冠狀動脈粥樣硬化性心臟病英文-課件

CoronaryAtheroscleroticHeartDiseasesAffiliatedHospitalofJiningMedicalCollegeDept.ofCardiacCareUnitGuoxiaDongdong.0321@163.com27/4/2023ContentsAtherosclerosisStableAnginaPectorisAcuteCoronarySyndromeUAandNSTEMIAMI(STEMI)37/4/2023Self-study

VariantAnginaCardiacSyndromeXSilentMyocardialIschemiaMyocardialBridging47/4/2023WhatIsAtherosclerosis?Atherosclerosisisthedescriptivetermforthickenedandhardenedlesionsofthemediumandlargemuscularandelasticarteries.57/4/2023WhatIsCoronaryHeartDisease?67/4/2023CoronaryheartdiseaseatherosclerosisCoronarystenosiscoronaryspasmMyocardialischemia,necrosisIschemicheartdisease77/4/202387/4/2023Atherosclerosis97/4/2023FoamcellFattysteak

atheromatousplaquerupturedplaquesFibrousplaqueEndothelialdamagefirstdecadeThirddecadeForthdecadeAdaptedfromStaryHCetal.Circulation1995;92:1355-1374.mediumdamage7/4/202310Whatdamagedoesatherosclerosiscause?

117/4/2023CommonlocationCoronaryHeartDiseaseCarotidArteryDiseasePeripheralArterialDiseaseChronicKidneyDisease127/4/2023Howdoesatherosclerosisstartandprogress?137/4/2023ElevatedlevelsofcholesterolandtriglyceridesinthebloodHighbloodpressureCigarettesmoking147/4/2023BiologicalprocessesAccumulationofintimalcellssmoothmusclecellsMacrophagesT-lymphocytes157/4/2023BiologicalprocessesProliferatedconnectivetissuematrixcollagenelastic

fibersproteoglycans

167/4/2023Biologicalprocesses3.Accumulationoflipid177/4/2023Atherosclerosis-Hypothesis

HypothesisoflipoproteininfiltrationAggregationofplateletsandthrombosisClonaltheoryTheresponse-to-injuryhypothesis187/4/2023Highbloodpressure,bacterium,virus,toxin,ox-LDL,immunefactor,vasoactivesubstance.Plateletsareactivated,

adhesionandaggregationofplatelets.Lipidoses,growthfactor,proliferationofsmoothmuclecells,collagen,lipolyticenzyme.Response-to-injury

197/4/2023Pathologyandpathophysiology

FattysteakFibrousplaqueComplicatedlesion207/4/2023InitiationofAtherosclerosis

Fattysteakformation217/4/2023InitiationofAtherosclerosis227/4/2023fibrousplaque237/4/2023247/4/2023

257/4/2023ThinCapVulnerablePlaqueThrombusUnstable“ActiveVolcano”ThickCapCalcifiedPlaqueFlow-limitingLesionStableAngina“DormantVolcano”SAPACSpressureorasqueezingpain!!!267/4/2023UnstableandStablePlaques薄的纖維帽炎性細(xì)胞少的平滑肌細(xì)胞內(nèi)皮細(xì)胞不完整巨噬細(xì)胞較厚的纖維帽沒有炎性細(xì)胞泡沫細(xì)胞完整的內(nèi)皮細(xì)胞較多平滑肌細(xì)胞LibbyP.Circulation.1995;91:2844-2850.unstablestable7/4/202328Atherosclerosis

ClinicalstagesAbsenceofsymptomorstageofincubationischemianecrosis(target

organ)fibrosis297/4/2023clinicalmanifestation

GeneralmanifestationAorticatherosclerosisCoronaryarteryatherosclerosisCerebral

atherosclerosisRAatherosclerosisMesentericatherosclerosisPeripheral

arteryatherosclerosis307/4/2023Laboratory

ExaminationLackofsensitiveandspecificmethodsforearlydiagnosisDyslipidemiaX-ray：DSAshowseverityofstenosisDopplerultrasound:bloodflow317/4/2023Laboratory

Examinationradionuclide：detectionofischemiaEchocardiogram：CHDECGandstresstest:CHDAngiography:themostdirectwayIntravascularultrasound,angioscopeCT,MRI327/4/2023Riskfactors

1.Lipiddisorders(Dyslipidemia)Increasedcholesterol:TcandLDL-c,TG,ApoB,Lp(a)Decreasedcholesterol:HDL-capoA2.Hypertension337/4/2023Riskfactors3.DM,MetabolicsyndromeorinsulinresistancesyndromeMorediffuselesionCADequivalent75-80%causeofdeathinadultDMarevasculardiseases:CAD,cerebrovasculardisease,orperipheralvasculardisease347/4/20237yearsincidenceofdeath/non-fatalMI(EastWestStudy)*ThesepatientshadnohistoryofmyocardialinfarctionHaffnerSM,etal.NEnglJMed.1998;339:229–234.05101520253035404550EventsofMIin7yearsNohistoryofMIOMINohistoryofMI*OMInon-diabetics diabetics n=1373 n=1059P<0.001P<0.0014%19%20%45%DM:CADequivalent357/4/2023Riskfactors

4.

Cigarettesmoking：morethrombogenic5.

Familyhistory6.

Aging：>40yrsadults，4/5fatalmyocardialinfarctionoccuredinpatiens>65yrs7.Malegender/postmenopausalstate：male:female=2：1,mendevelopCHD10-15yrsearlierthanwomen8.alcohol9.Others:diet,homocysteine,hemostaticfactorsinflammation/infection367/4/2023

Drugtherapy

anti-platelet：

aspirin,clopidogrel,GPIIb/IIIainhitibor,Dipyridamole,cilostazolLipid-loweringHMG-CoAreductaseinhibitors（statins）377/4/2023DoubtsofpatientsQuest1：Mybloodpressureisonlyabout100/60mmHg,Whygivemehypotensorlotensin?387/4/2023DoubtsofpatientsQuestion2：Myshapeisnotfat,lipidisnothigh,whygivemelipid-loweringdrugs,madeamistake?397/4/2023DoubtsofpatientsQuestion3：Ihavecoronaryheartdisease,thenshouldIdolessactivities

inordertoprotecttheheart?407/4/2023

CoronaryHeartDisease(CHD)

7/4/202341ClinicalTypeSilentmyocardialischemiaAnginapectorisMyocardialinfarctionIschemiccardiomyopathySuddencardiacdeath7/4/202342SilentMyocardialIschemiaDefinedasdocumentedepisodesofischemianotassociatedwithanytypicaloratypicalsymptomsthatamongpatientswithobstructivecoronaryarterydisease.TypeI:myocardialischemiaisdetectedonroutineECG,24hambulatoryECGmonitoring(Holter),etc.butnotexperienceanginaatanytime;TypeII:patientsaremostfrequentlyencounteredinclinicalpractice.Someepisodesofischemiaareassociatedwithchestdiscomfortandotherepisodesareasymptomatic.7/4/202343IschemicCardiomyopathySymptomsofheartfailure,causedbyischemicmyocardialdysfunction,diffusefibrosis,andmultipleinfarction,aloneorincombination.Manifestations:ventriclesenlargement(dominantleftventricle),heartfailureandarrhythmias.7/4/202344SuddenCardiacDeathSCDisnaturaldeathduetocardiaccauses,heraldedbyabruptlossofconsciousnesswithin1houroftheonsetofacutesymptoms.Thetimeandmodeofdeathareunexpected.WHOdefinition:unexpecteddeathwithin6hours.Thisdefinitionincorporatesthekeyelementsofnatural,

rapidandunexpected.OnehalfofSCDduetocoronaryheartdisease，causedbyseverearrhythmias,suchasventricularfibrillationandcardiacarrest.7/4/202345AcuteCoronarySyndromeACSrepresentsaspectrumofconditions.Acuteplaquechangecharacterizedbyplaqueruptureandexposureofsubstancesthatpromoteplateletactivationandthrombingeneration.7/4/202346STABLEANGINAPECTORIS477/4/2023Definition

Acuteandtransientmyocardialischemiaandanoxaemia.Usuallycausedbycoronaryinsufficiencyduringexertion.487/4/2023Characteristicsparoxysmalprecordialsqueezing-likechestpain,behindthemidsternumradiatedtoleftshoulderandupperarmprecipitatedbystressorexertionrelievedrapidlybyrestornitrates497/4/2023

hypoxiaCoronarystenosis(others:aorticvalvedisease,HOCM)+Myocardialoxygendemand（HRXSBP）increased

myocardialhypoxiaacumulationofmetabolicproduct,stimulateC1-5tocausethesensationofchestpain

mechanism507/4/2023inangiographySignificantcoronarylesionwithdiameterstenosis>70%in75%ptsNosignificantstenosisinabout5-10%pts,Ischemiamayberelatedtocoronaryspasmormicrovasculardysfunction.PathologyStableanginapectoris517/4/2023pathophysiology1.MetabolicandelectrophysiologyATPreduced,accumulationofacidsubstancesDysfunctionofionpump(Na+-K+,andNa+-Ca++)Earlydepolarization(STdeviation)2.LVfunctionandhemodynamicsituationLVcontractility,systolicBP,strokevolume,cardiacoutputdecreasedLVEDpressureandvolumeStunningofmyocardiumStableanginapectoris527/4/2023symptom：chestpainlocation

behindorslightlytotheleftofthemidsternumnodefiniteborderlineradiatedtotheleftshoulderandupperarmAtypicallocation:lowerjaw,thebackofneckClinicalmanifestationStableanginapectoris537/4/2023character：tightness,squeezing,burning,pressing,choking,bursting,rarelysharpduration：3－5minsprecipitatingfactor

exertionoremotionalagitationpainrelief:withinseveralminsafterrestorusingnitroglycerinClinicalmanifestationStableanginapectoris557/4/2023PhysicalexaminationincreasedHR,elevatedBPanxietycoolandsweatyskinoccasionally

galloprhythm，transientsystolicmurmurClinicalmanifestationStableanginapectoris567/4/2023

Auxiliaryexamination1.ECG：Resting

ECGECGduringchestpain:ST-Tchangefoundin95%ptsHolter:detectofslientischemiaStresstesting:Criteriaforpositive:STsegmentdepression0.1mV，last2minscontraindication：AMI,UAP,myocarditis,Hypertension,heartfailure,aorticstenosis,HOCM,severarrhythmia,aorticaneurysmEndofthetest：STor≥0.2mV，APattacks，BP>220mmHg，BPdrop，ventriculararrhythmiaStableanginapectoris577/4/2023StresstestrestExersciseStableanginapectoris587/4/2023

2.Echocardiography:3.Scintigraphyassessment:CandetectfillingdefectofInfarctionarea4.X-rayofheart 5.coronaryangiography：finaldiagnose6.others:IVUSAuxiliaryexaminationStableanginapectoris597/4/2023CoronaryAngiography607/4/2023StableAnginaPectorisDiagnosisChestpainriskfactorsECGevidenceofischemiaduringchestpainangiography617/4/2023Cardiovascular

causesNoncardiaccausesStableAnginaPectorisDifferentialdiagnosis627/4/2023Cardiovascular

cause

MyocardialinfarctionPericarditisAorticdissectionPulmonaryembolismPulmonaryhypertension637/4/2023Noncardiac

cause

PneumoniawithpleurisySpontaneouspneumothoraxMusculoskeletaldisordersHerpeszosterEsophagealrefluxPepticulcer647/4/2023Generaltreatment：riskfactorscontrol2.Drugtherapy3.Coronaryrevascularization:percutaneouscoronaryintervention(PCI)Coronaryarterybypasssurgery(CABG)SVG,IMAGTreatmentStableAnginaPectoris657/4/2023BloodandoxygensupplytotheheartMyocardial

bloodflowMyocardialoxygen

consumption4%oftotal

cardiacoutput

suppliedtothe

myocardium12%oftotalbodyoxygen,

usedatrestby

myocardium7/4/202366CoronaryReserveMyocardial

bloodflow

increasesupto

4times...…tomeet

increased

myocardialoxygen

demand7/4/202367Myocardialoxygen

supplyanddemandO2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2supplyO2demand7/4/202368AimsofmedicaltherapyArterialvasodilatationReducesarterial

resistanceReducesafterloadDecreases

sympatheticdriveReduceheartrate

andcontractileforceReducescardiacworkLVRVDilatationof

coronaryarteriesImprovescoronary

supplyVenodilatationReduces

venousreturnReducespreload7/4/202369antianginalandanti-ischemictherapyDrugtherapyOxygensupplyOxygendemanda.Nitratesb.Betablockersc.Calciumantagonistsd.DrugsimprovingmetabolismStableAnginaPectoris707/4/2023Drugtherapya.Nitratesloweroxygendemand:decreasearteriolarandvenoustone,reducepreloadandafterloadincreasecoronarysupply:CoronarydilatationNitroglycerinIsosorbidedinitrateisosorbide5-mononitrate(long-actingnitrates)StableAnginaPectoris717/4/2023NitratesinanginaReducepreload

through

venodilatationReduceafterloadby

loweringarterialresistanceReduceplateletaggregationIncreasecoronaryperfusion,includingischaemicareasReversalofcoronaryspasm7/4/202372b.?－blockers:reducemyocardialoxygen:reduceHR,myocardialcontractility,BP,theLVwallstressAbslutecontraindications：severbradycardia:high-degreeA-Vblock,SSS,severeunstableLVfailureRelativecontraindications:asthmaandbronchospasticdiseaseperipheralvasculardisease?1-selective：metoprolol,atenolol,bisoprololDrugtherapyStableAnginaPectoris737/4/2023c.Calciumantagonists：Increaseoxygensupply:dilateconduitandresistancevessels,releasespasm,improvemicrovascularfunctionDecreaseoxygendemand:negativeinotropiceffect,decreaseBPAntiplateleteffectd.DrugsimprovingmetabolismDrugtherapyStableAnginaPectoris747/4/2023preventMIanddeaththerapya.antiplateletangents：ASAclopidogrelCilostazolb.Lipid-loweringangents:statinsc.Angiotesin-convertingenzymeinhibitor(ACEI)DrugtherapyStableAnginaPectoris757/4/2023stentingStableAnginaPectoris767/4/2023UnstableAngina(UA)andnon-STEMI777/4/2023ACSNon-STelevationSTelevationUnstableanginaNon-QwaveAMIQwaveAMI*positiveserumcardiacmarkers****##occasionallyvariantanginaAcuteCoronarySyndrome(ACS)787/4/2023PathophysiologyofACS

stableangina UAP&non-Q-wAMI Q-wAMIAngiographicthrombus

0-1% 75% >90%IncreasedFPA/TAT 0-5% 60-80% 80-90%Activatedplatelets 0-5% 70-80% 80-90%Acutecoronaryocclusion 0-1% 10-25% >90%mortality 1-2% 3-8% 6-15%FPA：fibrinopeptideATAT：thrombin-antithrombincomplexesUAandnon-STEMI797/4/2023Occuringatrest(orwithmininalexertion):last>20minsseverandofnew-onset:within1-2months,CCSIIIOccuringwithacrescendopattern:DeteriorationofCCSclassfication,atleastCCSIIIDefinition

UAandnon-STEMIAnginapectorisorequivalentischemicdiscomfortwithatleastoneofthethreefeatures807/4/2023BraunwaldclassificationofunstableanginaSeverity：ClassI：New-onset,oracceleratedsevereanginanorestpainwithin2monthsClassII：Anginaatrest,subacuteanginaatrest(withintheprecedingmonthbutnotwithin48h)ClassIII：Anginaatrest,acute(withinthepreceding48h)UAandnon-STEMI817/4/2023BraunwaldclassificationofunstableanginaClinicalCircumstancesClassA：SecondaryUAPaclearlyidentifiedconditionextrinsictothecoronaryvascularbedthathasintensifiedmyocardialischemia,e.g.anemia,hypotension,tachy-arrhythmiaClassB：PrimaryunstableanginaClassC：Post-infarctionUAP(within2weeksofadocumentedMI)UAandnon-STEMI827/4/2023mechanism：

1.plaqueruptureanderosion,withnonocclusivethrombus2.dynamicobstruction:Vasoconstruction3.progressivemechnialobstruction(rapidlyadvancingorISRfollowingstenting)4.secondaryUAInflammationThrombogenesisUAandnon-STEMI837/4/2023

ECG:Non-STEMI:STdepressionlast>12hrCardiacbiomarkersofmyocardiumdamage:cTnT,cTnICK-MBUAPandnon-STEMICoronaryangiographyAngioscopyandIVUSOtherlaboratorytests847/4/2023Treatment1.Genearlmanagement:rest,oxygen,CCU2.DrugtherapyA.Anti-ischemicdrug:intravenously,orallynitrates-blockerCalcium

antagnoist:firstchoiceforvariantanginaMorphinesulfateUAandnon-STEMI857/4/2023Treatment

2.Drugtherapy:B.antithrombotictherapya.Anti-plateletAspirin:early,300mgloadingdoseADP-receptorantagonist:clopidogrel300mg-600mgloadingdose,75mg/dGPIIb/IIIareceptorinhibitor:usedinptsplannedtoPCIb.Anticoagulationtherapy:HeparinLowmolecularweightheparin(LMWH)Directanti-thrombindrug:bivalirudin,hirudin

UAandnon-STEMI867/4/2023Treatment2.Drugtherapy:C.othermedicaltherapy