心内科小讲课

, , , , , ,*, LOGO ,COMPANY LOGOTYPE INSERT,Click To Edit Title Style, , , , , ,*, LOGO ,COMPANY LOGOTYPE INSERT, , , , , ,*,Click To Edit Title Style, LOGO ,COMPANY LOGOTYPE INSERT, , , , , ,Click To Edit Title Style,*, LOGO ,COMPANY LOGOTYPE INSERT,Click To Edit Title Style, LOGO ,COMPANY LOGOTYPE INSERT,冠状动脉粥样硬化性心脏病,心绞痛,冠状动脉粥样硬化性心脏病,指冠状动脉粥样硬化使血管腔狭窄或阻塞，或 （和）因冠状动脉功能性改变（痉挛）导致心肌缺血缺氧或坏死而引起的心脏病，统称冠状动脉性心脏病,(coronary heart disease),冠心病（,CHD,），亦称缺血性心脏病。,1979,年,WHO,将冠心病分为,5,型：,无症状性心肌缺血,心绞痛,心肌梗死,缺血性心肌病,猝死,锐普,PPT,论坛,chinakui,转载：,稳定型心绞痛和不稳定型心绞痛,学习目标,掌握心绞痛的概念,1,了解心绞痛的病因病理,2,熟悉心绞痛的临床表现、辅助检查,3,掌握心绞痛的治疗措施,4,掌握心绞痛病人的护理问题及措施,5,锐普,PPT,论坛,chinakui,转载：,稳定型心绞痛,锐普,PPT,论坛,chinakui,转载：,亦称劳力型心绞痛，是冠状动 脉严重狭窄的基础上，由于心肌负荷的增加引起心肌急剧的、暂时的缺血缺氧的临床综合征,病因,冠状动脉粥样硬化,当冠状动脉的供血与心肌的需血之间发生矛盾，冠状动脉血流量不能满足心肌代谢的需要，引起心肌急剧的、暂时的缺血缺氧时，即可发生心绞痛。,临床表现,胸骨体中段或上段之后，可波及心前区，常放,射至左肩、左臂内侧及无名指和小指，或至颈,、咽或下颌部。,压榨性、闷胀性或窒息性也可有烧灼感，偶有,濒死的恐惧感。,体力劳动或情绪激动、饱食、寒冷、吸烟、心,动过速、休克等。,3,5,分钟，小于,15min,。,停止原来诱发症状的活动或舌下含用硝酸,甘油。,症状：以发作性胸痛为主要临床表现,部位,性质,诱因,持续时间,缓解方式,体征：,平时一般无异常体征。,心绞痛发作时常见心率增快、血压升高、表情焦虑、皮肤冷或出汗、有时出现第四或第三心音奔马律，可有暂时性心尖部收缩期杂音，第二心音可有逆分裂或出现交替脉等非特异性体征,实验室和其他检查,心电图,心电图负荷实验,运动负荷试验,（,exercise test,）,运动方式,：,分级踏板或蹬车运动,.,阳性标准：ST段水平型或下斜型,压低0.1mV持续2分钟,疼痛发作、室性心动过速、血压,下降：停止运动,禁忌证：心肌梗死急性期、,不稳,定型心绞痛、明显心衰、严重,心,律失常或急性疾病者。,静息心电图,约半数患者在正常范围，也可能有陈旧性心肌梗死的改变或非特异性,ST,段和,T,波异常,心电图连续监测,即做动态心电图（,Holter,）监测，常连续记录,24,小时心电图。,发作时心电图,绝大多数患者可出现暂时性心肌缺血而引起的,ST,段位移，常见反,应心内膜下的心肌缺血的,ST,段压低（,0.1mV,），有时出现,T,波倒置和假性正常化,锐普,PPT,论坛,chinakui,转载：,实验室和其他检查,放射性核素检查,冠状动脉造影,超声检查,诊断,冠状动脉造影,可明确诊断。,一般诊断方法,高危因素,心绞痛胸痛发作表现,心电图,心绞痛严重度分级,I,一般体力活动（如步行和登楼）不受限，仅在强、快或长时间劳力时发生心绞痛,II,一般体力活动轻度受限。快步、饭后、寒冷或刮风中、精神应激或醒后数小时内发作心绞痛。一般情况下步行,200,米以上或登楼一层以上受限。,III,一般体力活动明显受限，一般情况下步行,200,米，或登楼一层引起心绞痛。,IV,轻微活动或休息时即可发生心绞痛。,不稳定型心绞痛分组诊断,治疗原则,避免诱发因素,改善冠状动脉的血供和降低心肌耗氧,治疗动脉粥样硬化,治疗措施,一、预防并发症,长期服用阿司匹林 减少血栓形成,降血脂治疗 使粥样斑块稳定,二、发作时的治疗,休息 停止活动后症状即可消除。,药物治疗 硝酸酯制剂：扩张冠状动脉，增加冠状,循环的血流量；扩张周围血管，减少静脉回,心血量，减低心脏前后负荷和心肌的需氧。,常用药：,硝酸甘油、硝酸异山梨酯等,三、缓解期的治疗,药物治疗：,阿司匹林 硝酸脂制剂,氯吡格雷,CCB,-,受体阻滞剂,代谢性药物,调血脂药物 中医中药治疗,ACEI,非药物治疗,运动锻炼疗法,血管重建治疗,增强型体外反搏,心绞痛病人的护理,休息与活动,心理护理,给氧,疼痛观察,用药护理,减少避免诱因,疼痛：胸痛 与心肌缺血缺氧有关,评估活动受限程度,制定活动计划,观察与处理活动中不良反应,活动无耐力 与心肌氧的供需失调有关,其他的护理诊断,/,问题,潜在并发症 心肌梗死,知识缺乏 缺乏控制诱发因素及预防心绞痛发作的知识,恐惧，焦虑 与缺乏相关疾病知识和疼痛引的濒死感有关,健康指导,疾病知识指导,用药指导,病情监测指导,预后,大多能生存很多年，但有发生急性心肌梗死或猝死的危险。,决定预后的主要因素为冠状动脉病变范围和心功能。,射血分数降低和室壁运动障碍也有预后意义。,THANK YOU,Click To Edit Title Style,锐普,PPT,论坛,chinakui,转载：,Click To Edit Title Style,TEXT,ADD CONTENTS,TEXT,ADD CONTENTS,ADD CONTENTS,TEXT,ADD COsNTENTS,ADD CONTENTS,TEXT,ADD CONTENTS,ADD CONTENTS,TEXT,ADD CONTENTS,ADD CONTENTS,锐普,PPT,论坛,chinakui,转载：,Click To Edit Title Style,Premium,Design,Diversity,of Culture,Immense,Visual Appeal,Visual,Appealing,Immense,Visual Appeal,Sleek Diagram & Chart,Immense visual appeal Premade PowerPoint Templates,Professional quality templates in a couple of clicks away,!,Eye-Catching Visual,Feel the touch of art - PowerPoint Templates, PPT Slides,PPT Diagrams For Your Presentation,Ready to Use,Subscription offers you all designs youll ever need to make your PowerPoint,锐普,PPT,论坛,chinakui,转载：,Click To Edit Title Style,Stylish Design,Its about giving you the variety you need to meet the design on your mind.,We create powerpoint templates based on new visual trends thats fresh, relevant and always on the cutting edge.,More choices and,visual trends,PresenterTemplates provides the themes that surrounds you every day. 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