冠心病完整版

CoronaryArteryDiseaseDefinitionofCoronaryArteryDiseaseCoronaryArteryDisease(CAD)

ismostcommonlycausedbyobstructionofthecoronaryarteriesbyatheromatousplaqueandsecondarythrombosis.AnatomyofcoronaryarteryAtherosclerosisistheconditioninwhichanarterywallthickensastheresultofabuild-upoffattymaterialssuchascholesterol.Definitionofatherosclerosis

FromendothelialdysfunctiontoatherosclerosisEndothelialDysfunctionFatty-StreakFormationAtheromaUnstableAtheromaABDCAtherosclerosis:fromEgyptianmummies

7HighPrevalenceofCoronaryAtherosclerosisinAsymptomaticTeenagersandYoungAdults.EvidenceFromIntravascularUltrasound.Circulation.2001;103:2705.Prevalenceofcoronaryatherosclerosisbyage

Differentstageofatherosclerosis9

Oxygenrequirements(heartrate;contractility;walltension)Oxygensupply(coronarybloodflowandcoronaryarterialO2content)BalanceThefragilityofbalanceProducemyocardialischemiawithcontractilecardiacdysfunction,arrythmias,infarction,andpossiblydeathStableanginapectorisischaracterizedbyadeep,poorlylocalizedchestorarmdiscomfort(rarelydescribedaspain)thatisreproduciblyassociatedwithphysicalexertionoremotionalstressandrelievedwithin5to15minutesbyrestand/orsublingualnitroglycerin.DefinitionofstableanginaChecklistforhistorytaking?

Location?Radiation?Quality?Whatcausesandrelievesit?Durationandfrequency?AssociatedsymptomsLocationandradiationoftypicalanginaQualityofangina?

Stangling?

pressing?squeezing?constricting

?burning?crushing?heavy15Precipitationandaggravatingfactors

?exertion?walking?inthecold?heavymeal?strongemotionorfright16ReliefofPain?

rest?

nitroglycerin17?

sweating:angina?profusesweating:AMI?nauseaandvomiting:AMI

?shortnessofbreath?palpitation?syncopeAccompanyingSymptomsDifferentialdiagnosisGastroesophagealTypesofchestpain?AAspirinandAnti-ischemia?BBloodpressureandBeta-blocker?CCholesterolandCigarettesmoking?DDiabetesandDiet?EExerciseandEducationThegeneralprinciplesofnon-invasivetherapy21AntiplateletsAspirinCholesterolmodulationStatinsAnti-ischemiaBeta-blocker,CalciumBlockerandNitratesACEI/ARBsDrugtreatments穩(wěn)定性心絞痛的本質是什么？Thincapfibroatheroma(TCFA)VulnerableandstableplaqueVulnerablePlaqueStableplaque25Differentprogresstypesofvulnerableplaque1Adhesion3Aggregation2Activation4ThrombosisPlateletsCoagulationsystem斑塊破裂血小板粘附血小板聚集血管腔部分堵塞-不穩(wěn)定心絞痛血栓脫落，微血管栓塞-非ST段抬高心梗血管腔因血栓形成，急性閉塞-ST段抬高心梗AcutecoronarysyndromeACSNon-STELEVATIONACSSTELEVATIONACS非ST段抬高心梗（NSTEMI）ST段抬高心梗（STEMI）不穩(wěn)定心絞痛(UA)Unstableanginaisdefinedasanginapectoris(orequivalenttypeofischemicdiscomfort)withatleastoneoffourfeatures:(1)itoccursatrest(orwithminimalexertion)usuallylastingmorethan20minutes(ifnotinterruptedbynitroglycerin);(2)itissevereanddescribedasfrankpainandofnewonset(i.e.,within1month);(3)itoccurswithacrescendopattern(i.e.,moresevere,prolonged,orfrequentthanpreviously);(4)andpost-MIangina.Typesofunstableangina

severeandintolerable.

prolonged,usuallylastingformorethan30minutesandfrequentlyforanumberofhours.

describedasconstricting,crushing,oppressing,orcompressing;asensationofaheavyweightorasqueezinginthechest.

retrosternalinlocation,radiatesdowntheulnaraspectoftheleftarm

notrelievedbyrestandnitroglycerin.

accompaniedbydiaphoresis,nausea,andvomiting.CharacteristicsofchestpaininACSArrhythmia,evensuddendeath

(About50percentofthedeathsassociatedwithAMIoccurwithin1houroftheeventandareattributabletoarrhythmias,mostoftenventricularfibrillation)

AcuteheartfailureShock(includingcardiogenicshock,hypovolumicshock,etal.)SeverecomplicationsinACSECGinACSThedynamicchangesofECG(especiallyST-T)havetheimportancetoassessischmia.ECGExampleinNon-STEMIACS36ECGExampleinSTEMI37ECGNonSTelevationSTelevationBiomarkerUnstableanginaNon-STEMISTEMIACSBiomarkerThelevelofserumbiomarker(TroponinI,TandCK-MB)isusedtoevaluatetheextentofcardiomyocyteinjuryandnecrosisShort-termmortalityofACSEurHeartJ,2002;23:1190–1201.EuroHeartSurveyACSLong-termmortalityofACSCirculation.2009;119:3110-3117.TreatmentofACSAnti-thrombotictherapyAnti-platelettherapy

AspirinADPreceptorantagonist(Clopidogrel)GPⅡb/Ⅲaantagonist…Anti-coagulationtherapy

unfractionatedheparinlow-molecularweightheparin(LMWH)

ⅩainhibitorDirectthrombosisantagonist…ClassIIntheabsenceofcontraindications,fibrinolytictherapyshouldbeadministeredtoSTEMIpatientswithsymptomonsetwithintheprior12hoursandSTelevationgreaterthan0.1mVinatleast2contiguousprecordialleadsoratleast2adjacentlimbleads.(LevelofEvidence:A)2.Intheabsenceofcontraindications,fibrinolytictherapyshouldbeadministeredtoSTEMIpatientswithsymptomonsetwithintheprior12hoursandneworpresumablynewLBBB.(LevelofEvidence:A)RecommendationsforThrombolysisContraindicationsforThrombolysisThrombolysisforSTEMITheLancet1994;343:311-22.CoronaryArteryBypassSurgery(CABG)47Percut