內(nèi)科學(xué)教學(xué)課件：21 心血管系統(tǒng)疾病

心血管系統(tǒng)疾病CardiovascularDiseases教育不是灌輸，

而是點燃火焰?！竟畔ＥD】蘇格拉底Educationisnotthefillingofavessel,butthekindlingofaflame.——Socrates，BC470~3992005年７月２日晚，成功扮演“毛澤東”的特型演員古月在廣東省三水區(qū)因突發(fā)大面積心肌梗死，搶救無效去世，享年66歲。2005年8月17日晚，著名表演藝術(shù)家高秀敏在長春的家中因心臟病突發(fā)辭世，享年46歲。名人的意外事件名人的意外事件2006年12月20日上午，著名相聲表演藝術(shù)家馬季因心臟病逝世，享年72歲。2007年著名相聲表演藝術(shù)家侯耀文因突發(fā)心臟病被送往北醫(yī)三院，經(jīng)搶救無效去世，享年59歲。Yalta,Febr.1945DiastolicandSystolicArterialPressureofFranklinD.Rooseveltfrom1935untilHisDeathonApril12,1945F.Messerli:NewEnglandJournalofMedicine332:1038-1039,April13,1995選舉HeadlinesoftheSt.LouisPost-Dispatch,April13,1945F.Messerli:NewEnglandJournalofMedicine332:1038-1039,April13,1995心血管疾病居我國居民死亡構(gòu)成比首位冠心病是主要原因，其發(fā)生率呈逐年遞增《中國心血管病報告2006》衛(wèi)生部心血管病防治中心2008.04心血管疾病39.1%腫瘤呼吸系統(tǒng)疾病消化系統(tǒng)疾病損傷中毒內(nèi)分泌疾病泌尿系統(tǒng)疾病傳染病其他人心血管病流行狀況

——中國心血管病報告20052002年調(diào)查估計，我國每年心腦血管病新發(fā)及患病的病例數(shù)心臟的工作

各部，同時從肺部吸取新鮮血液，以便供左心室下一次收縮使用；右心室吸進從靜脈來的、帶有大量廢物和二氧化碳的血液，這種不新鮮的血通過右心房運送到肺部，在肺部吸收氧氣排出二氧化碳后，又變?yōu)轷r血流入左心房。心臟和與它相連的大血管組成一個密閉的管道網(wǎng)——血液循環(huán)系統(tǒng)。心臟工作起來就像一只泵，收縮時將左心室里富含氧氣和營養(yǎng)物質(zhì)的鮮血“壓”到主動脈去，通過動脈輸送到身體MyocardiumCoronaryarteriesConductionsystemValvesPericardiumArteriesVeinsCapilariesPreloadAfterloadContractionHeartrateChamberstiffnessOxygenconsumptionCoronarybloodsupply

DeterminantsofNormalCirculation

ClinicalHistoryLocationandradiationTimeanddurationFrequencyExertationoratrestBeforeoraftermealWeather(coldwinter)Relatedmedication......SymptomsChestpainSyncopeFatigueDyspneaPalpitationFeverCyanosisEdemaDizziness......

CharacteristicsRiskfactorsHypertensionDyslipidemiaSmokingPhysicalinactiveDiabetesmellitusInfectionStressFamilyhistory......

PhysicalExaminationInspection:Generalstatus,cyanosis,dyspnea......Palpation:Pulse,frequency,extrasystoli,edema,apical impulse,thrill......Percussion:MarginoftheheartAuscultation:

HeartrateCardiacrhythmCardiacsoundExtracardiacsound(Galloprhythm,openingsnap,pericardialknock)Cardiacmurmur(systolic,diastolic,continuous)

LaboratoryExaminationBloodWBC,RBC,thrombocytesESR,CRP, INR,TPT,CK-MB,Troponin-I,AST,LDHLipidGlucoseElectrolytesBloodgasUrine:Protein,RBC,......

Electrogram(Holter)andElectrophysiology

SurfaceECG

IntracardiacECG

CardiovascularImagingX-Ray,CT,MRIEcho-andDopplercardiographyRadioactiveNuclearimaging,PETCatheterization,angiography

CardiovascularImagingRadioactiveNuclearimaging

IntravascularUltrasoundImaginePreventiveCardiovascularMedicineA:AspirinACEIB:B-blockerBPC:CholesterolCigarettequittingD:DiabetesControlDietE:ExerciseEducation

ConventionalTherapyBehaviorandpsychotherapy(TypeAandTypeBbehavior)MedicationDosagei.v,oral,i.m.TimeFrequencyDruginteractions......AntihypertensiveLipid-loweringAntidiabeticagentsVasodilatorsDiureticsDigitalisAntiarrhythmics......UsageSideeffectsDrugsHypotensionLong-QTProarrhythmiaDisturbanceofelectrolytesDemagingofrenalandliverfunctionTachy-andBradycardia........FirstselectiveX-raycoronaryarteriogramMasonSonesOct301958目前臨床診斷冠狀動脈病變主要依賴于冠脈造影（金標準），但冠脈造影僅僅顯示被造影劑填充的管腔輪廓，不能客觀反映血管壁的病變及性質(zhì)，如果參照節(jié)段存在彌漫病變，冠脈造影通常會低估狹窄程度局限性病變彌漫性病變上世紀90年代初，血管內(nèi)超聲問世為客觀準確判定血管壁病變性質(zhì)及其程度提供了可能,多普勒技術(shù)為評價冠狀動脈功能提供了客觀手段評價冠狀動脈功能病變形態(tài)、性質(zhì)、狹窄程度多普勒血流測定僅顯示管腔輪廓血管內(nèi)超聲冠狀動脈造影

InterventionalTherapyAndreasGrüntzig,performedhisfirstcoronaryangioplastyprocedureinZurich,Switzerlandin1977;movedtotheUnitedStatestojointhefacultyofEmoryUniversityin1980,diedinaplanecrashinMonroeCounty,GeorgiaonOctober27,19851984

InterventionalTherapyAMIPTCAStenting術(shù)前球囊擴張

InterventionalTherapy植入支架術(shù)后

InterventionalTherapyAnnualNumbersofPCICasesinChina

Increase20-25%EachYearinthePast10YearsPhaseI:1985-1996PhaseII:1997-2001PhaseIII:2001-In2014,morethan450,000PCIswereperformedinChina我國冠脈介入治療數(shù)量呈逐年增加

CatheterAblationAblationofVTRFduringVT 3seconds

PacemakertherapyX-ray.MedtronicAttainLVleadinmid-lateralveinwithInSyncdevice.CardiacResynchronization

ICDTherapyICD-Secondaryprevention:Meta-Analysis(AVID,CIDS,CASH)NumberatriskICD:934715467273159104934715467273159104Amio:9326644272481288293266442724812882YearsYearsAmioICDAmioICD5040302010050403020100012345012345ConnollySJ.EurHeartJ2000;21:2071DeathRhythmogenicdeath

ProgressandPerspectivesAngiogenesisImplantationofself(autologous)bonemarrowstemcellsisarelativelysimplemethodforangiogenesiswithoutcausingtoxicityorimmunologicalrejectionIsnerJM,etal.JClinInvest1999;103:1231-6

ProgressandPerspectivesBoneMarrowCellsRegenerateInfarctedMyocardium

Orlicetal.Nature2001;410:701

Lin-c-kitPOSBMCfromtransgenicmiceinjectedintheperi-infarctedleftventricleoffemalemiceaftercoronaryligationNewlyformedmyocardiumoccupied68%oftheinfarctedportionoftheventricle9daysaftertransplantingthebonemarrowcells.DevelopingtissuecomprisedproliferatingmyocytesandvascularstructuresA.BonemarrowcellsandmyocardialregenerationB.Myocardialrepairandconnexin防止動脈粥樣硬化控制危險因素:高血脂、高血壓、糖尿病、吸煙、肥胖…冠心病的藥物和介入治療藥物支架:促進介入治療后修復(fù)、消除內(nèi)膜過度增生射頻消溶是根治快速性心律失常的里程碑對終末期冠心病、心力衰竭Angiogenesis：促進血管新生Myogenesis：Stemcelltransplant，…小結(jié)antegrad16.04.2002首例經(jīng)皮主動脈瓣植入術(shù)病史總結(jié)患者，男，75歲因“反復(fù)胸悶乏力7年”