冠心病課件(大醫(yī)英)

冠狀動脈粥樣硬化性心臟病

(coronaryatheroscleroticheartdisease)

大連醫(yī)科大學附屬二院心內科牛楠精品冠狀動脈粥樣硬化性心臟病

(coronaryatheros1動脈粥樣硬化

atherosclerosis精品動脈粥樣硬化

atherosclerosis精品2IntroductionArteriosclerosisThickeningandlossofelasticityofarterialwallsHardeningofthearteriesGreatestmorbidityandmortalityofallhumandiseasesviaNarrowingWeakening精品IntroductionArteriosclerosis精3PlaqueThatHasBeenSurgicallyRemovedfromCoronaryArteryCourtesyRonaldD.GregoryandJohnRiley,MD.精品PlaqueThatHasBeenSurgicall4

NonModifiableRiskFactorsAgeAdominantinfluenceAtherosclerosisbeginsintheyoung,butdoesnotprecipitateorganinjuryuntillaterinlifeGenderMenmorepronethanwomen,butbyage60-70aboutequalfrequencyFamilyHistoryFamilialclusterofriskfactorsGeneticdifferences精品

NonModifiableRiskFactorsAg5

ModifiableRiskFactors

(potentiallycontrollable)

HyperlipidemiaHypertensionCigarettesmokingDiabetesMellitusElevatedHomocysteineFactorsthataffecthemostasisandthrombosisInfections:Herpesvirus;ChlamydiapneumoniaeObesity,sedentarylifestyle,stress精品

ModifiableRiskFactors

(pot6PathogenesisofAtherosclerosisResponsetoinjuryhypothesisInjurytotheendothelium(dysfunctionalendothelium)ChronicinflammatoryresponseMigrationofSMCfrommediatointimaProliferationofSMCinintimaExcessproductionofECMEnhancedlipidaccumulation精品PathogenesisofAtherosclerosi7Responsetoinjury精品Responsetoinjury精品8Endotheliadysfunction精品Endotheliadysfunction精品9InitiationofFattyStreak精品精品10FattyStreak精品精品11Fibro-fattyAtheroma精品精品12AtherosclerosisTimelineFoamCellsFattyStreakIntermediateLesionAtheromaFibrousPlaqueComplicatedLesion/RuptureAdaptedfromPepineCJ.AmJCardiol.1998;82(suppl104).FromFirstDecadeFromThirdDecadeFromFourthDecadeEndothelialDysfunction精品AtherosclerosisTimelineFoamFa13AHAClassificationofatherosclerosis精品AHAClassificationofatherosc14動脈粥樣硬化血栓形成:

具共同病理基礎的進展性過程正常脂肪條紋纖維斑塊粥樣硬化斑塊斑塊破潰/

裂隙和血栓形成心肌梗死

缺血性中風/TIA

嚴重的下肢缺血臨床無癥狀心血管死亡年齡增長穩(wěn)定性心絞痛間歇性跛行不穩(wěn)定性心絞痛}ACS*ACS,急性冠脈綜合征;TIA,一過性腦缺血發(fā)作缺血性腎病缺血性腸病精品動脈粥樣硬化血栓形成:

具共同病理基礎的進展性過程正常脂肪15CoronaryArteryDisease冠心病精品CoronaryArteryDisease冠心病精品16Clinicalclassification(1979WHO)AsymptomaticCHD(隱匿型）AnginapectorisCHD（心絞痛型）MyocardialinfarctionCHD(心肌梗死型）IschemiccardiomyopathyCHD（缺血性心肌病型）SuddendeathCHD（猝死型）精品Clinicalclassification(1979W17ClassificationofIHDChronicischemicsyndrome:stableanginaasymptomaticCHDischemiccardiomyopathyCHDAcutecoronarysyndrome:unstableanginaSTEMI/NSTEMI精品ClassificationofIHDChronici18急性冠脈綜合癥的病理生理學Fusteretal.NEnglJMed.1992;326:310-318.Daviesetal.Circulation.1990;82(SupplII):II-38,II-46.不穩(wěn)定血栓(UA/NSTEMI)脂肪池巨噬細胞內在的壓力，張力外部的剪切力裂縫大裂縫小裂縫閉合血栓

(STEMI)動脈粥樣硬化斑塊斑塊破裂血栓精品急性冠脈綜合癥的病理生理學Fusteretal.NE19NoSTElevationSTElevationAcuteCoronarySyndromeUnstableAnginaNQMIQwMINSTEMIMyocardialInfarctionDaviesMJ

Heart83:361,2000IschemicDiscomfortPresentationWorkingDxECGBiochem.MarkerFinalDxHammLancet358:1533,2001精品NoSTElevationSTElevationAc20ANGINAPECTORIS精品ANGINAPECTORIS精品21DefinitionofAngina

Apainordiscomfortinthechestoradjacentareascausedbyinsufficientbloodflowtotheheartmuscle.精品DefinitionofAngina 精品22精品精品23ClinicalclassificationandpathologyStableangina:fixedatheromatousstenosisUnstableangina:dynamicobstructionbyplaquerupturewithsuperimposedthrombosisandspasm精品Clinicalclassificationandpa24斑塊破裂引起急性嚴重事件不穩(wěn)定心絞痛心肌梗死猝死穩(wěn)定性(勞力性)心絞痛不穩(wěn)定斑塊的進展過程穩(wěn)定斑塊的進展過程NissenSE.AmJCardiol.2000;86(suppl):12H-17H不穩(wěn)定斑塊斑塊破裂血栓形成穩(wěn)定斑塊斑塊體積增加管腔狹窄精品斑塊破裂引起急性嚴重事件不穩(wěn)定心肌梗死猝死穩(wěn)定性不穩(wěn)定斑塊25Stableanginapectoris精品Stableanginapectoris精品26ETIOLOGY.Ischemiaissecondarytocoronaryarterydiseasein95%ofpatients.Theleadingcauseiscertainlyatheroscleroticcoronaryarterydisease.Adecreasedoxygensupplyoranincreaseinoxygendemandcanleadtoaworseningofsymptoms..Ischemiacanoccurinpatientswithnormalcoronaryarteries精品ETIOLOGY.Ischemiaissecondary27Clinicalmenifestation

chestdiscomfortQuality-"squeezing,""griplike,""pressurelike,""suffocating"and"heavy”;ora"discomfort"butnot"pain."Anginaisalmostneversharporstabbing,andusuallydoesnotchangewithpositionorrespiration.Duration-anginalepisodeistypicallyminutesinduration.FleetingdiscomfortoradullachelastingforhoursisrarelyanginaLocation-usuallysubsternal,butradiationtotheneck,jaw,epigastrium,orarmsisnotuncommon.Painabovethemandible,belowtheepigastrium,orlocalizedtoasmallareaovertheleftlateralchestwallisrarelyanginal.Provocation-anginaisgenerallyprecipitatedbyexertionoremotionalstressandcommonlyrelievedbyrest.Sublingualnitroglycerinalsorelievesangina,usuallywithin30secondstoseveralminutes.精品Clinicalmenifestation

chestd28CategorizetheSeverityofAnginaCCSClassificationClass0asymptomaticClassIonstrenuousactivityClassIIonmoderateactivity

2blocksor2flightsofstairsClassIIIonmildactivity

2blocksor2flightsofstairsClassIVrestorminimalactivity精品CategorizetheSeverityofAn29Clinicalfeatures

PhysicalexaminationAnS4gallopmaybetransientlypresentduringanepisode,andthepatientmaybedyspneicordiaphoreticorhaveanewheartmurmur.High-riskfeaturesofanginaincludeheartfailureandhypotension.Acompletephysicalexamiscrucialinmakinganassessmentofrisk.Mostpt:(-)精品ClinicalfeaturesPhysicalexa30AlternativeDiagnosestoAnginaforPatientswithChestPainNon-IschemicCVaorticdissectionpericarditisPulmonarypulmonaryemboluspneumothoraxpneumoniapleuritisChestWallcostochondritisfibrositisribfracturesternoclaviculararthritisherpeszosterGastrointestinalEsophagealesophagitisspasmrefluxBiliarycoliccholecystitischoledocholithiasischolangitisPepticulcerPancreatitisPsychiatricAnxietydisordershyperventilationpanicdisorderprimaryanxietyAffectivedisordersdepressionSomatiformdisordersThoughtdisordersfixedocclusions精品AlternativeDiagnosestoAngin31Investigation12LeadRestingECGshouldberecordedinallpatientswithsymptomssuggestiveofanginapectorisnormalin50%ofpatientsanormalECGdoesnotexcludesevereCAD;however,itdoesimplynormalLVfunctionwithfavorableprognosis精品Investigation12LeadResting32CHDAtrest:

ECG精品CHDAtrest:ECG精品33冠心病Episodeofangina:ST-segmentdepressionECG精品冠心病Episodeofangina:ST-segme34CHDHolter精品CHDHolter精品35Exercisetesting精品Exercisetesting精品36Angina:ExerciseTesting

HighRiskPatientsSignificantST-segmentdepressionatlowlevelsofexerciseand/orheartrate<130FallinsystolicbloodpressureDiminishedexercisecapacityComplexventricularectopyatlowlevelofexercise精品Angina:ExerciseTesting

High37ExerciseTesting

ContraindicationsMI—impendingoracuteUnstableanginaAcutemyocarditis/pericarditisAcutesystemicillnessSevereaorticstenosisCongestiveheartfailureSeverehypertensionUncontrolledcardiacarrhythmias精品ExerciseTesting

Contraindicat38Investigation

Echocardiography.Thestressechocardiogramisawidelyperformedtestusedtoassesspatientsforcoronarydisease.Baselineechocardiographicimagesareobtainedatresttoevaluateleftventricularfunction,wallmotion,andvalvefunction.Imagesarethenacquiredduringpeakstress(thatis,duringaGXTorwithdobutamine)andcomparedwiththoseatrest.Regionalwall-motionabnormalitieswithstressindicateareasofhypoperfusionorischemia.精品InvestigationEchocardiography39InvestigationIsotopescanning:obtainingscintiscansofthemyocardiumatrestandduringstressafteradministrationofanintravenousradioactiveisotopesuchasthallium201精品InvestigationIsotopescanning:40Investigation

Coronaryangiography.

Usedtoidentifyfociofcoronarydisease.Itistheevaluationofchoiceinpatientswithanginathatis(1)poorlyresponsivetomedication,or(2)unstable.ItisalsoindicatedinpatientswithtestresultsconsistentwithahighriskforCAD.精品InvestigationCoronaryangiogr41冠心病Coronaryangiography精品冠心病Coronaryangiography精品42冠心病冠狀動脈造影精品冠心病冠狀動脈造影精品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:stenosi45ChronicStableAngina

TreatmentObjectivesPreventprogressionofcoronaryarterydiseaseandoptimiselifeexpectancyRelievesymptoms精品ChronicStableAngina

Treatme46ManagementAspirinbeta-adrenoreceptorblockingagents(-blockers)calciumantagonistsNitrates精品ManagementAspirin精品47NCEPPrimaryCHDRisk

GoalsforLoweringLDL-CLDL-CGoalNoCHD<2RF<160mg/dLNoCHD2RF<130mg/dLCHD100mg/dLTheNCEPrecommendsloweringLDL-Cevenfurtherthanthesegoals,ifpossible.RiskCategoryNHLBI;September1993精品NCEPPrimaryCHDRisk

Goalsf48CoronaryrevascularisationInvasivetreatment:coronaryangioplasty(PTCA);coronaryarterybypassgrafting(CABG)精品CoronaryrevascularisationInva49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PTCABeforePTCA afterPTCA精品冠心病PTCABeforePTCA aft52冠心病PTCA/S精品冠心病PTCA/S精品53AcutecoronarysyndromeUnstableanginaNon-STelevationmyocardialinfarction(NSTEMI)STelevationmyocardialinfarction(STEMI)精品AcutecoronarysyndromeUnstabl54UnstableAngina/NSTEMI精品UnstableAngina/NSTEMI精品55UnstableAngina

ClinicalPresentationandClassificationDiagnosisofunstableanginareferstoneworworseningsymptomsofmyocardialischemia:restanginanew-onsetsevereanginaincreasingangina精品UnstableAngina

ClinicalPrese56精品精品57評估住院期間和出院后長期缺血風險評估住院期間死亡風險

(c-index0.83)*及出院后6個月死亡風險(c-index0.81)**多個大型數據庫中驗證其有效性(c-indices分別為0.84*和0.75**)評價死亡/再發(fā)心梗的長期風險網絡版可下載

/GRACE *GrangerCB,etal.ArchinternMed.2003;163:2345-2353. **EagleK,atal.JAMA.2004;291:2727-2733.精品評估住院期間和出院后長期缺血風險評估住院期間死亡風險

(c58UnstableAnginaChestpainsyndrome,eithernewonsetorprogressiveanginaTransientST-segmentdepressionontheelectrocardiogram(ECG)WithoutevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponin精品UnstableAnginaChestpainsynd59NSTEMIChestpainsyndrome,eithernewonsetorprogressiveanginaTransientorpersistentST-segmentdepressionontheelectrocardiogram(ECG)WithevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponin精品NSTEMIChestpainsyndrome,eit60UnstableAngina/NSTEMISignificantlikelihoodofoccurrenceofmajorcardiacevents A.IncidenceofMI:8to10% B.Mortality:2to5%精品UnstableAngina/NSTEMISignific61UnstableAngina/NSTEMI:

PathophysiologyAcuteplaquefissuringandruptureSuperimposedthrombusTransientocclusionMediator-inducedvasospasmmaybepresent精品UnstableAngina/NSTEMI:

Pathop62DeterminantsofPlaqueVulnerabilityLipid-richcoresizeCapthicknessCapinflammationandrepair精品DeterminantsofPlaqueVulnera63精品精品64斑塊破裂引起急性嚴重事件不穩(wěn)定心絞痛心肌梗死猝死穩(wěn)定性(勞力性)心絞痛不穩(wěn)定斑塊的進展過程穩(wěn)定斑塊的進展過程NissenSE.AmJCardiol.2000;86(suppl):12H-17H不穩(wěn)定斑塊斑塊破裂血栓形成穩(wěn)定斑塊斑塊體積增加管腔狹窄精品斑塊破裂引起急性嚴重事件不穩(wěn)定心肌梗死猝死穩(wěn)定性不穩(wěn)定斑塊65PhysicalExaminatonNotthathelpfulMayhaveevidenceofCHF:JVD,rales,edemaMayhaveS4Mayhavemurmurofmitralregurgitationfrompapillarymuscledysfunction精品PhysicalExaminatonNotthathe66InvestigationECGCardiacEnzymeorTroponinCoronaryangiography精品InvestigationECG精品67精品精品68AcuteCoronarySyndromes精品AcuteCoronarySyndromes精品69評估住院期間和出院后長期缺血風險評估住院期間死亡風險

(c-index0.83)*及出院后6個月死亡風險(c-index0.81)**多個大型數據庫中驗證其有效性(c-indices分別為0.84*和0.75**)評價死亡/再發(fā)心梗的長期風險網絡版可下載

/GRACE *GrangerCB,etal.ArchinternMed.2003;163:2345-2353. **EagleK,atal.JAMA.2004;291:2727-2733.精品評估住院期間和出院后長期缺血風險評估住院期間死亡風險

(c70managementAdmittedtohospitalBestrest,OxygenAnti-platelet:asprin,Clopidogrel,GPIIb/IIIainhibitorsAnticoagulant:UFHorLMWHB-blockerNitrates(intravenous)CCBStatinsACEICoronaryrevascularisation精品managementAdmittedtohospital71DefiniteACSPossibleACS(–)ECG;NormalbiomarkersObserve;repeatECG,markersat4-8hrsNorecurrentpain;(–)follow-upstudiesRecurrentpain;(+)follow-upstudiesStresstest;LVfunctionifischemia(–)test:outptfollow-up(+)testAdmit,UseAcuteIschemiaPathwaySTUseMIGuidelinesNoSTST-T’s,chestpain,

markersInitialChestPain

EvaluationSymptomsSuggestiveofACS精品DefiniteACSPossibleACS(–)EC72AcuteCoronarySyndromes精品AcuteCoronarySyndromes精品73PreparationforDischargeAfterUA/NSTEMIAntiplateletRxASA75-162mg/dayClopidogrel75mg/dayBetaBlockerACEI/ARBEspeciallyifDM,HF,EF<40%,HTNStatinLDL<100mg/dL

(ideally<70mg/dL)SecondaryPreventionMeasuresSmokingCessationBP<140/90mmHGor<130/80mmHGforDMorchronickidneydisease

HbA1C<7%BMI18.5-24.9PhysicalExercise30-60minatleast5days/wk

精品PreparationforDischargeAfte74精品精品75NoSTElevationSTElevationAcuteCoronarySyndromeUnstableAnginaNQMIQwMINSTEMIMyocardialInfarctionDaviesMJ

Heart83:361,2000IschemicDiscomfortPresentationWorkingDxECGBiochem.MarkerFinalDxHammLancet358:1533,2001精品NoSTElevationSTElevationAc76Thankyou精品Thankyou精品77冠狀動脈粥樣硬化性心臟病

(coronaryatheroscleroticheartdisease)

大連醫(yī)科大學附屬二院心內科牛楠精品冠狀動脈粥樣硬化性心臟病

(coronaryatheros78動脈粥樣硬化

atherosclerosis精品動脈粥樣硬化

atherosclerosis精品79IntroductionArteriosclerosisThickeningandlossofelasticityofarterialwallsHardeningofthearteriesGreatestmorbidityandmortalityofallhumandiseasesviaNarrowingWeakening精品IntroductionArteriosclerosis精80PlaqueThatHasBeenSurgicallyRemovedfromCoronaryArteryCourtesyRonaldD.GregoryandJohnRiley,MD.精品PlaqueThatHasBeenSurgicall81

NonModifiableRiskFactorsAgeAdominantinfluenceAtherosclerosisbeginsintheyoung,butdoesnotprecipitateorganinjuryuntillaterinlifeGenderMenmorepronethanwomen,butbyage60-70aboutequalfrequencyFamilyHistoryFamilialclusterofriskfactorsGeneticdifferences精品

NonModifiableRiskFactorsAg82

ModifiableRiskFactors

(potentiallycontrollable)

HyperlipidemiaHypertensionCigarettesmokingDiabetesMellitusElevatedHomocysteineFactorsthataffecthemostasisandthrombosisInfections:Herpesvirus;ChlamydiapneumoniaeObesity,sedentarylifestyle,stress精品

ModifiableRiskFactors

(pot83PathogenesisofAtherosclerosisResponsetoinjuryhypothesisInjurytotheendothelium(dysfunctionalendothelium)ChronicinflammatoryresponseMigrationofSMCfrommediatointimaProliferationofSMCinintimaExcessproductionofECMEnhancedlipidaccumulation精品PathogenesisofAtherosclerosi84Responsetoinjury精品Responsetoinjury精品85Endotheliadysfunction精品Endotheliadysfunction精品86InitiationofFattyStreak精品精品87FattyStreak精品精品88Fibro-fattyAtheroma精品精品89AtherosclerosisTimelineFoamCellsFattyStreakIntermediateLesionAtheromaFibrousPlaqueComplicatedLesion/RuptureAdaptedfromPepineCJ.AmJCardiol.1998;82(suppl104).FromFirstDecadeFromThirdDecadeFromFourthDecadeEndothelialDysfunction精品AtherosclerosisTimelineFoamFa90AHAClassificationofatherosclerosis精品AHAClassificationofatherosc91動脈粥樣硬化血栓形成:

具共同病理基礎的進展性過程正常脂肪條紋纖維斑塊粥樣硬化斑塊斑塊破潰/

裂隙和血栓形成心肌梗死

缺血性中風/TIA

嚴重的下肢缺血臨床無癥狀心血管死亡年齡增長穩(wěn)定性心絞痛間歇性跛行不穩(wěn)定性心絞痛}ACS*ACS,急性冠脈綜合征;TIA,一過性腦缺血發(fā)作缺血性腎病缺血性腸病精品動脈粥樣硬化血栓形成:

具共同病理基礎的進展性過程正常脂肪92CoronaryArteryDisease冠心病精品CoronaryArteryDisease冠心病精品93Clinicalclassification(1979WHO)AsymptomaticCHD(隱匿型）AnginapectorisCHD（心絞痛型）MyocardialinfarctionCHD(心肌梗死型）IschemiccardiomyopathyCHD（缺血性心肌病型）SuddendeathCHD（猝死型）精品Clinicalclassification(1979W94ClassificationofIHDChronicischemicsyndrome:stableanginaasymptomaticCHDischemiccardiomyopathyCHDAcutecoronarysyndrome:unstableanginaSTEMI/NSTEMI精品ClassificationofIHDChronici95急性冠脈綜合癥的病理生理學Fusteretal.NEnglJMed.1992;326:310-318.Daviesetal.Circulation.1990;82(SupplII):II-38,II-46.不穩(wěn)定血栓(UA/NSTEMI)脂肪池巨噬細胞內在的壓力，張力外部的剪切力裂縫大裂縫小裂縫閉合血栓

(STEMI)動脈粥樣硬化斑塊斑塊破裂血栓精品急性冠脈綜合癥的病理生理學Fusteretal.NE96NoSTElevationSTElevationAcuteCoronarySyndromeUnstableAnginaNQMIQwMINSTEMIMyocardialInfarctionDaviesMJ

Heart83:361,2000IschemicDiscomfortPresentationWorkingDxECGBiochem.MarkerFinalDxHammLancet358:1533,2001精品NoSTElevationSTElevationAc97ANGINAPECTORIS精品ANGINAPECTORIS精品98DefinitionofAngina

Apainordiscomfortinthechestoradjacentareascausedbyinsufficientbloodflowtotheheartmuscle.精品DefinitionofAngina 精品99精品精品100ClinicalclassificationandpathologyStableangina:fixedatheromatousstenosisUnstableangina:dynamicobstructionbyplaquerupturewithsuperimposedthrombosisandspasm精品Clinicalclassificationandpa101斑塊破裂引起急性嚴重事件不穩(wěn)定心絞痛心肌梗死猝死穩(wěn)定性(勞力性)心絞痛不穩(wěn)定斑塊的進展過程穩(wěn)定斑塊的進展過程NissenSE.AmJCardiol.2000;86(suppl):12H-17H不穩(wěn)定斑塊斑塊破裂血栓形成穩(wěn)定斑塊斑塊體積增加管腔狹窄精品斑塊破裂引起急性嚴重事件不穩(wěn)定心肌梗死猝死穩(wěn)定性不穩(wěn)定斑塊102Stableanginapectoris精品Stableanginapectoris精品103ETIOLOGY.Ischemiaissecondarytocoronaryarterydiseasein95%ofpatients.Theleadingcauseiscertainlyatheroscleroticcoronaryarterydisease.Adecreasedoxygensupplyoranincreaseinoxygendemandcanleadtoaworseningofsymptoms..Ischemiacanoccurinpatientswithnormalcoronaryarteries精品ETIOLOGY.Ischemiaissecondary104Clinicalmenifestation

chestdiscomfortQuality-"squeezing,""griplike,""pressurelike,""suffocating"and"heavy”;ora"discomfort"butnot"pain."Anginaisalmostneversharporstabbing,andusuallydoesnotchangewithpositionorrespiration.Duration-anginalepisodeistypicallyminutesinduration.FleetingdiscomfortoradullachelastingforhoursisrarelyanginaLocation-usuallysubsternal,butradiationtotheneck,jaw,epigastrium,orarmsisnotuncommon.Painabovethemandible,belowtheepigastrium,orlocalizedtoasmallareaovertheleftlateralchestwallisrarelyanginal.Provocation-anginaisgenerallyprecipitatedbyexertionoremotionalstressandcommonlyrelievedbyrest.Sublingualnitroglycerinalsorelievesangina,usuallywithin30secondstoseveralminutes.精品Clinicalmenifestation

chestd105CategorizetheSeverityofAnginaCCSClassificationClass0asymptomaticClassIonstrenuousactivityClassIIonmoderateactivity

2blocksor2flightsofstairsClassIIIonmildactivity

2blocksor2flightsofstairsClassIVrestorminimalactivity精品CategorizetheSeverityofAn106Clinicalfeatures

PhysicalexaminationAnS4gallopmaybetransientlypresentduringanepisode,andthepatientmaybedyspneicordiaphoreticorhaveanewheartmurmur.High-riskfeaturesofanginaincludeheartfailureandhypotension.Acompletephysicalexamiscrucialinmakinganassessmentofrisk.Mostpt:(-)精品ClinicalfeaturesPhysicalexa107AlternativeDiagnosestoAnginaforPatientswithChestPainNon-IschemicCVaorticdissectionpericarditisPulmonarypulmonaryemboluspneumothoraxpneumoniapleuritisChestWallcostochondritisfibrositisribfracturesternoclaviculararthritisherpeszosterGastrointestinalEsophagealesophagitisspasmrefluxBiliarycoliccholecystitischoledocholithiasischolangitisPepticulcerPancreatitisPsychiatricAnxietydisordershyperventilationpanicdisorderprimaryanxietyAffectivedisordersdepressionSomatiformdisordersThoughtdisordersfixedocclusions精品AlternativeDiagnosestoAngin108Investigation12LeadRestingECGshouldberecordedinallpatientswithsymptomssuggestiveofanginapectorisnormalin50%ofpatientsanormalECGdoesnotexcludesevereCAD;however,itdoesimplynormalLVfunctionwithfavorableprognosis精品Investigation12LeadResting109CHDAtrest:

ECG精品CHDAtrest:ECG精品110冠心病Episodeofangina:ST-segmentdepressionECG精品冠心病Episodeofangina:ST-segme111CHDHolter精品CHDHolter精品112Exercisetesting精品Exercisetesting精品113Angina:ExerciseTesting

HighRiskPatientsSignificantST-segmentdepressionatlowlevelsofexerciseand/orheartrate<130FallinsystolicbloodpressureDiminishedexercisecapacityComplexventricularectopyatlowlevelofexercise精品Angina:ExerciseTesting

High114ExerciseTesting

ContraindicationsMI—impendingoracuteUnstableanginaAcutemyocarditis/pericarditisAcutesystemicillnessSevereaorticstenosisCongestiveheartfailureSeverehypertensionUncontrolledcardiacarrhythmias精品ExerciseTesting

Contraindicat115Investigation

Echocardiography.Thestressechocardiogramisawidelyperformedtestusedtoassesspatientsforcoronarydisease.Baselineechocardiographicimagesareobtainedatresttoevaluateleftventricularfunction,wallmotion,andvalvefunction.Imagesarethenacquiredduringpeakstress(thatis,duringaGXTorwithdobutamine)andcomparedwiththoseatrest.Regionalwall-motionabnormalitieswithstressindicateareasofhypoperfusionorischemia.精品InvestigationEchocardiography116InvestigationIsotopescanning:obtainingscintiscansofthemyocardiumatrestandduringstressafteradministrationofanintravenousradioactiveisotopesuchasthallium201精品InvestigationIsotopescanning:117Investigation

Coronaryangiography.

Usedtoidentifyfociofcoronarydisease.Itistheevaluationofchoiceinpatientswithanginathatis(1)poorlyresponsivetomedication,or(2)unstable.ItisalsoindicatedinpatientswithtestresultsconsistentwithahighriskforCAD.精品InvestigationCoronaryangiogr118冠心病Coronaryangiography精品冠心病Coronaryangiography精品119冠心病冠狀動脈造影精品冠心病冠狀動脈造影精品120冠心病LAD:stenosis LAD:normal精品冠心病LAD:stenosis LAD:121冠心病RCA:stenosis LCX:stenosis精品冠心病RCA:stenosis LCX:stenosi122ChronicStableAngina

TreatmentObjectivesPreventprogressionofcoronaryarterydiseaseandoptimiselifeexpectancyRelievesymptoms精品ChronicStableAngina

Treatme123ManagementAspirinbeta-adrenoreceptorblockingagents(-blockers)calciumantagonistsNitrates精品ManagementAspirin精品124NCEPPrimaryCHDRisk

GoalsforLoweringLDL-CLDL-CGoalNoCHD<2RF<160mg/dLNoCHD2RF<130mg/dLCHD100mg/dLTheNCEPrecommendsloweringLDL-Cevenfurtherthanthesegoals,ifpossible.RiskCategoryNHLBI;September1993精品NCEPPrimaryCHDRisk

Goalsf125CoronaryrevascularisationInvasivetreatment:coronaryangioplasty(PTCA);coronaryarterybypassgrafting(CABG)精品CoronaryrevascularisationInva126冠心病CABG精品冠心病CABG精品127冠心病PTCA精品冠心病PTCA精品128冠心病PTCABeforePTCA afterPTCA精品冠心病PTCABeforePTCA aft129冠心病PTCA/S精品冠心病PTCA/S精品130AcutecoronarysyndromeUnstableanginaNon-STelevationmyocardialinfarction(NSTEMI)STelevationmyocardialinfarction(STEMI)精品AcutecoronarysyndromeUnstabl131UnstableAngina/NSTEMI精品UnstableAngina/NSTEMI精品132UnstableAngina

ClinicalPresentationandClassificationDiagnosisofunstableanginareferstoneworworseningsymptomsofmyocardialischemia:restanginanew-onsetsevereanginaincreasingangina精品UnstableAngina

ClinicalPrese133精品精品134評估住院期間和出院后長期缺血風險評估住院期間死亡風險

(c-index0.83)*及出院后6個月死亡風險(c-index0.81)**多個大型數據庫中驗證其有效性(c-indices分別為0.84*和0.75**)評價死亡/再發(fā)心梗的長期風險網絡版可下載

/GRACE *GrangerCB,etal.ArchinternMed.2003;163:2345-2353. **EagleK,atal.JAMA.2004;291:2727-2733.精品評估住院期間和出院后長期缺血風險評估住院期間死亡風險

(c135UnstableAnginaChestpainsyndrome,eithernewonsetorprogressiveanginaTransientST-segmentdepressionontheelectrocardiogram(ECG)WithoutevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponin精品UnstableAnginaChestpainsynd136NSTEMIChestpainsyndrome,eithernewonsetorprogressiveanginaTransientorpersistentST-segmentdepressionontheelectrocardiogram(ECG)WithevidenceofmyocardialinfarctionbyCK,CK-MB,orTroponin精品NSTEMIChestpainsyndrome,eit137UnstableAngina/NSTEMISignificantlikelihoodofoccurrenceofmajorcardiacevents A.IncidenceofMI:8to10% B.