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(diǎn)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(bào)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(bào)告20052002年調(diào)查估計(jì)，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(shí)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(jìn)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(yùn)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(gè)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(shí)將左心室里富含氧氣和營養(yǎng)物質(zhì)的鮮血“壓”到主動(dòng)脈去，通過動(dòng)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(dòng)脈病變主要依賴于冠脈造影（金標(biāo)準(zhǔn)），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(huì)低估狹窄程度局限性病變彌漫性病變上世紀(jì)90年代初，血管內(nèi)超聲問世為客觀準(zhǔn)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(píng)價(jià)冠狀動(dòng)脈功能提供了客觀手段評(píng)價(jià)冠狀動(dòng)脈功能病變形態(tài)、性質(zhì)、狹窄程度多普勒血流測(cè)定僅顯示管腔輪廓血管內(nèi)超聲冠狀動(dòng)脈造影

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

InterventionalTherapyAMIPTCAStenting術(shù)前球囊擴(kuò)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(dòng)脈粥樣硬化控制危險(xiǎn)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(jìn)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(duì)終末期冠心病、心力衰竭Angiogenesis：促進(jìn)血管新生Myogenesis：Stemcelltransplant，…小結(jié)antegrad16.04.2002首例經(jīng)皮主動(dòng)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”