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1、血壓的形成,收縮壓 舒張壓,LCC,高血壓 分類,原發性高血壓 Primary Hypertension 續發性高血壓 Secondary Hypertension,LCC,遺傳基因的影響 鈉鹽的過度攝取 Renin-Angiotensin system 交感神經系統 細胞膜的異常 血管的增生肥厚 內皮細胞功能異常 胰島素抗性,原發性高血壓 致病機轉,LCC,續發性高血壓,高血壓的分類JNC7,Normal 120 80 Prehypertetnsion 120-139 or 80-89 Stage 1 hypertension 140-159 or 90-99 Stage 2 hyperte
2、nsion 160 or100,Initial Measurements,血壓的測定,基礎血壓 隨時血壓 休息血壓,LCC,Clinical pressure Ambulatory pressure Home pressure,血壓的測定,LCC,Blood Pressure Measurement,Ambulatory Measurement,Advantages of Self-Measurement,高血壓 臨床表現,頭重 頭痛 耳鳴 眼花 失眠 頭頸部酸痛 兩肩酸痛 大部分沒有症狀,40歲 20%罹患高血壓,隱形殺手,LCC,高血壓 自然病程,高血壓前期 遺傳-環境因素,惡性 高血壓,
3、心臟,大血管,腎,眼,腦,合併症,高血壓,高血壓早期,年齡 0-30 20-40 30-50,LCC,正確測量血壓 外觀: 脂肪分布 皮膚 肌肉 及神智狀況 眼底檢查 頸部頚動脈及甲狀腺觸診聽診 心臟大小節律及心音異常 肺有無囉音 腹部腫瘤? 動脈雜音 股動脈搏動 四肢動脈博動 水腫 神經檢查,高血壓 臨床檢查重點,LCC,Laboratory tests,Optimal Tests,What is the target of BP with therapy?,General: 140/90 mmHg Diabetes: 130/80 mmHg CHF or renal disease: 13
4、0/85 mmHg,LCC,Cardiovascular Risk In Patients with Hypertension,Clinical Risk factors for Stratification,高血壓的治療,危險因素的根除 外科手術 藥物治療 非藥物治療,LCC,Treatment,Not at good blood pressure,Treatment,Start at low dose and titrate upward Low dose combinations may be appropriate,Not at good blood pressure,Antihype
5、rtensive drugs,Treatment,Treatment,Treatment,Treatment,Treatment,Lifestyle Modifications,Treatment,Treatment,Follow Up,動脈粥狀硬化的故事,冠狀動脈,Left anterior Descending artery,Left circumflex artery,Right coronary artery,Left main coronary artery,LCC,The coronary arteries deliver oxygen-rich blood to the musc
6、le tissues of the heart. If they become blocked, heart tissue will die, resulting in a heart attack,Coronary arteries,冠狀動脈,氧供應,氧需求,平衡,冠狀動脈灌注壓力 小血管阻力 動靜脈氧氣差,心室容積 心室壓力 心室張力 心跳 心臟收縮情況,LCC,冠狀動脈的故事,Atherosclerosis timeline,Endothelial dysfunction,Foam fatty intermediate fibrous complicated Cells streak l
7、esion atheroma plaque lesion/rupture,From first decade,From third decade,From fourth decade,Growth mainly by lipid accumulation,Smooth Muscle and collagen,Thrombosis hematoma,LCC,血管內腔變小,粥狀硬塊,LCC,Plaque in Arterial wall,Blood clot,Left anterior Descending artery,Right Coronary artery,Atherothrombosis
8、 Thrombus and Plaque,Unstable and Stable Plaque,Thin fibrous cap,Inflammatory cells,Few SMCs,Eroded endothelium,Activated macrophages,Thick fibrous cap,Lack of inflammatory cells,Foam cells,Intact endothelium,More SMCs,Unstable,Stable,Risk Factors for Plaque Rupture,Impaired Fibrinolysis,Fibrinogen,
9、Diabetes Mellitus,Cholesterol,Smoking,Cap Fatigue,Atheromatous Core (size/consistency),Cap Inflammation,Systemic Factors,Local Factors,Homocysteine,Plaque Rupture,Cap Thickness/ Consistency,Plaque Rupture 誘發因素,Plaque rupture,運動 抽煙 寒冷天氣 發脾氣 心跳快 血壓高 週邊血管阻力大,LCC,心臟血管阻塞,膽固醇沉積于血管壁 形成粥狀硬塊 (Plaque, Atherom
10、a) 粥狀硬塊破裂 ( Rupture of Plaque ) 血小板 纖維蛋白等凝聚于破裂的粥狀硬塊上 修補破裂的粥狀硬塊 而形成血栓 粥狀硬塊加上血栓 阻塞血管,LCC,Hemostatic clot Formation,Thrombin,AGGREGATION,Fibrin,Hemostatic Clot,Clotting,Platelet Aggregation,0 min,10 min,5 min,SECONDARY,PRIMARY,COAGULATION,Thrombus formation,Platelet activation adhesion, aggregation,Coa
11、gulation-pathway activation and thrombin formation,Fibrinogen conversion to fibrin with cross-linking Of bands,LCC,platelet,fibrin,冠狀動脈疾病,穩定性 心絞痛,不穩定性心絞痛,ST elevation MI,NON-ST elevation MI,LCC,Plaque/atheroma obstruction of the coronary artery lumen,Chest pain,Ischemic Heart Disease,穩定性心絞痛,LCC,休息時胸
12、痛通常持續超過20分鐘 近二星期內新出現的胸痛 加重型胸痛 較頻繁 發作時間延長 較容易發生,不穩定性心絞痛 Unstable Angina Pectoris,LCC,Ischemic Heart Disease 胸痛,流冷汗 嘔吐 噁心,呼吸困難 窒息感 欲昏倒,30分鐘 對舌下nitroglycerine反應不好,急 性 心 肌 梗 塞,LCC,猝心絞痛 心肌梗塞 Sudden death,心肌梗塞 Sudden death 50%到達醫院前發生 ventricular fibrillation sudden death 發生時機胸痛後4小時 早期送醫 電擊器的使用可以救命,CPR,LCC
13、,冠狀動脈疾病,心肌梗塞 不穩定型心絞痛 PTCA,24%的男性和42%的女性會在發生心肌梗塞後的一年內死亡 不穩定型心絞痛的病人在三個月內的死亡率將近10 % 進行PTCA的病人中 有40 %可能在六個月內需要再進行手術,LCC,New Definition of MI-biochemist,Troponin or CK-MB elevations are defined as 3x above the normal (99% of normal) Total CK, SGOT, and LDH are not recommended (low specificity) Employ the
14、 full clinical picture to diagnose MI, not merely lab values,LCC,New Definition of MI-ECG,Non-ST segment elevation AMI Criteria are not adequate to define AMI ST segment elevation AMI New ST elevation in 2 or more leads (0.2 In V1-V3) 0.1 in other leads,LCC,急性心肌梗塞 Acute MYOCARDIAL INFARCTION,ST segm
15、ent elevation,Pathologic Q wave,LCC,New Definition of MI-established MI,In the absence of QRS confounders (BBB, LVH, WPW) Any Q wave in leads V1-V3 Q waves must be 30 msec duration Q waves in other leads must have Qs in 2 contiguous leads (eg, II and III) Qs must be 1mm in depth,LCC,New Definition o
16、f MI-image,Infarct manifests itself as decreased wall motion by echo or hypoperfusion by radionuclide SPECT Ischemia, stunning, and hibernation will produce similar changes,LCC,Use of cardiac markers in ACS,Cardiac troponin after classical AMI,CK-MB after AMI,Cardiac troponin after microinfarction,D
17、ays after onset of AMI,LCC,Chest pain Troponin I/T, CK-MB ECG changes Echocardiography Nuclear cardiology Cardiac catheterization,急性心肌梗塞-診斷,LCC,急性心肌梗塞 Acute MYOCARDIAL INFARCTION,Hypokinesia akinesia Hyperkinesia LV aneurysm LV size EF MR LV thrombus,LCC,急性心肌梗塞 Acute MYOCARDIAL INFARCTION,Hypoperfus
18、ion LV systolic function LV diastolic function,LCC,急性心肌梗塞-心導管,Filling defect,Contrast 造影劑,LCC,Myocardial infarction,arrhythmia,Loss of muscle,Sudden death,Ventricular remodeling,Ventricular dilation,Heart failure,death,LCC,LCC,Thrombin/Fibrin,Platelet,thrombus,Pre-PCI ASA Statin ACEI Clopidogrel,Pos
19、t-PCI ASA Statin ACEI Clopidogrel,GP IIb/IIIA Embolic protection Anti-inflammatory Coated stent,Plaque rupture,thrombus,LCC,Reperfusion,intervension,thrombolysis,LCC,Optimal Strategy UA/NSTEMI,TIMI IIIB,2002,Conservative,Invasive,VANQWISH,MATE,FRISC II,TACTICS- TIMI 18,VINO,RITA-3,TRUCS,急性心肌梗塞 Prima
20、ry PTCA,Initiate PTCA if available and suitable Goals: PTCA within 90 30 min,LCC,氣球擴張術,Stenting,Stenting,LCC,網狀支架置放術,Interventional Cardiology,post,Stenting,Sites of Anti-thrombotic Drug Action,Tissue factor,Plasma clotting cascade,Prothrombin,Thrombin,Fibrinogen,Fibrin,Thrombus,Platelet aggregation
21、,Conformational activation of GPIIb/IIIa,Collagen,Thromboxane A2,ADP,AT,AT,Factor Xa,Coagulation cascade,Platelet cascade,Plaque rupture,thrombus,LCC,Fibrin,Thrombin,Platelet,Fibrinolysis Antiplatelet Anti-thrombin,THROMBUS,PLATELET,Antiplatelet therapy -aspirin -clopidogrel -GP IIb/IIIa inhibitors
22、-persantin -ticlopidine,Thrombin,Antithrombin therapy -heparin,Fibrin,Plasminogen Activators -t-PA R-PA SK TNK-tPA,LCC,Streptokinase Urokinase,急性心肌梗塞 Thrombolysis,一般原則 胸痛 12小時內 ST segment elevation 75 years old 沒有禁忌 3小時內 好處最大,好 處,壞 處,LCC,急性心肌梗塞 Thrombolysis,12小時內 注射的好處 增加冠狀動脈血流 減少結疤的形成 減少心室擴大 梗塞區域可以
23、重新排列其構造 減少心臟衰竭 減少死亡率,好 處,壞 處,LCC,Thrombolysis tPA,Early reperfusion 價錢貴 腦溢血機會較高 需併用Heparin 使用於大片心肌壞死並且腦溢血機會較低者,靜脈注射15mg 30分鐘內以0.75mg/kg mg的量滴注50mg 60分鐘內以0.5mg/kg的量滴注35 mg,LCC,適用於發作時間較久 受損範圍較小患者 價錢較便宜 腦溢血機會較低 易過敏 2年內最好不要再使用第二次 不必併用Heparin 100萬單位1小時內 滴注完畢,Thrombolysis Streptokinase,LCC,Initiate fibrin
24、olysis if indicated Goals: 30 min from entry to ER,急性心肌梗塞 Thrombolysis,LCC,FIBRINOLYSIS ABSOLUTE CONTRAINDICATION,Previous HEMORRHAGIC STROKE at any time Other STROKES or CEREBROVASCULAR EVENTS within one year Known INTRACRANIAL NEOPLASMA Active INTERNAL BLEEDING ( does not include menses ) Suspecte
25、d AORTIC DISSECTION,LCC,FIBRINOLYSIS RELATIVE CONTRAINDICATION,Severe UNCONTROLLED HYPERTENSION (BP180/110 mmHg) History of PRIOR CVD or known INTRACEREBRAL PATHOLOGY Current use of ANTICOAGULANTS ( INR2-3 ) Known BLEEDING DIATHESIS RECENT TRAUMA (Within 2-4 WKS) Including head injury NONCOMPRESSIBL
26、E VASCULAR PUNCTURES,LCC,No benefit harmful,20%40% Decreased mortality,Non-ST segment elevation ACS,ST segment elevation ACS,Plaque rupture,ACS,Thrombolysis,LCC,THROMBUS,PLATELET,Antiplatelet therapy -aspirin -clopidogrel -GP IIb/IIIa inhibitors -persantin -ticlopidine,Thrombin,Antithrombin therapy
27、-heparin,Fibrin,Plasminogen Activators -t-PA R-PA SK TNK-tPA,LCC,Adhesion,Platelets Role in thrombosis,Aggregation,1,Activation,2,3,GP IIb/IIIa Inhibitors,1. Platelet Adhesion,2. Platelet Activation,Platelet,GP Ib,Plaque rupture,3. Platelet Aggregation,ASA, Clopidogrel/Ticlopidine,TxA2,Platelets Rol
28、e in Thrombosis,Acts by selective inhibition of ADP binding to its platelet receptor and prevents subsequent platelet aggregation,ADP,ADP,Fibrinogen Binding Site,Clopidogrel,Clopidogrel,Fibrinogen Binding Reduced,Fibrinogen,Platelet,LCC,Clopidogrel mechanism of action,Platelet aggregation,Inhibition
29、 of aggregation by GP IIb/IIIa inhibitors,LCC,Thrombin Serotonin Epinephrine Collagen,Activation,Activated Platelet,COX,Degranulation,Gp IIb/IIIa fibrinogen receptor,To neighboring platelet,Clopidogrel Ticlopidine,THROMBUS,PLATELET,Antiplatelet therapy -aspirin -clopidogrel -GP IIb/IIIa inhibitors -
30、persantin -ticlopidine,Thrombin,Antithrombin therapy -heparin,Fibrin,Plasminogen Activators -t-PA R-PA SK TNK-tPA,LCC,Unfractionated heparin Low molecular weight heparin Enoxaparin Dalteparin Nadroparin Direct Thrombin inhibitors Hirudin Bivalirudin warfarin,LCC,Antithrombotic Treatment,Sites of Ant
31、i-thrombotic Drug Action,Tissue factor,Plasma clotting cascade,Prothrombin,Thrombin,Fibrinogen,Fibrin,Thrombus,Platelet aggregation,Conformational activation of GPIIb/IIIa,Collagen,Thromboxane A2,ADP,AT,AT,Factor Xa,Coagulation cascade,Platelet cascade,MONA Morphine 靜脈注射 Oxygen 4L/min Nitroglycerine
32、 舌下錠或噴劑 Aspirin 160-325mg,急性心肌梗塞 胸痛,LCC,急性心肌梗塞 Morphine,解除胸痛 鎮靜 減少焦慮 每5-10分鐘 靜脈注射2-4mg,低血壓 病人平躺 補充生理食鹽水液 呼吸抑制 Naloxone 0.4mg IV 每三分鐘注射一次可重複三劑量,LCC,Management non-ST segment elevation ACS,Very high 15%,intermediate 38%,Very high 815%,Death MI,Aspirin heparin GP IIb/IIIa Urgent cath Clopidogrel prior
33、PCI,Aspirin LMWH GP IIb/IIIa Clopidogrel Coronary angio,Aspirin LMWH Ischemia- guided Rx,LCC,ACC/AHA UA/NSTEMI Guidelines Recommendations for Long-term Medical Therapy,Class I Aspirin 75 to 325 mg/day Clopidogrel 75 mg daily (in the absence of contraindications) when aspirin is not tolerated because
34、 of hypersensitivity or gastrointestinal intolerance The combination of aspirin and clopidogrel for 9 months after UA/NSTEMI -Blockers in the absence of contraindications Lipid-lowering agents and diet in post-ACS and postrevascularization patients with LDL-C 130 mg/dL Lipid-lowering agents if LDL-C
35、 level after diet is 100 mg/dL ACE inhibitors for patients with CHF, LV dysfunction (EF 0.40), hypertension, or diabetes,Management of ACS,Focal Rx of ruptured culprit lesion (stents). Systemic Rx to prevent future ischemic events. Risk factor modification + 5 drugs for long-term medical therapy to
36、treat: “Athero + thrombosis” Statins ASA ACE inhibitor Clopidogrel -blocker,?,LCC,心臟血管疾病的危險因素,Multiple Risk Factors,Lifestyle Smoking Diet Lack of exercise,Genetic Traits Gender PlA2,Generalized Disorders Age Obesity,Systemic Conditions Hypertension Hyperlipidemia Diabetes Hypercoagulable states Hom
37、ocysteinemia,Atherothrombotic Manifestations (MI, stroke, vascular death),Inflammation Elevated CRP CD40 Ligand, IL-6 Prothrombotic factors (F I and II) Fibrinogen,Local Factors Blood flow patterns Shear stress Vessel diameter Arterial wall structure % arterial stenosis,中性脂肪 增加,糖尿病,高血壓,肥胖,抽煙,運動 不足,壓
38、力 人格,痛風,LDL 增加,HDL 減少,高膽固 醇症,性別,家族 病史,遺傳,老化,血管狹窄,Plaque,LCC,怎樣生活不傷心 血脂肪,總膽固醇 :HDL-C 小于 5:1 不飽和脂肪酸 使血液凝塊較不易形成 全穀類 水果 蔬菜,食用油 不飽和脂肪酸 沙拉油 葵花油 豆油 膽固醇 每天的攝取量不超過 300 mg 蛋 壹星期內不超過 3-4個 肉類 魚 (深海魚類) 雞 (去皮),LCC,怎樣生活不傷心 抽煙,動脈血管硬化阻塞 心臟血管阻塞 腦血管阻塞 周邊血管阻塞 慢性阻塞性肺病 COPD 癌症,LCC,怎樣生活不傷心 抽煙,禁煙 1年 心臟病發作的危險性 減少 50%以上 禁煙 1
39、5年 心臟病發作的危險性 同一般正常人,LCC,怎樣生活不傷心 肥胖,身體的脂肪過多 BODY MASS INDEX: kg/m2正常 18.5-24.9 BMI OVERWEIGHT 25-30 BMI OBESITY 30 BMI,LCC,遺傳 文化背景 社交行為 生理 新陳代謝,怎樣生活不傷心 肥胖,高血壓 高血脂肪 糖尿病 冠狀動脈心臟病 腦中風 死亡率較高,膽結石 惡化關節炎 呼吸系統易生問題 子宮 乳房 前列腺 大腸等易生癌症,LCC,怎樣生活不傷心 肥胖,飲食治療 低熱量 低脂肪 運動治療 適當運動 30-45分鐘 3-5天/週 熱量消耗 500-1000 kcal/天,減輕體重
40、 6月內 10% 行為治療 藥物治療 外科手術,LCC,適當運動好處多,增加高密度脂蛋白膽固醇 (HDL-C) 降低血壓 血糖控制較佳 減輕體重及肥胖 較容易戒菸 骨骼 肌肉 關節 較 不易退化,較少發生大腸癌 減輕憂鬱及焦慮 對人生感覺較良好及較有信心 預防心臟病發作 減少死亡率,LCC,ACC/AHA UA/NSTEMI* Guideline Update: Risk Factor Modification,Class I Smoking cessation Achieving optimal weight Daily exercise AHA diet BP control to 130 mg/dL Lipid-lowering agent if LDL-C after diet is 100 mg/dL A fibrate or niacin if HDL-C 40 mg/dL,心臟病六大害,高血壓 糖尿病 高血 脂 抽煙 肥胖 缺乏適當運動,LCC,LCC,保護心臟,預防 才是最好的 治療,LCC,再,再,見,見,