOther signs：arrhythmias，heart failure，shock.coro
42、naryheartdiseaseAMI KillipAMI Killip Heart Heart Function ClassFunction ClassClass Class ：no heart failureno heart failureClass Class ：left heart failureleft heart failureClass Class ：acute pulmonary edemaacute pulmonary edemaClass Class ：cardiac shockcardiac shockcoronaryheartdiseaseComplicationsDy
43、sfunction or rupture of papillary muscleRupture of the heartEmbolismCardiac aneurysmPostinfaction syndromecoronaryheartdiseaseECGDiagnosis1.Definitive ECG diagnosisDefinitive ECG diagnosis2. Dynamic evolvement of ECG2. Dynamic evolvement of ECG3. Localized diagnosis of MI3. Localized diagnosis of MI
44、coronaryheartdiseaseDefinitive ECG diagnosisDefinitive ECG diagnosisQ-wavesQ-waves ST-segment elevation ST-segment elevation T-waves inversionT-waves inversioncoronaryheartdiseaseDynamic Evolvement of ECGDynamic Evolvement of ECGSerialECGfindings:T-waves ST-segmentelevationandQ-waveselevatedST-segme
45、ntreturnT-wavesinversioncoronaryheartdiseaseLocalized Diagnosis of MILocalized Diagnosis of MIAnteriorseptalMI：V1-V3AnteriorMI：V2-V4LargeanteriorMI：V1-V5（V6 6）LateralMI：I、avLInferiorMI：、avFPosteriorMI：V7、V8、V9RightventricularMI:V3R-V5Rcoronaryheartdisease ProximalLeftAnteriorDescendingArteryOcclusio
46、ncoronaryheartdiseaseRightCoronaryArteryOcclusioncoronaryheartdiseaseLeftCircumflexorOMArteryLADdiagonalbranchArterycoronaryheartdiseaseAcuteInferiorMIcoronaryheartdiseaseAcuteAnteriorMIcoronaryheartdiseaseOldInferiorMIcoronaryheartdiseaseSerumMarkersofCardiacDamage Markers Initial Peak Return Marke
47、rs Initial Peak Return elevation to normal elevation to normal CK 6h 24h 3-4d CK 6h 24h 3-4d CK-MB 6h 24h 3-4d CK-MB 6h 24h 3-4d cTnT/I 4-6h 14d cTnT/I 4-6h 14dcoronaryheartdiseaseSerumMarkersofCardiacDamagecoronaryheartdiseaseDiagnosisCharacterizedchestpainSerummarkersofcardiacdamage：cTnT/IDefiniti
48、veECGchangescoronaryheartdiseaseDifferentialDiagnosisofAMIAngina pectorisAngina pectorisAcute pericarditisAcute pericarditisMyocarditisMyocarditisAcute aortic dissectionAcute aortic dissectionPulmonary embolismPulmonary embolismAcute cholecystitisAcute cholecystitiscoronaryheartdiseaseAMITherapyObje
49、ctiveObjectiveObjectiveObjective：Limitation of infarct sizeLimitation of infarct sizeLimitation of infarct sizeLimitation of infarct size prevent and treat complications prevent and treat complications prevent and treat complications prevent and treat complications 1.1.1.1.Nursing and general treatm
50、entNursing and general treatmentNursing and general treatmentNursing and general treatment2.2.2.2.ReperfusionReperfusionReperfusionReperfusion3.3.3.3.AntiarrhythmicsAntiarrhythmicsAntiarrhythmicsAntiarrhythmics4.4.4.4.Shock treatmentShock treatmentShock treatmentShock treatment5.5.5.5.Management of
51、heart failureManagement of heart failureManagement of heart failureManagement of heart failure6.6.6.6.Secondary prevention of AMISecondary prevention of AMISecondary prevention of AMISecondary prevention of AMIcoronaryheartdiseaseAMITherapyNursing and general treatmentNursing and general treatmentNu
52、rsing and general treatmentNursing and general treatmentReperfusionReperfusionReperfusionReperfusionAntiarrhythmicsAntiarrhythmicsAntiarrhythmicsAntiarrhythmicsShock treatmentShock treatmentShock treatmentShock treatmentManagement of heart failureManagement of heart failureManagement of heart failur
53、eManagement of heart failureSecondary prevention of AMISecondary prevention of AMISecondary prevention of AMISecondary prevention of AMI Relaxing Relaxing Oxygen Oxygen Monitoring Monitoring Nursing Nursing Chest pain Chest pain Analgesics Analgesics Nitrate Nitrate Beta-blocker Beta-blocker Aspirin
54、 Aspirin Nursing and general treatmentNursing and general treatmentcoronaryheartdiseaseAMITherapy ReperfusionThrombolysisThrombolysisDirect PTCA and Stent Direct PTCA and Stent Direct CABGDirect CABG Nursing and general treatmentNursing and general treatmentReperfusionReperfusionAntiarrhythmicsAntia
55、rrhythmicsShock treatmentShock treatmentManagement of heart failureManagement of heart failureSecondary prevention of AMISecondary prevention of AMIcoronaryheartdiseaseAMITherapy Thrombolysis agentsThrombolysis agents SK SK、UKUK、r-SKr-SK t-PA t-PA、r-tPAr-tPANursing and general treatmentNursing and g
56、eneral treatmentReperfusionReperfusionAntiarrhythmicsAntiarrhythmicsShock treatmentShock treatmentManagement of heart failureManagement of heart failureSecondary prevention of AMISecondary prevention of AMIcoronaryheartdiseaseAMITherapy适应症适应症 典型缺血性胸痛典型缺血性胸痛3030minmin，含硝酸甘油无效含硝酸甘油无效 两个相邻胸前或肢导联两个相邻胸前或
57、肢导联STST段抬高段抬高0.10.1mvmv 6-12h 6-12h内内 75 200/120mmHgBP200/120mmHgBP200/120mmHgBP200/120mmHg出血性视网膜病或眼病出血性视网膜病或眼病出血性视网膜病或眼病出血性视网膜病或眼病对扩容和升压药物无反应的休克对扩容和升压药物无反应的休克对扩容和升压药物无反应的休克对扩容和升压药物无反应的休克妊娠、妊娠、妊娠、妊娠、SIESIESIESIE、心腔内有血栓者心腔内有血栓者心腔内有血栓者心腔内有血栓者Nursing and general treatmentNursing and general treatmentRe
58、perfusionReperfusionAntiarrhythmicsAntiarrhythmicsShock treatmentShock treatmentManagement of heart failureManagement of heart failureSecondary prevention of AMISecondary prevention of AMIcoronaryheartdiseaseAMITherapy相对禁忌症相对禁忌症近期外伤史或两周内手术史。近期外伤史或两周内手术史。近期外伤史或两周内手术史。近期外伤史或两周内手术史。慢性严重高血压病史。慢性严重高血压病史。
59、慢性严重高血压病史。慢性严重高血压病史。脑血管意外史。脑血管意外史。脑血管意外史。脑血管意外史。6-96-96-96-9月内用过月内用过月内用过月内用过SKSKSKSK、r-SKr-SKr-SKr-SK、 tPA tPA tPA tPA、r-tPA r-tPA r-tPA r-tPA 不能重复用药不能重复用药不能重复用药不能重复用药Nursing and general treatmentNursing and general treatmentReperfusionReperfusionAntiarrhythmicsAntiarrhythmicsShock treatmentShock tr
60、eatmentManagement of heart failureManagement of heart failureSecondary prevention of AMISecondary prevention of AMIcoronaryheartdiseaseAMITherapy常用药剂量及用法常用药剂量及用法 尿尿激激酶酶（UKUK） 尿尿中中提提取取，半半衰衰期期1616minmin。150150万万30min30min静静点点, ,再再通通率率60%. 60%. 低低价价，无无抗抗原性。原性。Nursing and general treatmentNursing and ge
61、neral treatmentReperfusionReperfusionAntiarrhythmicsAntiarrhythmicsShock treatmentShock treatmentManagement of heart failureManagement of heart failureSecondary prevention of AMISecondary prevention of AMIcoronaryheartdiseaseAMITherapy重重组组链链激激酶酶（r-SKr-SK）是是由由基基因因工工程程生生产产的的溶溶栓栓药药，再再通通率率77.1%(?)77.1%(
62、?) 万万minmin静静点不良反应与点不良反应与U U无显著差异。无显著差异。Nursing and general treatmentNursing and general treatmentReperfusionReperfusionAntiarrhythmicsAntiarrhythmicsShock treatmentShock treatmentManagement of heart failureManagement of heart failureSecondary prevention of AMISecondary prevention of AMIcoronaryhear
63、tdiseaseAMITherapy组织型纤溶酶原激活剂（组织型纤溶酶原激活剂（组织型纤溶酶原激活剂（组织型纤溶酶原激活剂（tPAtPA）重组组织型纤溶酶原激活剂（重组组织型纤溶酶原激活剂（重组组织型纤溶酶原激活剂（重组组织型纤溶酶原激活剂（rtPArtPA） tPAtPA是是是是由由由由血血血血管管管管内内内内皮皮皮皮细细细细胞胞胞胞等等等等组组组组织织织织合合合合成成成成的的的的一一一一种种种种丝丝丝丝氨氨氨氨酸酸酸酸蛋蛋蛋蛋白白白白酶酶酶酶半衰期半衰期半衰期半衰期5-85-8minmin，再通率高于再通率高于再通率高于再通率高于U U。 先先先先静静静静注注注注1010mgmg，继继继继
64、而而而而1 1h h内内内内静静静静点点点点4040mgmg，其其其其后后后后2 2h h内内内内再再再再静静静静点点点点5050mgmg国国国国内内内内亦亦亦亦有有有有半半半半量量量量法法法法，先先先先静静静静注注注注1010mgmg，然然然然后后后后9090minmin内内内内静静静静点点点点4040mgmgNursing and general treatmentNursing and general treatmentReperfusionReperfusionAntiarrhythmicsAntiarrhythmicsShock treatmentShock treatmentMan
65、agement of heart failureManagement of heart failureSecondary prevention of AMISecondary prevention of AMIcoronaryheartdiseaseAMITherapy 溶栓治疗效果评价溶栓治疗效果评价冠脉造影标准：（、冠脉造影标准：（、冠脉造影标准：（、冠脉造影标准：（、级）级）级）级）临床评价标准：临床评价标准：临床评价标准：临床评价标准： 2 2 2 2小时内基本胸痛缓解小时内基本胸痛缓解小时内基本胸痛缓解小时内基本胸痛缓解 2 2 2 2小时内小时内小时内小时内STSTSTST段降低段
66、降低段降低段降低50%50%50%50% 酶峰值提前酶峰值提前酶峰值提前酶峰值提前 再灌注心律失常再灌注心律失常再灌注心律失常再灌注心律失常Nursing and general treatmentNursing and general treatmentReperfusionReperfusionAntiarrhythmicsAntiarrhythmicsShock treatmentShock treatmentManagement of heart failureManagement of heart failureSecondary prevention of AMISecondary
67、 prevention of AMIcoronaryheartdiseaseAMITherapy 溶栓不良反应及处理溶栓不良反应及处理出出出出 血：血：血：血： 轻度出血发生率轻度出血发生率轻度出血发生率轻度出血发生率5-10%,5-10%,5-10%,5-10%,不需特殊处理不需特殊处理不需特殊处理不需特殊处理. . . .大量出血大量出血大量出血大量出血 发生率发生率发生率发生率1-2%,1-2%,1-2%,1-2%,需输新鲜血或血浆及纤维蛋白原需输新鲜血或血浆及纤维蛋白原需输新鲜血或血浆及纤维蛋白原需输新鲜血或血浆及纤维蛋白原, , , , 并停止溶栓并停止溶栓并停止溶栓并停止溶栓. .
68、 . .过敏反应：过敏反应：过敏反应：过敏反应： 过敏反应发生率过敏反应发生率过敏反应发生率过敏反应发生率5%5%5%5%。严重反应少见，可用激素。严重反应少见，可用激素。严重反应少见，可用激素。严重反应少见，可用激素. . . .低低低低 血血血血 压：压：压：压： 低血压的发生率低血压的发生率低血压的发生率低血压的发生率5-10%,5-10%,5-10%,5-10%,多发生在下、后壁多发生在下、后壁多发生在下、后壁多发生在下、后壁MI,MI,MI,MI,并常并常并常并常 合并缓慢性心律失常合并缓慢性心律失常合并缓慢性心律失常合并缓慢性心律失常. . . .给于扩容及阿托品后可缓解给于扩容及
69、阿托品后可缓解给于扩容及阿托品后可缓解给于扩容及阿托品后可缓解, , , , 严重者需加用多巴胺严重者需加用多巴胺严重者需加用多巴胺严重者需加用多巴胺. . . .coronaryheartdiseaseAMITherapy Adjuvant TherapyAdjuvant TherapyAntithrombotic therapyAntithrombotic therapyAntiplatlet therapyAntiplatlet therapyNitrateNitrateetaeta- -blockerblockerACEIACEIStatinStatincoronaryheartdis
70、easeAMITherapy Secondary prevention of AMI (Secondary prevention of AMI (A,B,C,D,E)A: Aspirin, ACE inhibitor A: Aspirin, ACE inhibitor A: Aspirin, ACE inhibitor A: Aspirin, ACE inhibitor B: -blocker, Blood pressure controlB: -blocker, Blood pressure controlB: -blocker, Blood pressure controlB: -bloc
71、ker, Blood pressure controlC: Cholesterol-lowering, Cigarette-quittingC: Cholesterol-lowering, Cigarette-quittingC: Cholesterol-lowering, Cigarette-quittingC: Cholesterol-lowering, Cigarette-quittingD:Diet,D:Diet,DiabetesDiabetescontrolcontrolE:Exercise,educationE:Exercise,educationNursing and general treatmentNursing and general treatmentReperfusionReperfusionAntiarrhythmicsAntiarrhythmicsShock treatmentShock treatmentManagement of heart failureManagement of heart failureSecondary prevention of AMISecondary prevention of AMIcoronaryheartdisease
