冠心病ppt课件(大医英)

,单击此处编辑母版标题样式,精品,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,精品,*,冠状动脉粥样硬化性心脏病,(,coronary atherosclerotic heart disease),大连医科大学附属二院心内科,牛 楠,精品,冠状动脉粥样硬化性心脏病(coronary atheros,1,动脉粥样硬化,atherosclerosis,精品,动脉粥样硬化atherosclerosis精品,2,Introduction,Arteriosclerosis,Thickening and loss of elasticity of arterial walls,Hardening of the arteries,Greatest morbidity and mortality of all human diseases via,Narrowing,Weakening,精品,IntroductionArteriosclerosis 精,3,Plaque That Has Been Surgically Removed from Coronary Artery,Courtesy Ronald D. Gregory and John Riley, MD.,精品,Plaque That Has Been Surgicall,4,Non Modifiable Risk Factors,Age,A dominant influence,Atherosclerosis begins in the young, but does not precipitate organ injury until later in life,Gender,Men more prone than women, but by age 60-70,about equal frequency,Family History,Familial cluster of risk factors,Genetic differences,精品,Non Modifiable Risk FactorsAg,5,Modifiable Risk Factors,(potentially controllable),Hyperlipidemia,Hypertension,Cigarette smoking,Diabetes Mellitus,Elevated Homocysteine,Factors that affect hemostasis and thrombosis,Infections: Herpes virus; Chlamydia pneumoniae,Obesity, sedentary lifestyle, stress,精品,Modifiable Risk Factors (pot,6,Pathogenesis o,f Atherosclerosis,Response to injury hypothesis,Injury to the endothelium(dysfunctional endothelium),Chronic inflammatory response,Migration of SMC from media to intima,Proliferation of SMC in intima,Excess production of ECM,Enhanced lipid accumulation,精品,Pathogenesis of Atherosclerosi,7,Response to injury,精品,Response to injury精品,8,Endothelia dysfunction,精品,Endothelia dysfunction精品,9,Initiation of Fatty Streak,精品,精品,10,Fatty Streak,精品,精品,11,Fibro-fatty Atheroma,精品,精品,12,Atherosclerosis Timeline,Foam,Cells,Fatty,Streak,Intermediate,Lesion,Atheroma,Fibrous,Plaque,Complicated,Lesion/,Rupture,Adapted from Pepine CJ.,Am J Cardiol.,1998;82(suppl 104).,From First,Decade,From Third,Decade,From Fourth,Decade,Endothelial Dysfunction,精品,Atherosclerosis TimelineFoamFa,13,AHA Classification of atherosclerosis,精品,AHA Classification of atherosc,14,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,精品,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,15,Coronary Artery Disease,冠心病,精品,Coronary Artery Disease冠心病精品,16,Clinical classification(1979 WHO),Asymptomatic CHD(,隐匿型）,Angina pectoris CHD,（心绞痛型）,Myocardial infarction CHD(,心肌梗死型）,Ischemic cardiomyopathy CHD,（缺血性心肌病型）,Sudden death CHD,（猝死型）,精品,Clinical classification(1979 W,17,Classification of IHD,Chronic ischemic syndrome:,stable angina,asymptomatic CHD,ischemic cardiomyopathy CHD,Acute coronary syndrome:,unstable angina,STEMI/NSTEMI,精品,Classification of IHDChronic i,18,急性冠脉综合症的病理生理学,Fuster et al.,N Engl J Med.,1992;326:310-318.,Davies et al.,Circulation.,1990;82(Suppl II):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,精品,急性冠脉综合症的病理生理学Fuster et al. N E,19,No ST Elevation,ST Elevation,Acute Coronary Syndrome,Unstable Angina,NQMI,Qw MI,NSTEMI,Myocardial Infarction,Davies MJ Heart 83:361, 2000,Ischemic Discomfort,Presentation,Working Dx,ECG,Biochem. Marker,Final Dx,Hamm Lancet 358:1533,2001,精品,No ST ElevationST ElevationAc,20,ANGINA PECTORIS,精品,ANGINA PECTORIS精品,21,Definition of Angina,A pain or discomfort in the chest or adjacent areas caused by insufficient blood flow to the heart muscle.,精品,Definition of Angina精品,22,精品,精品,23,Clinical classification and pathology,Stable angina,:fixed atheromatous stenosis,Unstable angina,:dynamic obstruction by plaque rupture with superimposed thrombosis and spasm,精品,Clinical classification and pa,24,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,Nissen SE. Am J Cardiol. 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,精品,斑块破裂引起急性严重事件不稳定心肌梗死猝死稳定性 不稳定斑块,25,Stable angina pectoris,精品,Stable angina pectoris精品,26,ETIOLOGY,.Ischemia is secondary to coronary artery disease in 95% of patients. The leading cause is certainly atherosclerotic coronary artery disease,.A decreased oxygen supply or an increase in oxygen demand can lead to a worsening of symptoms.,.Ischemia can occur in patients with normal coronary arteries,精品,ETIOLOGY.Ischemia is secondary,27,Clinical menifestation,chest discomfort,Quality,- squeezing, griplike, pressurelike, suffocating and heavy”; or a discomfort but not pain. Angina is almost never sharp or stabbing, and usually does not change with position or respiration.,Duration,- anginal episode is typically minutes in duration. Fleeting discomfort or a dull ache lasting for hours is rarely angina,Location,- usually substernal, but radiation to the neck, jaw, epigastrium, or arms is not uncommon. Pain above the mandible, below the epigastrium, or localized to a small area over the left lateral chest wall is rarely anginal.,Provocation,- angina is generally precipitated by exertion or emotional stress and commonly relieved by rest. Sublingual nitroglycerin also relieves angina, usually within 30 seconds to several minutes.,精品,Clinical menifestationchest d,28,Categorize the Severity of Angina,CCS Classification,Class 0,asymptomatic,Class I,on strenuous activity,Class II,on moderate activity,2 blocks or 2 flights of stairs,Class III,on mild activity,2 blocks or 2 flights of stairs,Class IV,rest or minimal activity,精品,Categorize the Severity of An,29,Clinical features,Physical examination,An S,4,gallop may be transiently present during an episode, and the patient may be dyspneic or diaphoretic or have a new heart murmur.,High-risk features of angina include heart failure and hypotension. A complete physical exam is crucial in making an assessment of risk.,Most pt:(-),精品,Clinical features Physical exa,30,Alternative Diagnoses to Angina for Patients with Chest Pain,Non-Ischemic CV,aortic dissection,pericarditis,Pulmonary,pulmonary embolus,pneumothorax,pneumonia,pleuritis,Chest Wall,costochondritis,fibrositis,rib fracture,sternoclavicular arthritis,herpes zoster,Gastrointestinal,Esophageal,esophagitis,spasm,reflux,Biliary,colic,cholecystitis,choledocholithiasis,cholangitis,Peptic ulcer,Pancreatitis,Psychiatric,Anxiety disorders,hyperventilation,panic disorder,primary anxiety,Affective disorders,depression,Somatiform disorders,Thought disorders,fixed occlusions,精品,Alternative Diagnoses to Angin,31,Investigation,12 Lead Resting ECG,should be recorded in all patients with symptoms suggestive of angina pectoris,normal in, 50% of patients,a normal ECG does not exclude severe CAD; however, it does imply normal LV function with favorable prognosis,精品,Investigation 12 Lead Resting,32,CHD,At rest:,ECG,精品,CHD At rest:ECG精品,33,冠心病,Episode of angina:ST-segment depression,ECG,精品,冠心病 Episode of angina:ST-segme,34,CHD,Holter,精品,CHD Holter精品,35,Exercise testing,精品,Exercise testing 精品,36,Angina: Exercise TestingHigh Risk Patients,Significant ST-segment depression at low levels of exercise and/or heart rate130,Fall in systolic blood pressure,Diminished exercise capacity,Complex ventricular ectopy at low level of exercise,精品,Angina: Exercise TestingHigh,37,Exercise TestingContraindications,MIimpending or acute,Unstable angina,Acute myocarditis/pericarditis,Acute systemic illness,Severe aortic stenosis,Congestive heart failure,Severe hypertension,Uncontrolled cardiac arrhythmias,精品,Exercise TestingContraindicat,38,Investigation,Echocardiography.,The stress echocardiogram is a widely performed test used to assess patients for coronary disease.,Baseline echocardiographic images are obtained at rest to evaluate left ventricular function, wall motion, and valve function.,Images are then acquired during peak stress (that is, during a GXT or with dobutamine) and compared with those at rest. Regional wall-motion abnormalities with stress indicate areas of hypoperfusion or ischemia.,精品,Investigation Echocardiography,39,Investigation,Isotope scanning,:obtaining scintiscans of the myocardium at rest and during stress after administration of an intravenous radioactive isotope such as thallium 201,精品,InvestigationIsotope scanning:,40,Investigation,Coronary angiography.,Used to identify foci of coronary disease. It is the evaluation of choice in patients with angina that is (1) poorly responsive to medication, or (2) unstable. It is also indicated in patients with test results consistent with a high risk for CAD.,精品,Investigation Coronary angiogr,41,冠心病,Coronary angiography,精品,冠心病 Coronary angiography精品,42,冠心病,冠状动脉造影,精品,冠心病 冠状动脉造影精品,43,冠心病,LAD:stenosis LAD:normal,精品,冠心病 LAD:stenosis LAD:,44,冠心病,RCA:stenosis LCX:stenosis,精品,冠心病 RCA:stenosis LCX:stenosi,45,Chronic Stable Angina,Treatment Objectives,Prevent progression of coronary artery disease and optimise life expectancy,Relieve symptoms,精品,Chronic Stable Angina Treatme,46,Management,Aspirin,beta-adrenoreceptor blocking agents (,-blockers),calcium antagonists,Nitrates,精品,ManagementAspirin精品,47,NCEP Primary CHD Risk Goals for Lowering LDL-C,LDL-C Goal,No CHD,2 RF,160 mg/dL,No CHD,2 RF,130 mg/dL,CHD,100 mg/dL,The NCEP recommends lowering LDL-C even further than these goals, if possible.,Risk Category,NHLBI; September 1993,精品,NCEP Primary CHD Risk Goals f,48,Coronary revascularisation,Invasive treatment: coronary angioplasty (PTCA); coronary artery bypass grafting (CABG),精品,Coronary revascularisationInva,49,冠心病,CABG,精品,冠心病 CABG精品,50,冠心病,PTCA,精品,冠心病 PTCA精品,51,冠心病,PTCA,Before PTCA after PTCA,精品,冠心病 PTCABefore PTCA aft,52,冠心病,PTCA/S,精品,冠心病 PTCA/S精品,53,Acute coronary syndrome,Unstable angina,Non-ST elevation myocardial infarction (NSTEMI),ST elevation myocardial infarction(STEMI),精品,Acute coronary syndromeUnstabl,54,Unstable Angina/NSTEMI,精品,Unstable Angina/NSTEMI精品,55,Unstable Angina,Clinical Presentation and Classification,Diagnosis of unstable angina refers to new or worsening symptoms of myocardial ischemia:,rest angina,new-onset severe angina,increasing angina,精品,Unstable AnginaClinical Prese,56,精品,精品,57,评估住院期间和出院后长期缺血风险,评估住院期间死亡风险,(c-index 0.83)*,及出院后,6,个月死亡风险,(c-index 0.81)*,多个大型数据库中验证其有效性,(c-indices,分别为,0.84*,和,0.75*),评价死亡,/,再发心梗的长期风险,网络版可下载,www.outcomes-umassmed.org/GRACE,*Granger CB, et al.,Arch intern Med,. 2003;163:2345-2353.,*Eagle K, at al.,JAMA,. 2004;291:2727-2733.,精品,评估住院期间和出院后长期缺血风险评估住院期间死亡风险 (c,58,Unstable Angina,Chest pain syndrome, either new onset or progressive angina,Transient ST-segment depression on the electrocardiogram (ECG),Without evidence of myocardial infarction by CK, CK-MB, or Troponin,精品,Unstable AnginaChest pain synd,59,NSTEMI,Chest pain syndrome, either new onset or progressive angina,Transient or persistent ST-segment depression on the electrocardiogram (ECG),With evidence of myocardial infarction by CK, CK-MB, or Troponin,精品,NSTEMIChest pain syndrome, eit,60,Unstable Angina/NSTEMI,Significant likelihood of occurrence of major cardiac events,A. Incidence of MI: 8 to 10%,B. Mortality: 2 to 5%,精品,Unstable Angina/NSTEMISignific,61,Unstable Angina/NSTEMI:Pathophysiology,Acute plaque fissuring and rupture,Superimposed thrombus,Transient occlusion,Mediator-induced vasospasm may be present,精品,Unstable Angina/NSTEMI:Pathop,62,Determinants of Plaque Vulnerability,Lipid-rich core size,Cap thickness,Cap inflammation and repair,精品,Determinants of Plaque Vulnera,63,精品,精品,64,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,Nissen SE. Am J Cardiol. 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,精品,斑块破裂引起急性严重事件不稳定心肌梗死猝死稳定性 不稳定斑块,65,Physical Examinaton,Not that helpful,May have evidence of CHF: JVD, rales, edema,May have S4,May have murmur of mitral regurgitation from papillary muscle dysfunction,精品,Physical ExaminatonNot that he,66,Investigation,ECG,Cardiac Enzyme or Troponin,Coronary angiography,精品,Investigation ECG精品,67,精品,精品,68,Acute Coronary Syndromes,精品,Acute Coronary Syndromes精品,69,评估住院期间和出院后长期缺血风险,评估住院期间死亡风险,(c-index 0.83)*,及出院后,6,个月死亡风险,(c-index 0.81)*,多个大型数据库中验证其有效性,(c-indices,分别为,0.84*,和,0.75*),评价死亡,/,再发心梗的长期风险,网络版可下载,www.outcomes-umassmed.org/GRACE,*Granger CB, et al.,Arch intern Med,. 2003;163:2345-2353.,*Eagle K, at al.,JAMA,. 2004;291:2727-2733.,精品,评估住院期间和出院后长期缺血风险评估住院期间死亡风险 (c,70,management,Admitted to hospital,Best rest,Oxygen,Anti-platelet:asprin, Clopidogrel ,GP IIb/IIIa inhibitors,Anticoagulant: UFH or LMWH,B-blocker,Nitrates (intravenous),CCB,Statins,ACEI,Coronary revascularisation,精品,managementAdmitted to hospital,71,Definite ACS,Possible ACS,() ECG;,Normal biomarkers,Observe; repeat ECG,markers at 4-8 hrs,No recurrent pain;,() follow-up studies,Recurrent pain;,(+) follow-up studies,Stress test;,LV,function if ischemia,() test: outpt follow-up,(+) test,Admit, Use Acute,Ischemia Pathway,ST,Use MI,Guidelines,No ST,ST-T,s,chest pain,markers,Initial Chest Pain,Evaluation,Symptoms Suggestive of ACS,精品,Definite ACSPossible ACS() EC,72,Acute Coronary Syndromes,精品,Acute Coronary Syndromes精品,73,Preparation for Discharge After UA/NSTEMI,Antiplatelet Rx,ASA,75 - 162 mg/day,Clopidogrel,75 mg/day,Beta Blocker,ACEI / ARB,Especially if DM, HF, EF 40%, HTN,Statin,LDL,100 mg/dL,(ideally 70 mg/dL),Secondary Prevention Measures,Smoking Cessation,BP,140/90 mm HG or 130/80 mm HG for DM or chronic kidney disease,HbA1C,7%,BMI,18.5-24.9,Physical Exercise,30-60 min at least 5 days/wk,精品,Preparation for Discharge Afte,74,精品,精品,75,No ST Elevation,ST Elevation,Acute Coronary Syndrome,Unstable Angina,NQMI,Qw MI,NSTEMI,Myocardial Infarction,Davies MJ Heart 83:361, 2000,Ischemic Discomfort,Presentation,Working Dx,ECG,Biochem. Marker,Final Dx,Hamm Lancet 358:1533,2001,精品,No ST ElevationST ElevationAc,76,Thank you,精品,Thank you精品,77,