冠状动脉痉挛课件

,#,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,冠状动脉痉挛,Coronary artery spasm,Shuangdun Fan,31 March,2012,冠状动脉痉挛Coronary artery spasmShu,目 录,治 疗 与 探 讨,病 例 分 析,诊断方法：临床表现,/ECG/,造影,/,激发试验,/,核素,发 生 机 制,定义 危险因素 特点,冠状动脉痉挛,目 录治 疗 与 探,2,冠脉一过性痉挛,冠状动脉痉挛定义,冠脉管腔（完全,/,几乎完全）闭塞,症状,心绞痛,心律失常,心梗,猝死,心电图,ST,段抬高,（透壁性缺血）,ST,段压低,（心内膜下缺血）,冠脉一过性痉挛 冠状,3,冠状动脉痉挛的特点,Text in,here,冠状动,脉痉挛,多发于病变冠脉,少数发生于正常冠脉,闭塞性,(,透壁性,/ST,段抬高,),非闭塞性,(,心内膜下,/ST,段下移,),单冠脉的主支,/,分支,单冠脉多个阶段,少有多冠脉同时痉挛,发生率,前降,右冠,回旋,对角和后降。,（正常冠脉）右冠最多,其次为前降支,发作过程中心电图,缺血期,ST,段逐渐升高,再灌注期,ST,段逐渐下降,ST,段抬高导联与冠脉供血部位相应导联对应。,ST,段实际抬高导联数,欧美,危险因素内因吸烟肌桥,5,冠状动脉痉挛机制,1,2,3,4,5,炎症,血管平滑肌细胞的收缩反应性增高,血管内皮细胞结构和功能紊乱,神经机制：植物神经功能失衡,体液机制,:,舒张,/,收缩血管物质失平衡,冠状动脉痉挛机制12,6,基础知识,1,Content Title,+,+,基础知识 1 Con,7,基础知识,2,花生四烯酸,膜磷酯,PGG,2,/PGH,2,TXA,2,PGI,2,血管收缩、血小板聚集,TXA,2,合成酶,PGI,2,合成酶,（血小板）,（内皮）,+,-,磷酯酶,环加氧酶,TXA,2,PGI,2,内皮素,(EDCF),内皮源舒张,因子,(EDRF),前列腺素,(PG),代谢,体液平衡调节血管口径,Back,基础知识 2 花生四,8,基础知识,3,四个平衡,冠脉口径,TXA2/PGI2,ET/EDRF,交感,/,迷走,受体,/,受体,交感,+/,受体,+/,TXA2/ET,冠脉收缩,迷走,+/,受体,/PGI2/EDRF,冠脉舒张,基础知识 3四个平衡,9,神经机制：植物神经功能失衡,NE,*应激（兴奋,/,紧张,/,焦虑,/,惊恐,）,*寒冷刺激,*剧烈运动,交感神经,+,*夜间,迷走神经,+,节前纤维,ACh,毒蕈碱受体,+,交感节后纤维,NE,冠状动脉舒张,冠状动脉收缩,*,受体阻滞剂,-,神经机制：植物神经功,10,体液机制,血小板与前列腺素（,PG,）,血 管 内 皮 素（,ET,）,冠脉硬化,血流淤滞,血小板聚集,TXA2,内膜合成,PG,功能,内皮损伤,PGI2,内膜合成释放,ET,心肌缺血,ET,受体密度,ET,强列缩血管,NE/5-HT,缩血管增敏,破坏,TXA2/PGI2,平衡,冠脉痉挛,体液机制血小板与前列,11,其它机制,血管内皮细胞结构,/,功能紊乱,血管平滑肌细胞的收缩反应性增高,炎症,代谢紊乱、吸烟等,氧化应激,血管内皮细胞的损伤,NOET,炎性因子的刺激,调节酶类基因突变,血管平滑肌细胞对常规收缩激动剂呈过度收缩反应,1.CAS,临床表现具波动性,2.,相似的环境下并非均发作,3.,发作期,hsCRP,强烈提示炎症因素可能参与,CAS,的发生,其它机制血管内皮细胞,12,Diagnostic methods,*Clinical manifestations*ECG *Coronary angiography *Provocation test *Cardiac radionuclide,诊断方法,*变 异 型 心 绞 痛,*劳 力 型 心 绞 痛,*急 性 心 肌 梗 死,*猝 死,*闭 塞 性,(,透壁性,/ST,段 抬高,),*非 闭 塞 性,(,心内膜下,/ST,段下移,),*冷 加 压 试 验,*过 度 换 气 试 验,*乙 酰 胆 碱 试 验？,*麦 角 新 碱 试 验,铊心肌灌注造影,冠脉痉挛时：缺血区核素灌注不足性缺损。,痉挛缓解后：心肌灌注可好转。,*正常,(,硬化,),冠脉一过性狭窄,/,闭塞,*狭窄,/,闭塞自行,(,或使用扩管药物,),迅速消失,临床,表现,心电图,冠脉,造影,激发 试验,心脏,核素,Diagnostic,13,Company Logo,临床表现,/,病例分享,冠状动脉痉挛,变异型心绞痛,劳力型心绞痛,急性心肌梗死,猝 死,Company Lo,14,临床表现：变异型心绞痛,Figure 1.A:basal ECG in sinus rhythm without ST-segment alterations.B:ECG 6 minutes after,with signs of angina,there is a second-degree AV block and ST-segment elevation in leads II,III,aVF,and V5-V6.,下壁导联 多见,多为女性（,50Y,）,正常冠脉（右冠多见）,02,前、侧壁导联多见,多为男性,冠脉硬化,01,分型,发生基础,性别,ECG(ST,段抬高,),后 果,缺血时可伴窦缓、房室传导阻滞，一般不发生心肌梗死,缺血时伴有室性早搏,短阵室速或室颤,可发展成心肌梗死,变异型心绞痛特点,A,B,临床表现：变异型心绞,15,Case analysis 1,Symptom,：,chest pain,Risk factors,：,History of smoking,hypertension,Echocardiogram,：,inferior wall hypokinesia,Electrocardiogram,：,ST-depression over antero-lateral leads,Panel A.Electrocardiogram at presentation,Panel B.Electrocardiogram(post-nitroglycerin injection).,Panel C.LAD and LCX,Panel D.LAD and LCX(post-nitroglycerin injection).,Panel E.RCA,Panel F.RCA(after the first bolus intracoronary,nitroglycerin injection).,Panel G.RCA(after three boluses of intracoronary,nitroglycerin injection).,Case analysis,1,Basic information,：,A 69-year-old male,Test results:,Coronary,angiography,：,Case analy,16,Panel A.at presentation.,ST-depression over antero-lateral leads,Panel B.post-nitroglycerin injection,Case analysis 1,Panel A.a,17,Case analysis 1,Panel C.,non-obstructive diffusely diseased vessels over.,Panel D.,(post-nitroglycerin injection).,appeared bigger in calibre and were non-obstructive.,Panel E.,appeared even smaller in calibre and was occluded,Panel F.,after the first bolus intracoronary nitroglycerin injection,Panel G.,After three boluses of intracoronary nitroglycerin,a normal looking RCA was unmasked.,Case analy,18,Case analysis 2,Basic,information,：,Predisposing,factors,Symptom,Electrocardiogram,4.*,Figure 1.Complete AVB with inferoposterolateral ST segment elevation.,*Figure 2.Normal atrioventricular conduction with anterior ST segment elevation.,5.(,48 hours later),normal coronary vasculature and no angiographic lesions.,1.56-year-old woman,hypertension,2.,taking a walk,3.,mid-chest pain,sudden syncope,(a few minutes later),The patient was discharged with 240 mg of diltiazem per day.Six months later,there was no evidence of symptom recurrence.,multivessel,coronary,spasm,Coronary,angiography,Case analy,19,Figure 1.She experienced another syncopal episode,preceded by mid-chest pain.consciousness,Complete atrioventricular block and escape rhythm.,ST segment elevation at II,III,aVF,V5,V6,and aVL,and depression at V1 to V3,Case analysis 2,After only a few minutes,A new chest pain(Figure 2),Figure 1.,20,Figure 2.A new chest pain.,Normal atrioventricular conduction,ST segment elevation at V1 to V4.,Case analysis 2,Figure 2.,21,Coronary angiography:48 hours later showed normal coronary vasculature and no angiographic lesions.,Case analysis 2,Coronary a,22,Company Logo,临床表现：劳力型心绞痛,冠状动脉造影发现部分劳力型心绞痛患者冠状动脉完全通畅,心绞痛全由冠状动脉痉挛引起。,此类心绞痛发作时,ST,段抬高,且不同运动量,ST,段变化较大。,冠脉,痉挛,冠脉,血栓,心肌耗氧,心率,心肌收缩力,心室肌张力,冠脉,硬化,心肌供氧 ,心肌缺,血缺氧,心绞痛,刺激神经末梢,乳酸、丙酮酸、组胺、,K+,聚积,Company Lo,23,3,粥样硬化冠脉易痉挛,冠状动脉痉挛,冠脉部分堵塞,冠脉完全堵塞,正常冠脉持续痉挛,心肌持续缺血,临床表现：急性心肌梗死,冠脉持续痉挛,血流淤滞,/,血管内膜损伤,促血小板聚集和斑块形成,形成血栓,急 性 心 肌 梗 死,2,1,3粥样硬化冠脉易痉挛,24,临床表现：猝