冠狀動脈粥樣硬化性心臟病英文

CoronaryAtheroscleroticHeartDiseasesAffiliatedHospitalofJiningMedicalCollegeDept.ofCardiacCareUnitGuoxiaDongdong.2021/3/1012021/3/102ContentsAtherosclerosisStableAnginaPectorisAcuteCoronarySyndromeUAandNSTEMIAMI(STEMI)2021/3/103Self-studyVariantAnginaCardiacSyndromeXSilentMyocardialIschemiaMyocardialBridging2021/3/104WhatIsAtherosclerosis?Atherosclerosisisthedescriptivetermforthickenedandhardenedlesionsofthemediumandlargemuscularandelasticarteries.2021/3/105WhatIsCoronaryHeartDisease?2021/3/106CoronaryheartdiseaseatherosclerosisCoronarystenosiscoronaryspasmMyocardialischemia,necrosisIschemicheartdisease2021/3/1072021/3/108Atherosclerosis2021/3/109FoamcellFattysteakatheromatousplaquerupturedplaquesFibrousplaqueEndothelialdamagefirstdecadeThirddecadeForthdecadeAdaptedfromStaryHCetal.Circulation1995;92:1355-1374.mediumdamage2021/3/1010Whatdamagedoesatherosclerosiscause?

2021/3/1011CommonlocationCoronaryHeartDiseaseCarotidArteryDiseasePeripheralArterialDiseaseChronicKidneyDisease2021/3/1012Howdoesatherosclerosisstartandprogress?2021/3/1013ElevatedlevelsofcholesterolandtriglyceridesinthebloodHighbloodpressureCigarettesmoking2021/3/1014BiologicalprocessesAccumulationofintimalcellssmoothmusclecellsMacrophagesT-lymphocytes2021/3/1015BiologicalprocessesProliferatedconnectivetissuematrixcollagenelasticfibersproteoglycans2021/3/1016Biologicalprocesses3.Accumulationoflipid2021/3/1017Atherosclerosis-Hypothesis

HypothesisoflipoproteininfiltrationAggregationofplateletsandthrombosisClonaltheoryTheresponse-to-injuryhypothesis2021/3/1018Highbloodpressure,bacterium,virus,toxin,ox-LDL,immunefactor,vasoactivesubstance.Plateletsareactivated,adhesionandaggregationofplatelets.Lipidoses,growthfactor,proliferationofsmoothmuclecells,collagen,lipolyticenzyme.Response-to-injury

2021/3/1019Pathologyandpathophysiology

FattysteakFibrousplaqueComplicatedlesion2021/3/1020InitiationofAtherosclerosis

Fattysteakformation2021/3/1021InitiationofAtherosclerosis2021/3/1022fibrousplaque2021/3/10232021/3/1024

2021/3/1025ThinCapVulnerablePlaqueThrombusUnstable“ActiveVolcano”ThickCapCalcifiedPlaqueFlow-limitingLesionStableAngina“DormantVolcano”SAPACSpressureorasqueezingpain!!!2021/3/1026UnstableandStablePlaques薄的纖維帽炎性細胞少的平滑肌細胞內(nèi)皮細胞不完整巨噬細胞較厚的纖維帽沒有炎性細胞泡沫細胞完整的內(nèi)皮細胞較多平滑肌細胞LibbyP.Circulation.1995;91:2844-2850.unstablestable2021/3/10272021/3/1028Atherosclerosis

ClinicalstagesAbsenceofsymptomorstageofincubationischemianecrosis(targetorgan)fibrosis2021/3/1029clinicalmanifestation

GeneralmanifestationAorticatherosclerosisCoronaryarteryatherosclerosisCerebralatherosclerosisRAatherosclerosisMesentericatherosclerosisPeripheralarteryatherosclerosis2021/3/1030LaboratoryExaminationLackofsensitiveandspecificmethodsforearlydiagnosisDyslipidemiaX-ray：DSAshowseverityofstenosisDopplerultrasound:bloodflow2021/3/1031LaboratoryExaminationradionuclide：detectionofischemiaEchocardiogram：CHDECGandstresstest:CHDAngiography:themostdirectwayIntravascularultrasound,angioscopeCT,MRI2021/3/1032Riskfactors

1.Lipiddisorders(Dyslipidemia)Increasedcholesterol:TcandLDL-c,TG,ApoB,Lp(a)Decreasedcholesterol:HDL-capoA2.Hypertension2021/3/1033Riskfactors3.DM,MetabolicsyndromeorinsulinresistancesyndromeMorediffuselesionCADequivalent75-80%causeofdeathinadultDMarevasculardiseases:CAD,cerebrovasculardisease,orperipheralvasculardisease2021/3/10347yearsincidenceofdeath/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:CADequivalent2021/3/1035Riskfactors

4.Cigarettesmoking：morethrombogenic5.Familyhistory6.Aging：>40yrsadults，4/5fatalmyocardialinfarctionoccuredinpatiens>65yrs7.Malegender/postmenopausalstate：male:female=2：1,mendevelopCHD10-15yrsearlierthanwomen8.alcohol9.Others:diet,homocysteine,hemostaticfactorsinflammation/infection2021/3/1036

Drugtherapy

anti-platelet：aspirin,clopidogrel,GPIIb/IIIainhitibor,Dipyridamole,cilostazolLipid-loweringHMG-CoAreductaseinhibitors（statins）2021/3/1037DoubtsofpatientsQuest1：Mybloodpressureisonlyabout100/60mmHg,Whygivemehypotensorlotensin?2021/3/1038DoubtsofpatientsQuestion2：Myshapeisnotfat,lipidisnothigh,whygivemelipid-loweringdrugs,madeamistake?2021/3/1039DoubtsofpatientsQuestion3：Ihavecoronaryheartdisease,thenshouldIdolessactivities

inordertoprotecttheheart?2021/3/1040

CoronaryHeartDisease(CHD)

2021/3/1041ClinicalTypeSilentmyocardialischemiaAnginapectorisMyocardialinfarctionIschemiccardiomyopathySuddencardiacdeath2021/3/1042SilentMyocardialIschemiaDefinedasdocumentedepisodesofischemianotassociatedwithanytypicaloratypicalsymptomsthatamongpatientswithobstructivecoronaryarterydisease.TypeI:myocardialischemiaisdetectedonroutineECG,24hambulatoryECGmonitoring(Holter),etc.butnotexperienceanginaatanytime;TypeII:patientsaremostfrequentlyencounteredinclinicalpractice.Someepisodesofischemiaareassociatedwithchestdiscomfortandotherepisodesareasymptomatic.2021/3/1043IschemicCardiomyopathySymptomsofheartfailure,causedbyischemicmyocardialdysfunction,diffusefibrosis,andmultipleinfarction,aloneorincombination.Manifestations:ventriclesenlargement(dominantleftventricle),heartfailureandarrhythmias.2021/3/1044SuddenCardiacDeathSCDisnaturaldeathduetocardiaccauses,heraldedbyabruptlossofconsciousnesswithin1houroftheonsetofacutesymptoms.Thetimeandmodeofdeathareunexpected.WHOdefinition:unexpecteddeathwithin6hours.Thisdefinitionincorporatesthekeyelementsofnatural,rapidandunexpected.OnehalfofSCDduetocoronaryheartdisease，causedbyseverearrhythmias,suchasventricularfibrillationandcardiacarrest.2021/3/1045AcuteCoronarySyndromeACSrepresentsaspectrumofconditions.Acuteplaquechangecharacterizedbyplaqueruptureandexposureofsubstancesthatpromoteplateletactivationandthrombingeneration.2021/3/1046STABLEANGINAPECTORIS2021/3/1047Definition

Acuteandtransientmyocardialischemiaandanoxaemia.Usuallycausedbycoronaryinsufficiencyduringexertion.2021/3/1048Characteristicsparoxysmalprecordialsqueezing-likechestpain,behindthemidsternumradiatedtoleftshoulderandupperarmprecipitatedbystressorexertionrelievedrapidlybyrestornitrates2021/3/1049 hypoxiaCoronarystenosis(others:aorticvalvedisease,HOCM)+Myocardialoxygendemand（HRXSBP）increased

myocardialhypoxiaacumulationofmetabolicproduct,stimulateC1-5tocausethesensationofchestpain

mechanism2021/3/1050inangiographySignificantcoronarylesionwithdiameterstenosis>70%in75%ptsNosignificantstenosisinabout5-10%pts,Ischemiamayberelatedtocoronaryspasmormicrovasculardysfunction.PathologyStableanginapectoris2021/3/1051pathophysiology1.MetabolicandelectrophysiologyATPreduced,accumulationofacidsubstancesDysfunctionofionpump(Na+-K+,andNa+-Ca++)Earlydepolarization(STdeviation)2.LVfunctionandhemodynamicsituationLVcontractility,systolicBP,strokevolume,cardiacoutputdecreasedLVEDpressureandvolumeStunningofmyocardiumStableanginapectoris2021/3/1052symptom：chestpainlocationbehindorslightlytotheleftofthemidsternumnodefiniteborderlineradiatedtotheleftshoulderandupperarmAtypicallocation:lowerjaw,thebackofneckClinicalmanifestationStableanginapectoris2021/3/10532021/3/1054character：tightness,squeezing,burning,pressing,choking,bursting,rarelysharpduration：3－5minsprecipitatingfactorexertionoremotionalagitationpainrelief:withinseveralminsafterrestorusingnitroglycerinClinicalmanifestationStableanginapectoris2021/3/1055PhysicalexaminationincreasedHR,elevatedBPanxietycoolandsweatyskinoccasionallygalloprhythm，transientsystolicmurmurClinicalmanifestationStableanginapectoris2021/3/1056

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，ventriculararrhythmiaStableanginapectoris2021/3/1057StresstestrestExersciseStableanginapectoris2021/3/10582.Echocardiography:3.Scintigraphyassessment:CandetectfillingdefectofInfarctionarea4.X-rayofheart 5.coronaryangiography：finaldiagnose6.others:IVUSAuxiliaryexaminationStableanginapectoris2021/3/1059CoronaryAngiography2021/3/1060StableAnginaPectorisDiagnosisChestpainriskfactorsECGevidenceofischemiaduringchestpainangiography2021/3/1061CardiovascularcausesNoncardiaccausesStableAnginaPectorisDifferentialdiagnosis2021/3/1062Cardiovascularcause

MyocardialinfarctionPericarditisAorticdissectionPulmonaryembolismPulmonaryhypertension2021/3/1063Noncardiaccause

PneumoniawithpleurisySpontaneouspneumothoraxMusculoskeletaldisordersHerpeszosterEsophagealrefluxPepticulcer2021/3/1064Generaltreatment：riskfactorscontrol2.Drugtherapy3.Coronaryrevascularization:percutaneouscoronaryintervention(PCI)Coronaryarterybypasssurgery(CABG)SVG,IMAGTreatmentStableAnginaPectoris2021/3/1065BloodandoxygensupplytotheheartMyocardial

bloodflowMyocardialoxygen

consumption4%oftotal

cardiacoutput

suppliedtothe

myocardium12%oftotalbodyoxygen,

usedatrestby

myocardium2021/3/1066CoronaryReserveMyocardial

bloodflow

increasesupto

4times...…tomeet

increased

myocardialoxygen

demand2021/3/1067Myocardialoxygen

supplyanddemandO2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2supplyO2demand2021/3/1068AimsofmedicaltherapyArterialvasodilatationReducesarterial

resistanceReducesafterloadDecreases

sympatheticdriveReduceheartrate

andcontractileforceReducescardiacworkLVRVDilatationof

coronaryarteriesImprovescoronary

supplyVenodilatationReduces

venousreturnReducespreload2021/3/1069antianginalandanti-ischemictherapyDrugtherapyOxygensupplyOxygendemanda.Nitratesb.Betablockersc.Calciumantagonistsd.DrugsimprovingmetabolismStableAnginaPectoris2021/3/1070Drugtherapya.Nitratesloweroxygendemand:decreasearteriolarandvenoustone,reducepreloadandafterloadincreasecoronarysupply:CoronarydilatationNitroglycerinIsosorbidedinitrateisosorbide5-mononitrate(long-actingnitrates)StableAnginaPectoris2021/3/1071NitratesinanginaReducepreload

through

venodilatationReduceafterloadby

loweringarterialresistanceReduceplateletaggregationIncreasecoronaryperfusion,includingischaemicareasReversalofcoronaryspasm2021/3/1072b.?－blockers:reducemyocardialoxygen:reduceHR,myocardialcontractility,BP,theLVwallstressAbslutecontraindications：severbradycardia:high-degreeA-Vblock,SSS,severeunstableLVfailureRelativecontraindications:asthmaandbronchospasticdiseaseperipheralvasculardisease?1-selective：metoprolol,atenolol,bisoprololDrugtherapyStableAnginaPectoris2021/3/1073c.Calciumantagonists：Increaseoxygensupply:dilateconduitandresistancevessels,releasespasm,improvemicrovascularfunctionDecreaseoxygendemand:negativeinotropiceffect,decreaseBPAntiplateleteffectd.DrugsimprovingmetabolismDrugtherapyStableAnginaPectoris2021/3/1074preventMIanddeaththerapya.antiplateletangents：ASAclopidogrelCilostazolb.Lipid-loweringangents:statinsc.Angiotesin-convertingenzymeinhibitor(ACEI)DrugtherapyStableAnginaPectoris2021/3/1075stentingStableAnginaPectoris2021/3/1076UnstableAngina(UA)andnon-STEMI2021/3/1077ACSNon-STelevationSTelevationUnstableanginaNon-QwaveAMIQwaveAMI*positiveserumcardiacmarkers****##occasionallyvariantanginaAcuteCoronarySyndrome(ACS)2021/3/1078PathophysiologyofACS 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-STEMI2021/3/1079Occuringatrest(orwithmininalexertion):last>20minsseverandofnew-onset:within1-2months,CCSIIIOccuringwithacrescendopattern:DeteriorationofCCSclassfication,atleastCCSIIIDefinitionUAandnon-STEMIAnginapectorisorequivalentischemicdiscomfortwithatleastoneofthethreefeatures2021/3/1080BraunwaldclassificationofunstableanginaSeverity：ClassI：New-onset,oracceleratedsevereanginanorestpainwithin2monthsClassII：Anginaatrest,subacuteanginaatrest(withintheprecedingmonthbutnotwithin48h)ClassIII：Anginaatrest,acute(withinthepreceding48h)UAandnon-STEMI2021/3/1081BraunwaldclassificationofunstableanginaClinicalCircumstancesClassA：SecondaryUAPaclearlyidentifiedconditionextrinsictothecoronaryvascularbedthathasintensifiedmyocardialischemia,e.g.anemia,hypotension,tachy-arrhythmiaClassB：PrimaryunstableanginaClassC：Post-infarctionUAP(within2weeksofadocumentedMI)UAandnon-STEMI2021/3/1082mechanism：

1.plaqueruptureanderosion,withnonocclusivethrombus2.dynamicobstruction:Vasoconstruction3.progressivemechnialobstruction(rapidlyadvancingorISRfollowingstenting)4.secondaryUAInflammationThrombogenesisUAandnon-STEMI2021/3/1083ECG:Non-STEMI:STdepressionlast>12hrCardiacbiomarkersofmyocardiumdamage:cTnT,cTnICK-MBUAPandnon-STEMICoronaryangiographyAngioscopyandIVUSOtherlaboratorytests2021/3/1084Treatment1.Genearlmanagement:rest,oxygen,CCU2.DrugtherapyA.Anti-ischemicdrug:intravenously,orallynitrates-blockerCalciumantagnoist:firstchoiceforvariantanginaMorphinesulfateUAandnon-STEMI2021/3/1085Treatment2.Drugtherapy:B.antithrombotictherapya.Anti-plateletAspirin:early,300mgloadingdoseADP-receptorantagonist:clopidogrel300mg-600mgloadingdose,75mg/dGPIIb/IIIareceptorinhibitor:usedinptsplannedtoPCIb.Anticoagulationtherapy:HeparinLowmolecularweightheparin(LMWH)Directanti-thrombindrug:bivalirudin,hirudin

UAandnon-STEMI2021/3/1086Treatment2.Drugtherapy:C.othermedicaltherapya.li