全科醫(yī)學(xué) 冠心病

AnalysisofCoronaryHeartDiseaseCadreWardLiHuiCase1SubjectiveData:A68-year-oldwomanwithtypeⅡdiabetes(5years)andmildhypertension(10years)wasadmittedforevaluationofdyspneaandprecordialgiaonexertionin6months.ObjectiveData:T:37.0℃,P:96bpm,BP:150/92mmHgHeight:160cm,Weight:82kg,BIM:32kg/㎡PreliminaryAssessmentThepossiblereasonofprecordialgia：CoronaryHeartDisease,GastroesophagealReflux,PulmonaryEmbolism,SpontaneousPneumothorax,AorticDissection,Pericarditis,VentricularAneurysm,RibCartilagePain,Hyperventilationandsoon.

Thispatienthadnosymptomsofacuteseverechest.coronaryheartdiseasemaybeassessedfirstforthehighincidenceandmortalitySupplementaryDataBiologicalaspects1、HPIthedurationandcauseshortnessofbreathcauseandmitigatingfactorsofdyspneaandprecordialgiawhethertherearerelatedinjuries.SupplementaryDataBiologicalaspects2、PMH(1)theriskfactors,theexistenceofcardiovasculardiseasessuchashypertension,diabetesandotherchronicdiseases.(2)thetimeofdiagnosisofhypertensionanddiabetes(3)whetheranulcerorbiliarytractdisease.3、MedsWhethertheuseofotherdrugsinadditiontothetreatmentofhypertension,diabetes.SupplementaryDataSocialaspect1.FHxFamilymemberswhohadsufferedfromhypertensionordiabetes,andcardiovasculardiseasesuchasstroke.Recordageoftheillness,clinicalcourseandtreatment2.SmokingStatus3.Drinkingsituation4.Relationshipbetweenfamilymembers5.DietaryhabitsSupplementaryDataPsychologicalaspect1.Thepatient'sfeelingsandconcerndegreetothediseasewithyearsofchronicdiseasehistory,2.Herfamilyfactorshavewhatkindofinfluencetoher3.Thepatient'sexpectations.2.Doesthepatientsufferedfromanxietyandfearforthechestdiscomfort?1.Whatisthepatientmostwanttosolvethroughthisvisit?SupplementaryDataLabdata:BloodLipid:TotalCholesterol:4.82mmol/LHDL-C:1.04mmol/LLDL-C:3.00mmol/LTriglyceride:1.73mmol/L，BloodRT,TSH,Liverandkidneyfunction：allnormal，F(xiàn)astingbloodglucose：8.0mmol/LGlycosylatedhemoglobin：7.6%ECG:Sinusrhythm,heartrate90beats/min,PRandnormalQRSinterval,V3V6STsegmentof0.05mV,leftventricularhighvoltageandsuggestthatleftventricularhypertrophywithstrain,nopathologicalQwaveEvidence-basedMedicineApplicationofevidence-basedmedicinetheoryandmethodtoconstructandanswertheclinicalquestionWhatissignificanttothepatientofcoronaryheartdiseaseriskfactors?Coronaryarterydiseaseisthemostcommoncardiovasculardisease,isthemaincauseofdeathinChinese.AccordingtoaresearchreportfromCirculation;CardiovascularQualityandOutcomesmagazineDuetoaging,smoking,hypertensionandotherriskfactors,to2030,inChina,themorbidityandthemortalityrateofcardiovasculardiseasewouldbeincreasedto73%.Themainriskfactorsforcoronaryarterydiseaseissmoking,diabetesandhypertension.Theworldwillhavetofacetheenormouspressuretotheincreaseofcardiovasculardiseasemorbidityandmortality.SothegeneralpractitionersshouldpaymoreattentiontothepreventionandtreatmentofcoronaryheartdiseaseEvidence-basedMedicineTheriskfactorsofcoronaryheartdisease:1.Age(male≥45，female≥55）2.SmokingStatus（smokingorsmokedin6months）3.FHx（AMIOrMIonfirst-degreerelativesbeforetheageof55）4.Hhypertension（systolicpressure>140mmHgAnd(or)diastolicpressure>90mmHg）5.Hyperlipidemia(totalcholesterol>5.2mmo1/L,LDL-C>3.4mmol/L,HDL-C<0.9mmo1/L)6.diabetes(Fastingbloodglucose>7.0mmol/L)7.Obesity(BMI>28kg/㎡，orwaist>90cm)8.Sedentarylifestyle(Donotmeettheminimumrequirementsofphysicalactivity)ThemostsuitableexaminationCoronaryheartdiseasereferstocoronaryarteryplaqueformationintheinnerlayer,whichleadtocoronaryarterystenosisorocclusion,andblockthebloodsupplyofcoronaryarterytomyocardium.Someexpertsthinkthatmorethan50%ofthediameterofthelumenofcoronaryarterystenosiscanbedefinedascoronaryheartdisease.Ontheother,someexpertsbelievethatitis70%.Studyconfirmedthatthenatureoftheplaqueismoreimportantthanthedegreeofstenosis.Becauseofthesevulnerableplaqueincreasedtheriskofruptureandthrombosis.Therefore,forthegeneralpractitioner,takeeffectivemeasurestofound"significant"patientswithcoronaryheartdiseaseisveryimportant.Evidence-basedMedicineInChina,thereareseveralnoninvasivecanbeusedtoassesssuspectedpatientswithcoronaryheartdisease.Thesecheckshavedifferentsensitivityandspecificity,alsohasitsownuniqueadvantages,disadvantagesandrisks.Including:Exerciseloadtest(withorwithouttheuseofdrugs)EchocardiographyRadionuclideperfusion(SPECTorMyocardialScintigraphy)Evidence-basedMedicineSearchingPICOontheNationalLibraryofMedicinewebsite.PICOisnotonlyusedtoevaluatetheeffectoftreatment,canalsobeusedfortheevaluationofdiagnostictestvalueandcomparison."Coronaryarterydisease"inputastheresearchproblem,"Stressecho"astheintervention,"Nuclearstresstest"asacontrol,Thetypeismetaanalysis.Thenwegotfivearticles.Conclusion:echocardiographymaybemoresuitableforfemalepatients,becauseithasahigherspecificityfordiagnosis.Isthisevidenceapplicabletothecaseofthepatient?6in14ofthestudiescomparedthefemalestressechocardiographyand99mTcMIBImyocardialperfusionscan,displayechocardiographyhashigherspecificity.Evidence-basedMedicineEvidence-basedMedicineThenextsteptochangethePICOsearchstrategy.Comparisonofechocardiography(stressecho)andSPECTscanningwithsinglephotonemissioncomputedtomography(singlephotoemissionCT)andCTimage.Insummary:Itshouldbeprovidedtopatientsthatadiagnostictestcannotonlysensitivelydiagnosebutalsospecificallyexcludethecoronaryheartdisease.Highsensitivitytestishelpfultofindthepatientsneedfurtherexamination(suchascardiaccatheterization),Testofhighspecificityishelpfultocorrectlyidentifypatientswithoutcoronaryheartdisease.TherearerisksduetocardiaccatheterizationThepatientshouldavoidunnecessarycardiaccatheterization,Weneedadiagnostictestforhighspecificity(lowfalsepositiverate).Echocardiographyisthebestexamination(87.1%specificity),Andalsohasaveryhighsensitivity(79.1%).EchocardiographycostslessthanSPECTandEBCTForpatientsattheirownexpense,ithasobviousadvantages.Sowecancometotheconclusion:Thediagnosisofcoronaryheartdisease,echocardiographyisaccurate,andcost-effectivemeansofdiagnosis.Anditismoresuitableforfemalepatients.Evidence-basedMedicineForthepatientswithcoronaryheartdiseaseriskfactors,shouldfocusonprimarypreventionpatients.Theriskfactorsofthepatientcanbechangedishypertension,diabetesandobesity.HOT(HypertensionOptimalTreatment)showsthat,whendiastolicpressureis82.6mmHg,theincidenceofcardiovasculareventsisthelowest.Therefore,themajorityofhypertensionguidelinesrecommendbloodpressureunder130/80mmHg.ThereisevidencethatACEinhibitorshaverenalprotectiveeffectondiabeticpatients.Thispatientswithhypertensionanddiabetes,willbebenefitfromtheuseofACEIorARBdrugstocontrolbloodpressure.Forthepatientswithdiabetes,accordingtothetestresultsofACCORD(theactiontocontrolcardiovascularriskindiabetes),ThepatientHbA1cshouldbecontroledin7%oralittlehigher.AnotherexperimentinHOTisthataspirincanreduce29%majorcardiovascularevents(P=0.03)and36%myocardialinfarction(P=0.002),someofthepatientsinthestudyalsosufferedfromdiabetes.Today'sresearchshowsthatobesityincreasestheincidencerateandmortalityrateofvariousdiseases,soencouragepatientstoloseweightisalsoveryimportant.Finally,duetothelowactivity/sedentaryofthispatient,andsedentarylifestyleisindependentriskfactorsofcoronaryheartdisease,soitisrecommendedthatthepatientshouldmakesomeregular,moderateexercise.ComprehensiveAnalysis1.Metforminincreasedto1000mg/times,2timesaday,oral(glycatedhemoglobincontrolinabout7%).2.Hydrochlorothiazide,25mg/times,onceaday,oral.3.Lisinopril,10mg/times,onceaday,oral.4.Aspirin75mg/times,onceaday,oral.5.Reducingtheweightof10%.6.regularexercise.7.lowsaltlowfat,eatmorevegetablesandfruits.8.twoweeksafterthetreatmentofrenalfunction,bloodpressure,bodyweightandfastingbloodglucose.TreatmentAsprimaryhealthcareworkers,thegeneralpractitionershouldprovideclinicalpreventiveservicesforpatients.This68yearolddiabeticpatientshouldberecommendedtoinfluenzavaccination,pneumococcalvaccineeveryyear.Andevery1to2years,thispatientshouldacceptamammographyandbonescaninscreeningforosteoporosis,andwerecommendhertoregularlyscreeningforcolorectalcancer.Hereisanacutecoronaryeventsafterthediagnosisofcoronaryheartdiseasepatientswithevidence-basedtreatment.Treatment

CASE2SubjectiveData:A61-year-oldman,whowasrecentlyhospitalizedfornonSTsegmentelevationmyocardialinfarction,cametothegeneralout-patientclinic.Duringhospitalization,duetotheinferiorwallmyocardialinfarction,thispatienthadthePTCAandtwostentsimplantedintotherightcoronaryarteryandleftcircumflexcoronaryarteryEchocardiographyatdischargeshowedthatpartoftheleftventricularanteriorwallmotionedabnormallywhiletheejectionfractionwas50%.Patientsfeltgoodafterdischarged.Therewasnochestpainorshortnessofbreathatrestorwalk,nonocturnalparoxysmaldyspneaandnoorthopnea.

CASE2ObjectiveData:Noobviousrespiratorydistress.BP:150/92mmHg，P:66bpm，T:37℃Height:175cm，Weight:78kgBIM:25.5kg/㎡。PreliminaryAssessment1.AMI2.AfterPCISupplementaryDataBiologicalaspects1、HPI(1)whetherthereisasymptomsofshortnessofbreath?(2)whetherthereisachestdiscomfort?2、PMHWhetherthereisariskfactorforcardiovasculardisease,suchashighbloodpressure,diabetesandotherchronicdiseases.3、MedsWhethertakingotherdrugs.

SupplementaryData

Socialaspect1.FHxFamilymemberswhohadsufferedfromhypertensionordia