冠狀動脈粥樣硬化性心臟病英文-2

111/11/2024ContentsAtherosclerosisStableAnginaPectorisAcuteCoronarySyndromeUAandNSTEMIAMI(STEMI)211/11/2024Self-study

VariantAnginaCardiacSyndromeXSilentMyocardialIschemiaMyocardialBridging311/11/2024WhatIsAtherosclerosis?Atherosclerosisisthedescriptivetermforthickenedandhardenedlesionsofthemediumandlargemuscularandelasticarteries.411/11/2024WhatIsCoronaryHeartDisease?511/11/2024CoronaryheartdiseaseatherosclerosisCoronarystenosiscoronaryspasmMyocardialischemia,necrosisIschemicheartdisease611/11/2024711/11/2024Atherosclerosis811/11/2024FoamcellFattysteak

atheromatousplaquerupturedplaquesFibrousplaqueEndothelialdamagefirstdecadeThirddecadeForthdecadeAdaptedfromStaryHCetal.Circulation1995;92:1355-1374.mediumdamage11/11/20249Whatdamagedoesatherosclerosiscause?

1011/11/2024CommonlocationCoronaryHeartDiseaseCarotidArteryDiseasePeripheralArterialDiseaseChronicKidneyDisease1111/11/2024Howdoesatherosclerosisstartandprogress?1211/11/2024ElevatedlevelsofcholesterolandtriglyceridesinthebloodHighbloodpressureCigarettesmoking1311/11/2024BiologicalprocessesAccumulationofintimalcellssmoothmusclecellsMacrophagesT-lymphocytes1411/11/2024BiologicalprocessesProliferatedconnectivetissuematrixcollagenelastic

fibersproteoglycans

1511/11/2024Biologicalprocesses3.Accumulationoflipid1611/11/2024Atherosclerosis-Hypothesis

HypothesisoflipoproteininfiltrationAggregationofplateletsandthrombosisClonaltheoryTheresponse-to-injuryhypothesis1711/11/2024Highbloodpressure,bacterium,virus,toxin,ox-LDL,immunefactor,vasoactivesubstance.Plateletsareactivated,

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

1811/11/2024Pathologyandpathophysiology

FattysteakFibrousplaqueComplicatedlesion1911/11/2024InitiationofAtherosclerosis

Fattysteakformation2011/11/2024InitiationofAtherosclerosis2111/11/2024fibrousplaque2211/11/20242311/11/2024

2411/11/2024ThinCapVulnerablePlaqueThrombusUnstable“ActiveVolcano”ThickCapCalcifiedPlaqueFlow-limitingLesionStableAngina“DormantVolcano”SAPACSpressureorasqueezingpain!!!2511/11/2024UnstableandStablePlaques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.unstablestable11/11/202427Atherosclerosis

ClinicalstagesAbsenceofsymptomorstageofincubationischemianecrosis(target

organ)fibrosis2811/11/2024clinicalmanifestation

GeneralmanifestationAorticatherosclerosisCoronaryarteryatherosclerosisCerebral

atherosclerosisRAatherosclerosisMesentericatherosclerosisPeripheral

arteryatherosclerosis2911/11/2024Laboratory

ExaminationLackofsensitiveandspecificmethodsforearlydiagnosisDyslipidemiaX-ray：DSAshowseverityofstenosisDopplerultrasound:bloodflow3011/11/2024Laboratory

Examinationradionuclide：detectionofischemiaEchocardiogram：CHDECGandstresstest:CHDAngiography:themostdirectwayIntravascularultrasound,angioscopeCT,MRI3111/11/2024Riskfactors

1.Lipiddisorders(Dyslipidemia)Increasedcholesterol:TcandLDL-c,TG,ApoB,Lp(a)Decreasedcholesterol:HDL-capoA2.Hypertension3211/11/2024Riskfactors3.DM,MetabolicsyndromeorinsulinresistancesyndromeMorediffuselesionCADequivalent75-80%causeofdeathinadultDMarevasculardiseases:CAD,cerebrovasculardisease,orperipheralvasculardisease3311/11/20247yearsincidenceofdeath/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:CADequivalent3411/11/2024Riskfactors

4.

Cigarettesmoking：morethrombogenic5.

Familyhistory6.

Aging：>40yrsadults，4/5fatalmyocardialinfarctionoccuredinpatiens>65yrs7.Malegender/postmenopausalstate：male:female=2：1,mendevelopCHD10-15yrsearlierthanwomen8.alcohol9.Others:diet,homocysteine,hemostaticfactorsinflammation/infection3511/11/2024

Drugtherapy

anti-platelet：

aspirin,clopidogrel,GPIIb/IIIainhitibor,Dipyridamole,cilostazolLipid-loweringHMG-CoAreductaseinhibitors（statins）3611/11/2024DoubtsofpatientsQuest1：Mybloodpressureisonlyabout100/60mmHg,Whygivemehypotensorlotensin?3711/11/2024DoubtsofpatientsQuestion2：Myshapeisnotfat,lipidisnothigh,whygivemelipid-loweringdrugs,madeamistake?3811/11/2024DoubtsofpatientsQuestion3：Ihavecoronaryheartdisease,thenshouldIdolessactivities

inordertoprotecttheheart?3911/11/2024

CoronaryHeartDisease(CHD)

11/11/202440ClinicalTypeSilentmyocardialischemiaAnginapectorisMyocardialinfarctionIschemiccardiomyopathySuddencardiacdeath11/11/202441SilentMyocardialIschemiaDefinedasdocumentedepisodesofischemianotassociatedwithanytypicaloratypicalsymptomsthatamongpatientswithobstructivecoronaryarterydisease.TypeI:myocardialischemiaisdetectedonroutineECG,24hambulatoryECGmonitoring(Holter),etc.butnotexperienceanginaatanytime;TypeII:patientsaremostfrequentlyencounteredinclinicalpractice.Someepisodesofischemiaareassociatedwithchestdiscomfortandotherepisodesareasymptomatic.11/11/202442IschemicCardiomyopathySymptomsofheartfailure,causedbyischemicmyocardialdysfunction,diffusefibrosis,andmultipleinfarction,aloneorincombination.Manifestations:ventriclesenlargement(dominantleftventricle),heartfailureandarrhythmias.11/11/202443SuddenCardiacDeathSCDisnaturaldeathduetocardiaccauses,heraldedbyabruptlossofconsciousnesswithin1houroftheonsetofacutesymptoms.Thetimeandmodeofdeathareunexpected.WHOdefinition:unexpecteddeathwithin6hours.Thisdefinitionincorporatesthekeyelementsofnatural,

rapidandunexpected.OnehalfofSCDduetocoronaryheartdisease，causedbyseverearrhythmias,suchasventricularfibrillationandcardiacarrest.11/11/202444AcuteCoronarySyndromeACSrepresentsaspectrumofconditions.Acuteplaquechangecharacterizedbyplaqueruptureandexposureofsubstancesthatpromoteplateletactivationandthrombingeneration.11/11/202445StableAnginaPectoris4611/11/2024Definition

Acuteandtransientmyocardialischemiaandanoxaemia.Usuallycausedbycoronaryinsufficiencyduringexertion.4711/11/2024Characteristicsparoxysmalprecordialsqueezing-likechestpain,behindthemidsternumradiatedtoleftshoulderandupperarmprecipitatedbystressorexertionrelievedrapidlybyrestornitrates4811/11/2024

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

myocardialhypoxiaacumulationofmetabolicproduct,stimulateC1-5tocausethesensationofchestpain

mechanism4911/11/2024inangiographySignificantcoronarylesionwithdiameterstenosis>70%in75%ptsNosignificantstenosisinabout5-10%pts,Ischemiamayberelatedtocoronaryspasmormicrovasculardysfunction.PathologyStableanginapectoris5011/11/2024pathophysiology1.MetabolicandelectrophysiologyATPreduced,accumulationofacidsubstancesDysfunctionofionpump(Na+-K+,andNa+-Ca++)Earlydepolarization(STdeviation)2.LVfunctionandhemodynamicsituationLVcontractility,systolicBP,strokevolume,cardiacoutputdecreasedLVEDpressureandvolumeStunningofmyocardiumStableanginapectoris5111/11/2024symptom：chestpainlocation

behindorslightlytotheleftofthemidsternumnodefiniteborderlineradiatedtotheleftshoulderandupperarmAtypicallocation:lowerjaw,thebackofneckClinicalmanifestationStableanginapectoris5211/11/2024character：tightness,squeezing,burning,pressing,choking,bursting,rarelysharpduration：3－5minsprecipitatingfactor

exertionoremotionalagitationpainrelief:withinseveralminsafterrestorusingnitroglycerinClinicalmanifestationStableanginapectoris5411/11/2024PhysicalexaminationincreasedHR,elevatedBPanxietycoolandsweatyskinoccasionally

galloprhythm，transientsystolicmurmurClinicalmanifestationStableanginapectoris5511/11/2024

Auxiliaryexamination1.ECG：Resting

ECGECGduringchestpain:ST-Tchangefoundin95%ptsHolter:detectofslientischemiaStresstesting:Criteriaforpositive:STsegmentdepression

0.1mV，last2minscontraindication：AMI,UAP,myocarditis,Hypertension,heartfailure,aorticstenosis,HOCM,severarrhythmia,aorticaneurysmEndofthetest：STor≥0.2mV，APattacks，BP>220mmHg，BPdrop，ventriculararrhythmiaStableanginapectoris5611/11/2024StresstestrestExersciseStableanginapectoris5711/11/2024

2.Echocardiography:3.Scintigraphyassessment:CandetectfillingdefectofInfarctionarea4.X-rayofheart 5.coronaryangiography：finaldiagnose6.others:IVUSAuxiliaryexaminationStableanginapectoris5811/11/2024CoronaryAngiography5911/11/2024StableAnginaPectorisDiagnosisChestpainriskfactorsECGevidenceofischemiaduringchestpainangiography6011/11/2024Cardiovascular

causesNoncardiaccausesStableAnginaPectorisDifferentialdiagnosis6111/11/2024Cardiovascular

cause

MyocardialinfarctionPericarditisAorticdissectionPulmonaryembolismPulmonaryhypertension6211/11/2024Noncardiac

cause

PneumoniawithpleurisySpontaneouspneumothoraxMusculoskeletaldisordersHerpeszosterEsophagealrefluxPepticulcer6311/11/2024Generaltreatment：riskfactorscontrol2.Drugtherapy3.Coronaryrevascularization:percutaneouscoronaryintervention(PCI)Coronaryarterybypasssurgery(CABG)SVG,IMAGTreatmentStableAnginaPectoris6411/11/2024BloodandoxygensupplytotheheartMyocardial

bloodflowMyocardialoxygen

consumption4%oftotal

cardiacoutput

suppliedtothe

myocardium12%oftotalbodyoxygen,

usedatrestby

myocardium11/11/202465CoronaryReserveMyocardial

bloodflow

increasesupto

4times...…tomeet

increased

myocardialoxygen

demand11/11/202466Myocardialoxygen

supplyanddemandO2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2supplyO2demand11/11/202467AimsofmedicaltherapyArterialvasodilatationReducesarterial

resistanceReducesafterloadDecreases

sympatheticdriveReduceheartrate

andcontractileforceReducescardiacworkLVRVDilatationof

coronaryarteriesImprovescoronary

supplyVenodilatationReduces

venousreturnReducespreload11/11/202468antianginalandanti-ischemictherapyDrugtherapyOxygensupplyOxygendemanda.Nitratesb.Betablockersc.Calciumantagonistsd.DrugsimprovingmetabolismStableAnginaPectoris6911/11/2024Drugtherapya.Nitratesloweroxygendemand:decreasearteriolarandvenoustone,reducepreloadandafterloadincreasecoronarysupply:CoronarydilatationNitroglycerinIsosorbidedinitrateisosorbide5-mononitrate(long-actingnitrates)StableAnginaPectoris7011/11/2024NitratesinanginaReducepreload

through

venodilatationReduceafterloadby

loweringarterialresistanceReduceplateletaggregationIncreasecoronaryperfusion,includingischaemicareasReversalofcoronaryspasm11/11/202471b.?－blockers:reducemyocardialoxygen:reduceHR,myocardialcontractility,BP,theLVwallstressAbslutecontraindications：severbradycardia:high-degreeA-Vblock,SSS,severeunstableLVfailureRelativecontraindications:asthmaandbronchospasticdiseaseperipheralvasculardisease?1-selective：metoprolol,atenolol,bisoprololDrugtherapyStableAnginaPectoris7211/11/2024c.Calciumantagonists：Increaseoxygensupply:dilateconduitandresistancevessels,releasespasm,improvemicrovascularfunctionDecreaseoxygendemand:negativeinotropiceffect,decreaseBPAntiplateleteffectd.DrugsimprovingmetabolismDrugtherapyStableAnginaPectoris7311/11/2024preventMIanddeaththerapya.antiplateletangents：ASAclopidogrelCilostazolb.Lipid-loweringangents:statinsc.Angiotesin-convertingenzymeinhibitor(ACEI)DrugtherapyStableAnginaPectoris7411/11/2024stentingStableAnginaPectoris7511/11/2024UnstableAngina(UA)andnon-STEMI7611/11/2024ACSNon-STelevationSTelevationUnstableanginaNon-QwaveAMIQwaveAMI*positiveserumcardiacmarkers****##occasionallyvariantanginaAcuteCoronarySyndrome(ACS)7711/11/2024PathophysiologyofACS

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-STEMI7811/11/2024Occuringatrest(orwithmininalexertion):last>20minsseverandofnew-onset:within1-2months,CCSIIIOccuringwithacrescendopattern:DeteriorationofCCSclassfication,atleastCCSIIIDefinition

UAandnon-STEMIAnginapectorisorequivalentischemicdiscomfortwithatleastoneofthethreefeatures7911/11/2024BraunwaldclassificationofunstableanginaSeverity：ClassI：New-onset,oracceleratedsevereanginanorestpainwithin2monthsClassII：Anginaatrest,subacuteanginaatrest(withintheprecedingmonthbutnotwithin48h)ClassIII：Anginaatrest,acute(withinthepreceding48h)UAandnon-STEMI8011/11/2024BraunwaldclassificationofunstableanginaClinicalCircumstancesClassA：SecondaryUAPaclearlyidentifiedconditionextrinsictothecoronaryvascularbedthathasintensifiedmyocardialischemia,e.g.anemia,hypotension,tachy-arrhythmiaClassB：PrimaryunstableanginaClassC：Post-infarctionUAP(within2weeksofadocumentedMI)UAandnon-STEMI8111/11/2024mechanism：

1.plaqueruptureanderosion,withnonocclusivethrombus2.dynamicobstruction:Vasoconstruction3.progressivemechnialobstruction(rapidlyadvancingorISRfollowingstenting)4.secondaryUAInflammationThrombogenesisUAandnon-STEMI8211/11/2024

ECG:Non-STEMI:STdepressionlast>12hrCardiacbiomarkersofmyocardiumdamage:cTnT,cTnICK-MBUAPandnon-STEMICoronaryangiographyAngioscopyandIVUSOtherlaboratorytests8311/11/2024Treatment1.Genearlmanagement:rest,oxygen,CCU2.DrugtherapyA.Anti-ischemicdrug:intravenously,orallynitrates

-blockerCalcium

antagnoist:firstchoiceforvariantanginaMorphinesulfateUAandnon-STEMI8411/11/2024Treatment

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

UAandnon-STEMI8511/11/2024Treatment2.Drugtherapy:C.othermedicaltherapya.lipid-loweringdrugs:

statins,earlyuse(infirst24hrs)LDL-ctarget:<100mg/dl

b.ACEI:

long-termsecondarypreventionUAandnon-STEMI8611/11/2024Treatment3.Invasiveversusconservativestrategyearlyinvasivestrategyindicatedforhighriskpatients:within48-72hrs,Followingbycoronaryrevascularization(PCIorCABG)4.Long-termmanagement

?-blockers,Statin,ACEI,aspirinclopidegrel(12m)UAandnon-STEMI8711/11/202411/11/202488SymptomsSuggestiveofACSDefiniteACSNoSTelevationAlgorithmfortheEvaluationandManagement

ofPatientsSuspectedofHavinganACS.STelevationPossibleACSChronicStableAnginaNoncardiacDiagnosisTreatmentas

indicatedby

alternativediagnosisSeeACC/AHA/ACP

GuidelinesforChronic

StableAnginaNondiagnosticECG

NormalInitialserum

cardiacmarkersSTand/orTwavechanges

Ongoingpain

Positivecardiacmarkers

HemodynamicabnormalitiesObserve

Follow-upat4-8hours;

ECG,cardiacmarkersEvaluationfor

reperfusiontherapySeeACC/AHA

Guidelinesfor

AcuteMINorecurrentpain;Negativefollow-upstudiesRecurrentischemicpain

orpositivefollow-upstudiesDiagnosisofACSconfirmedAdmittohospital

ManageviaacuteischemiapathwayStressstudytoprovokeischemia

ConsiderevaluationofLV