(優(yōu)選)留學生心絞痛課件

1、（優(yōu)選）留學生心絞痛1 Brief IntroductionCoronary heart disease Teatment of Angina Pectoris:1. Dilation of blood vessels2. Reducing blood lipid level3. Reducing blood glucose level4. Antithrombosis5. Anti-painContractilityHeart RateCardiac Wall TensionPreload and Afterload1. Beta-Blockers2. Glyceryl trinitrate

2、 3. L-CB Anti-angina pectoris AgentsCoronary heart disease prescription:Nitrate estersAntihypertensive agentsAntilipemic agents 2 Nitrate Vasodilator In blood vessel wall, GTN produce NO with the help of mitochondrial aldehyde dehydrogenase (mtALDH)NO induce dilation of blood vesselsOver dose / long

3、 time administration of GTN also can induce active oxygen and induce tolerance. Blood vessel dilation mechanismGTN:Glyceryl NitratePETN:pentaerythrityl tetranitrate ISDN :isosorbide dinitrate ISMN :isosorbide-5-mononitrate Soluble guanylyl cyclase (sGC) is the only known receptor for NO. It is solub

4、le, i.e. completely intracellular. It is most notably involved in vasodilation. In humans, it is encoded by the genes GUCY1A2, GUCY1A3, and GUCY1B3Effects of GTNTo lower the oxygen demand of the heart2. To dilate coronary artery and increase the ischemia area blood irrigation3. To decrease the left

5、ventricular endocardial pressure, increase the endocardial blood supply and improve the adaptability of the left ventricle4. To protect ischemic cardiac cells： NO-induced PGI2 and calcitonin gene-related peptides(CGRP)5. Anti-arrythmia and Inhibition of platelet aggregationBefore GTNAfter GTNIschemi

6、c zoneNormal zonePharmacokinetics of GTN High lipophilic propertyExtensive first-pass effects for P.O.: If sublingual route, F is 80%, the onset of action is 1 to 2 minutes, and the duration of action is 20 to 30 minutes. INDICATIONS OF GTN1. Acute angina pectoris attack2. Prophylaxis of angina pect

7、oris GTN patches, ointment 3. Acute myocardial infarction 4. Congestive heart failure Isosorbide Dinitrate(消心痛）Isosorbide Mononitrate（異樂定）Angina PreventionHeart Failure TreatmentP.O.Weak Tolerance醫(yī)大一院有大夫：高血壓合并心絞痛， 異樂定 + 福新普利？Ads of GTNPostural hypotensionReflex tachycardiaThrobbing headacheFlushing,

8、 DizzinessHigh Intracerebral/Intraocular PressureTolerance目前常用于心絞痛的藥物：異樂定（欣康，硝酸酯類）消心痛（硝酸酯類）心痛定（硝苯地平）圣通平（硝苯地平緩釋）拜新同（硝苯地平控釋）波依定（非洛地平）絡活喜（氨氯地平）司樂平（拉西地平）異搏定（維拉帕米）比索洛爾（Beta1阻滯劑，選擇性最高）貝他樂克（Beta1阻滯劑）阿替洛爾（Beta1阻滯劑）心得安（Beta阻滯劑）蒙諾（ACEI，福新普利），諾迪康（藏藥）萬爽力（新型藥物，改變心肌代謝）The current commonly used in angina medicine:

9、Xinkang, nitratesIsosorbide dinitrate (nitrate)Nifedipine Nifedipine（ slow-release）Nifedipine （controlled-release)Felodipine)AmlodipineLacidipineVerapamil Bisoprolol (Beta1 blockers, the highest selectivity)Betaloc (Beta1 blocker)Atenolol (Beta1 blocker)Propranolol (Beta blocker)Fosinopril (ACEI), N

10、uodikang (Medicine)Trimetazidine ( changes in myocardial metabolism)Bisoprolol ( Bisoprolol, Beta1 blockers, high selectivity )Metoprolol ( Beta1blockers )Atenolol ( Beta1 blockers )Propranolol ( Beta blockers )3 Beta-R Blockers To lower heart rate, V-pressure and contractilityTo slow fat decomposit

11、ionTo increase V-volume To contract coronary arteries( Propranolol)-blockers is effective against the stable angina pectoris not in variant angina pectoris. 和硝酸之類的區(qū)別？For Angina Pectoris:Beta Blockers + GTN?Contraindications of Beta-Blockers: Asthma Heart Failure Bradycardia Hyperlipidemia Variant An

12、gina4 Ca2+ Channel Blockers 1. Reduction of myocardial oxygen demand? 2. Dilation of coronary vessels 3. Protection of ischemic myocardial cell4. Inhibition of platelet aggregation Nifidipine: variant anginaNifedipine + -blockers?Verapamil, diltiazem: variant, stable, and unstable angina pectoris. S

13、ummary 1. Acute attacks of angina are treated with: Sublingual nitrates Nifedipine 2. Acute anginal pain is treated with morphine 3. Stable angina is treated with Long-lasting nitrates -adrenergic receptor blockers Ca2+ channel blockers 4. Unstable angina is treated with: Aspirin Heparin 疏血通，金納多等病例

14、高血壓合并心絞痛一職業(yè)高中教師，男76歲（退休）。當年45歲時候，患高血壓，主要靠復方降壓片治療。隨著時間的推移，藥物逐漸失效，并患有冠心病。某“地方小醫(yī)院”處方卡托普利、復方降壓片（北京0號類似）和心痛定（硝苯地平片）。后來發(fā)生腦梗塞，經(jīng)治療，基本恢復。最近感到頭疼，血壓升高，來到中國醫(yī)大一院心血管內(nèi)科?；颊呒捌浼覍?，告訴大夫上述降壓藥物已經(jīng)使用多年，效果不理想，希望換藥。大夫?qū)⑷绾翁幏?？早晨：替米沙坦?5h），阿替羅爾（24h）晚上：貝尼地平（24h，抗心絞痛），小劑量阿司匹林（間隔半小時），飯后。你認為處方是否合理，為什么？復方降壓片：本品為復方制劑，其成分為每片含：利血平0.032m

15、g，氫氯噻嗪3.1mg，維生素B61.0mg，混旋泛酸鈣1.0mg，三硅酸鎂30mg，氯化鉀30mg，維生素B11.0mg，硫酸雙肼屈嗪4.2mg，鹽酸異丙嗪2.1mg，輔料適量。 患者女性，82歲，有典型的勞力型心絞痛發(fā)作史，口含硝酸甘油均可以迅速緩解?；颊哂?006年7月15日5 pm嘔血約400 ml后突發(fā)心前區(qū)劇烈疼痛，經(jīng)查是胃底靜脈曲張破裂，查心電圖示：心房纖顫，伴快速心室率，普遍導聯(lián)ST壓低，反復含服硝酸甘油無效，即刻輸血800 ml后患者心前區(qū)疼痛癥狀緩解，復查心電圖示：竇性心律，心肌缺血較前好轉(zhuǎn)?；颊卟∏榉€(wěn)定后于2006年7月27日出院。出院后隨訪3個月，患者未再發(fā)嘔血及出現(xiàn)持續(xù)劇烈心絞痛癥 。硝酸甘油為何無效？止血劑的應用：酌情選用安絡血止血敏或止血芳酸，加入補液中滴注；自胃管灌注濃度為80mgL去甲腎上腺素或凝血酶；胃鏡下局部止血可選用噴灑止血劑，如80mgL去甲腎上腺素或凝血酶；或者注射止血劑，如12mg腎上腺素加入10鹽水10ml，作分點注射；或高頻電凝止血；或微波止血；或激光止血。 病例女,68歲.