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1、Coronary Atherosclerotic Heart Disease (CHD),Definition,Coronary atherosclerotic heart disease: Coronary heart disease: Ischemic heart disease:,Clinical Type,Silent myocardial ischemia Angina pectoris Myocardial infarction Ischemic cardiomyopathy Sudden cardiac death,Silent Myocardial Ischemia,Defin
2、ed as documented episodes of ischemia not associated with any typical or atypical symptoms that among patients with obstructive coronary artery disease. Type I: myocardial ischemia is detected on routine ECG, 24h ambulatory ECG monitoring (Holter), etc. but not experience angina at any time; Type II
3、: patients are most frequently encountered in clinical practice. Some episodes of ischemia are associated with chest discomfort and other episodes are asymptomatic.,Ischemic Cardiomyopathy,Symptoms of heart failure, caused by ischemic myocardial dysfunction (hibernation), diffuse fibrosis, and multi
4、ple infarction, alone or in combination. Manifestations: ventricles enlargement (dominant left ventricle), heart failure and arrhythmias.,Sudden Cardiac Death,SCD is natural death due to cardiac causes, heralded by abrupt loss of consciousness within 1 hours of the onset of acute symptoms. The time
5、and mode of death are unexpected. WHO definition: unexpected death within 6 hours. This definition incorporates the key elements of natural, rapid and unexpected. One half of SCD due to coronary heart disease，caused by severe arrhythmias, such as ventricular fibrillation and cardiac arrest.,Acute Co
6、ronary Syndromes（ACS）,ACS represents a spectrum of conditions: including: acute MI, unstable angina and sudden cardiac death. Acute plaque change characterized by plaque rupture and exposure of substances that promote platelet activation and thrombin generation.,Risk Factor,Age, gender and family hi
7、story Hypertension Dislipidmia Diabetes mellitus Tobacco use Obesity,Candidate Risk Factor,Homocystein Fibrinogen LP(a) Fibrinolytic activity（tPA） Plasminogen activator inhibitor（PAI） C reactive protein Coagulation factor Estrogens Alcohol Type A personality and stress,Angina Pectoris,Definition：,A
8、clinical syndrome due to myocardial ischemia characterized by episodes of precordial discomfort or pressure, typically precipitated by exertion and relieved by rest or sublingual nitroglycerin.,Coronary arterial stenosis Coronary arterial spasm Myocardial oxygen consumption ,Mechanism and Pathophysi
9、ology,心绞痛发生机制,心肌缺血缺氧,酸性或肽类物质,刺激心脏植物神经传入纤维,15胸交感神经节及相应脊髓段,大脑,疼 痛,牵涉痛发生机制,胸骨后、两前臂内侧及小指（左侧多见）疼痛,反映在1-5胸交感神经节相应脊髓段脊神经,Clinical Presentation:,Episodes of chest pain： Location Character Trigger Duration Relieve,Symptom:,In general, no abnormal sign HR 、BP S3、S4 gallop Apical systolic murmur,Clinical Prese
10、ntation:,Signs:,Electrocardiogram,ECG at rest ECG at episodes of chest pain Exercise ECG Ambulatory ECG monitoring (Holter),ECG at Episodes of chest pain,Coronary Angiography,1、 心绞痛无法确诊者。 2、对内科治疗中心绞痛仍较重者，明确动脉病变情况以考虑介入治疗或旁路移植手术。 3 、冠脉痉挛行麦角新碱试验。,Other Diagnostic Testing,心脏X线检查 放射性核素检查 二维超声心动图 血管镜,Clin
11、ical Type of Angina,劳累性心绞痛 stable angina pectoris initial onset angina pectoris accelerated angina pectoris 自发性心绞痛 angina decubitus Prinzmetals variant angina pectoris acute coronary insufficiency postinfarction angina pectoris 混合型心绞痛,Stable angina pectoris Unstable angina pectoris,Typing by stabili
12、ty or quiescence of an atherosclerotic plaque:,Clinical Type of Angina,Classification of Angina,Class：ordinary physical activity does not cause angina Class ： slight limitation of ordinary physical activity Class ：marked limitation of ordinary physical activity Class ：inability to carry on any activ
13、ity without discomfort,Canadian Class:,Differential Diagnosis,心脏神经官能症 急性心肌梗塞 其它疾病引起的心绞痛 消化道疾病 呼吸系统引起的胸痛 心包疾病,Therapy of Angina,Medical therapy Percutaneous transluminal coronary angioplasty (PTCA) Coronary artery bypass grafting （CABG）,Platelet inhibitors： Aspirin、ticlipidine、clopidogrel Nitrates -b
14、lockers Calcium channel blockers Lipid-lowering agents 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) (statin) fibrate,Therapy of Angina,Pharmacologic therapy:,阿司匹林 抑制环氧酶，阻止花生四烯酸转化为前列腺素G2、前列腺素H2，使血小板合成血栓素A2(TXA2)减少，抑制血小板的聚集和释放。剂量：0.050.3/天，长期服用。 噻氯匹啶(Ticlopidine,抵克力得) 机制不清，可能与ADP介导的血小板聚集有关。剂量：0.250
15、.5/天，长期服用。 氯吡格雷(Chlopidogrel) 与抵克力得类似，但起效快、作用更强，没有降低白细胞之副作用。剂量：75mg/天，长期服用。,Pharmacologic therapy,硝酸酯类 机理：扩张冠脉。 扩张周围血管，特别是静脉，减少回流及缩小心脏。同时降低血压，从而降低心肌耗氧量。 制剂及用法： 硝酸甘油片（0.6mg/片）、消心痛（10mg/片）、5单硝酸异山梨醇酯（20mg、50mg、60mg/片），含化或口服（13次/日）。尚有气雾剂、贴剂及注射剂。 副作用：头痛、颜面潮红、血压下降。,Pharmacologic therapy,阻滞剂 机理：降低心率及心肌收缩力，
16、而减低心肌耗氧量。因可诱发冠脉痉挛，仅适用于劳累型心绞痛。 剂型及用法：普奈洛尔（心得安，Propranolol),10mg/片，1040mg.tid.。 心脏1受体选择性阻滞剂： 美托洛尔（Betaloc,倍它乐克），25、50mg/片，2550mg，tid.。 阿替洛尔（Atenolol,氨酰心安），25mg/片，25mg,bid.。 副作用：心动过缓、诱发或加重心衰、支气管痉挛、血压下降。,Pharmacologic therapy,钙拮抗剂:主要用于自发型心绞痛（变异型） 机理：抑制Ca+进入细胞内，也抑制心肌细胞兴奋收缩耦联中Ca+的利用。 作用：扩张冠脉、抑制心肌收缩力、扩张周围血
17、管（动脉）、降低血液粘度、抗血小板聚集、改善心肌微循环。 剂型及用法： 地尔硫卓（Diltiazem,合心爽、合贝爽），30、90mg/片，30mg,tid.，90mg,qd.，亦有注射剂。 韦拉帕米及硝苯吡啶很少使用。 副作用：抑制房室传导、诱发及加重心衰。,Pharmacologic therapy,Therapy of Angina,PTCA and stent CABG,Revascularization:,Acute Myocardial Infarction,Definition： The rupture of plaque leads to the coronary occlus
18、ion and blood flow interruption, the persistent ischemia results in myocardial necrosis .,Pathology,The role of acute plaque changes,Pathology,Pathology,Occlusive coronary thrombosis: 20-30min necrosis 1-2h coagulation necrosis and myocytolysis 1-2w fibrosis 6-8w connective tissue scar Transmural in
19、farction,subendocardial infarction Q-wave and non-Q-wave infarction rupture of free wall, interventricular septum, papillary muscle, aneurysm,Pathophysiology,Left ventricular function: dyssynchrony hypokinesis akinesis dyskinesis(paradoxical expansion) Ventricular remodeling: infarct expansion ventr
20、icular dilation,Pathophysiology,Pathophysiology,Symptoms,Prodromal symptoms Chest pain General symptoms Arrhythmias Hypotension and cardiac shock Gastrointestinal symptoms Heart failure,Signs,Cardiac signs： HR increase or decrease S1 S4 or S3 gallop Apical SM or/and mid and late systolic click， peri
21、cardial friction sound， hypotension Other signs：arrhythmias，heart failure，shock.,AMI Killip Heart Function Class,Class ：no heart failure Class ：left heart failure Class ：acute pulmonary edema Class ：cardiac shock,Complications,Dysfunction or rupture of papillary muscle Rupture of the heart Embolism
22、Cardiac aneurysm Postinfaction syndrome,ECG Diagnosis,1. Definitive ECG diagnosis 2. Dynamic evolvement of ECG 3. Localized diagnosis of MI,Definitive ECG diagnosis,Q-waves ST-segment elevation T-waves inversion,Dynamic Evolvement of ECG,Serial ECG findings: T-waves ST-segment elevation and Q-waves
23、elevated ST-segment return T-waves inversion,Localized Diagnosis of MI,Anterior septal MI： V1-V3 Anterior MI ： V2-V4 Large anterior MI： V1-V5 （V6） Lateral MI： I、avL Inferior MI： 、avF Posterior MI： V7、V8、V9 Right ventricular MI: V3R-V5R,Proximal Left Anterior Descending Artery Occlusion,Right Coronar
24、y Artery Occlusion,Left Circumflex or OM Artery LAD diagonal branch Artery,Acute Inferior MI,Acute Anterior MI,Old Inferior MI,Serum Markers of Cardiac Damage,Markers Initial Peak Return elevation to normal CK 6h 24h 3-4d CK-MB 6h 24h 3-4d cTnT/I 4-6h 14d,Serum Markers of Cardiac Damage,Diagnosis,Ch
25、aracterized chest pain Serum markers of cardiac damage ：cTnT/I Definitive ECG changes,Differential Diagnosis of AMI,Angina pectoris Acute pericarditis Myocarditis Acute aortic dissection Pulmonary embolism Acute cholecystitis,AMI Therapy,Objective：Limitation of infarct size prevent and treat complic
26、ations Nursing and general treatment Reperfusion Antiarrhythmics Shock treatment Management of heart failure Secondary prevention of AMI,AMI Therapy,Nursing and general treatment Reperfusion Antiarrhythmics Shock treatment Management of heart failure Secondary prevention of AMI,Relaxing Oxygen Monit
27、oring Nursing Chest pain Analgesics Nitrate Beta-blocker Aspirin,Nursing and general treatment,AMI Therapy,Reperfusion Thrombolysis Direct PTCA and Stent Direct CABG,Nursing and general treatment Reperfusion Antiarrhythmics Shock treatment Management of heart failure Secondary prevention of AMI,AMI
28、Therapy,Thrombolysis agents SK、UK、r-SK t-PA、r-tPA,Nursing and general treatment Reperfusion Antiarrhythmics Shock treatment Management of heart failure Secondary prevention of AMI,AMI Therapy,适应症 典型缺血性胸痛30min，含硝酸甘油无效 两个相邻胸前或肢导联ST段抬高0.1mv 6-12h内 75岁 无溶栓禁忌,Nursing and general treatment Reperfusion Ant
29、iarrhythmics Shock treatment Management of heart failure Secondary prevention of AMI,AMI Therapy,绝对禁忌症 2周内活动性内脏出血 主动脉夹层 长时间或创伤性心肺复苏 近期脑外伤或颅内肿物 BP200/120mmHg 出血性视网膜病或眼病 对扩容和升压药物无反应的休克 妊娠、SIE、心腔内有血栓者,Nursing and general treatment Reperfusion Antiarrhythmics Shock treatment Management of heart failure
30、Secondary prevention of AMI,AMI Therapy,相对禁忌症 近期外伤史或两周内手术史。 慢性严重高血压病史。 脑血管意外史。 6-9月内用过SK、r-SK、 tPA、r-tPA 不能重复用药,Nursing and general treatment Reperfusion Antiarrhythmics Shock treatment Management of heart failure Secondary prevention of AMI,AMI Therapy,常用药剂量及用法 尿激酶（UK） 尿中提取，半衰期16min。150万30min静点,再通率
31、60%. 低价，无抗原性。,Nursing and general treatment Reperfusion Antiarrhythmics Shock treatment Management of heart failure Secondary prevention of AMI,AMI Therapy,重组链激酶（r-SK）是由基因工程生产的溶栓药，再通率77.1%(?) 万min静点不良反应与U无显著差异。,Nursing and general treatment Reperfusion Antiarrhythmics Shock treatment Management of h
32、eart failure Secondary prevention of AMI,AMI Therapy,组织型纤溶酶原激活剂（tPA） 重组组织型纤溶酶原激活剂（rtPA） tPA是由血管内皮细胞等组织合成的一种丝氨酸蛋白酶半衰期5-8min，再通率高于U。 先静注10mg，继而1h内静点40mg，其后2h内再静点50mg国内亦有半量法，先静注10mg，然后90min内静点40mg,Nursing and general treatment Reperfusion Antiarrhythmics Shock treatment Management of heart failure Seco
33、ndary prevention of AMI,AMI Therapy,溶栓治疗效果评价 冠脉造影标准：（、级） 临床评价标准： 2小时内基本胸痛缓解 2小时内ST段降低50% 酶峰值提前 再灌注心律失常,Nursing and general treatment Reperfusion Antiarrhythmics Shock treatment Management of heart failure Secondary prevention of AMI,AMI Therapy,溶栓不良反应及处理 出 血： 轻度出血发生率5-10%,不需特殊处理.大量出血 发生率1-2%,需输新鲜血或血
34、浆及纤维蛋白原, 并停止溶栓. 过敏反应： 过敏反应发生率5%。严重反应少见，可用激素. 低 血 压： 低血压的发生率5-10%,多发生在下、后壁MI,并常 合并缓慢性心律失常.给于扩容及阿托品后可缓解, 严重者需加用多巴胺.,AMI Therapy,Adjuvant Therapy Antithrombotic therapy Antiplatlet therapy Nitrate eta-blocker ACEI Statin,AMI Therapy,Secondary prevention of AMI (A, B, C, D, E) A: Aspirin, ACE inhibitor B: -blocker, Blood pressure control C: Cholesterol-lowering, Cigarette-quitting D: Diet, Diabetes control E: Exercise, education,Nursing and general treatment Reperfusion Antiarrhythmics Shock treatment Management of heart failure Secondary prevention of AMI,