方全-心绞痛ppt课件

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,*,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.,病史特点男性，59岁,1,思考,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,思考胸痛的鉴别,2,心绞痛的鉴别(1),Non-ischemic CV,Aortic dissection,Pericarditis,Pulmonary,Pulmonary embolus,Pneumothorax,Pneumonia,Pleuritis,Gastrointestinal,Esophageal,Esophagitis,Spasm,Reflux,Biliary,Colic,Cholecystitis,Choledocholithiasis,Cholangitis,Peptic ulcer,Pancreatitis,心绞痛的鉴别(1)Non-ischemic CVGastr,3,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 disorder,Primary anxiety,Affective disorders,(e.g.,depression),Somatiform disorders,Thought disorders,(e.g.,fixed delusions),心绞痛的鉴别(2)Chest WallPsychiatri,4,心绞痛特点,SAVES U：,Sudden onset;,Anterior chest;,Vague sensation;,Exercise precipitated;,Short duration;,Unanimous attack.,心绞痛特点SAVES U：,5,Grading of Angina Pectoris by CCSC,Class I:,日常体力活动不引起心绞痛.,Class 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。,Grading of Angina Pectoris by,6,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 forms of OT obstruction;,Mental or physical impairment;,Noninvasive Testing:Exercise,15,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 3.5ml/kg per min.),ST depression,1mm for 60-80ms after the end of QRS,during or after exercise.,Noninvasive Testing:Exercise,16,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;,Technical difficulties;,Sustained VT;,ST elevation in leads without Q waves.,Noninvasive Testing:Exercise,17,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 bradyarrhythmias,BBB or IVCB,Increasing chest pain;Serious symptoms.,Noninvasive Testing:Exercise,18,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.,LBBB:,RBBB:,LV hypertrophy:More false-positive.,Rest ST depression:Additional ST,significant.,Noninvasive Testing:Exercise,19,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.,Stress Imaging StudiesGood can,20,Pharmacologic 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 ADE are rare,but may cause severe bronchospasm in patients with asthma or COPD.,Pharmacologic Modalities(Vaso,21,Pharmacologic Modalities(Dobutamine)Used in Stress Imaging,In high doses(20 to 40,g/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%).,Pharmacologic Modalities(Dobu,22,Invasive Testing-Angiography(Indications),Chest pain,possible ischemic,coexisting COPD not a candidate for,Exercise test because of dyspnea;,Perfusion imaging with dipyridamole or adenosine because of bronchospasm and theophylline therapy;,Stress ECHO because of poor images.,Invasive Testing-Angiography,23,Invasive Testing-Angiography(Indications),Typical or atypical symptoms and a high clinical probability of sever CAD.,Most appropriate for a patient with a high-risk treadmill outcome.,Symptoms suggestive but not characteristic,special occupation,eg.Pilots,firefighters etc.,A low threshold angiography is appropriate for diabetics.,Invasive Testing-Angiography,24,RISK STRATIFICATION,A.Clinical Assessment,B.ECG/Chest X-Ray,Noninvasive Testing,Coronary Angiography and Left Ventriculography,RISK STRATIFICATIONA.Clinical,25,Risk Stratification(Clinical Assessment),Prognosis of CAD for Death or Nonfatal MI:,LV function,:the strongest predictor,EF is the most commonly used;,Anatomic extent and severity,of coronary tree involvement.The number of diseased vessels.,A recent coronary,plaque rupture,:worsening clinical sympto