1、(优选)留学生心绞痛1 Brief IntroductionCoronary heart disease Teatment of Angina Pectoris:1. Dilation of blood vessels2. Reducing blood lipid level3. Reducing blood glucose level4. Antithrombosis5. Anti-painContractilityHeart RateCardiac Wall TensionPreload and Afterload1. Beta-Blockers2. Glyceryl trinitrate
2、 3. L-CB Anti-angina pectoris AgentsCoronary heart disease prescription:Nitrate estersAntihypertensive agentsAntilipemic agents 2 Nitrate Vasodilator 1. In blood vessel wall, GTN produce NO with the help of mitochondrial aldehyde dehydrogenase (mtALDH)2. NO induce dilation of blood vessels3. Over do
3、se / long time administration of GTN also can induce active oxygen and induce tolerance. Blood vessel dilation mechanismGTN:Glyceryl NitratePETN:pentaerythrityl tetranitrate ISDN :isosorbide dinitrate ISMN :isosorbide-5-mononitrate Soluble guanylyl cyclase (sGC) is the only known receptor for NO. It
4、 is soluble, i.e. completely intracellular. It is most notably involved in vasodilation. In humans, it is encoded by the genes GUCY1A2, GUCY1A3, and GUCY1B3Effects of GTN1. To lower the oxygen demand of the heart2. To dilate coronary artery and increase the ischemia area blood irrigation3. To decrea
5、se the left ventricular endocardial pressure, increase the endocardial blood supply and improve the adaptability of the left ventricle4. To protect ischemic cardiac cells: NO-induced PGI2 and calcitonin gene-related peptides(CGRP)5. Anti-arrythmia and Inhibition of platelet aggregationBefore GTNAfte
6、r GTNIschemic zoneNormal zonePharmacokinetics of GTN 1. High lipophilic property2. Extensive first-pass effects for P.O.: If sublingual route, F is 80%, the onset of action is 1 to 2 minutes, and the duration of action is 20 to 30 minutes. INDICATIONS OF GTN1. Acute angina pectoris attack2. Prophyla
7、xis of angina pectoris GTN patches, ointment 3. Acute myocardial infarction 4. Congestive heart failure Isosorbide Dinitrate( (消心痛)消心痛)Isosorbide Mononitrate(异乐定)(异乐定)1. Angina Prevention2. Heart Failure TreatmentP.O.Weak Tolerance医大一院有大夫:高血压合并心绞痛,医大一院有大夫:高血压合并心绞痛, 异乐定异乐定 + + 福新普利?福新普利?Ads of GTN1.P
8、ostural hypotension2.Reflex tachycardia3.Throbbing headache4.Flushing, Dizziness5.High Intracerebral/Intraocular Pressure6.Tolerance目前常用于心绞痛的药物:目前常用于心绞痛的药物:异乐定(欣康,硝酸酯类)异乐定(欣康,硝酸酯类)消心痛(硝酸酯类)消心痛(硝酸酯类)心痛定(硝苯地平)心痛定(硝苯地平)圣通平(硝苯地平缓释)圣通平(硝苯地平缓释)拜新同(拜新同(硝苯地平控释)硝苯地平控释)波依定(非洛地平)波依定(非洛地平)络活喜(氨氯地平)络活喜(氨氯地平)司乐平(
9、拉西地平)司乐平(拉西地平)异搏定(维拉帕米)异搏定(维拉帕米)比索洛尔(比索洛尔(Beta1阻滞剂,选择性最高)阻滞剂,选择性最高)贝他乐克(贝他乐克(Beta1阻滞剂)阻滞剂)阿替洛尔(阿替洛尔(Beta1阻滞剂)阻滞剂)心得安(心得安(Beta阻滞剂)阻滞剂)蒙诺(蒙诺(ACEI,福新普利),诺迪康(藏药),福新普利),诺迪康(藏药)万爽力(新型药物,改变心肌代谢)万爽力(新型药物,改变心肌代谢)The current commonly used in angina medicine:Xinkang, nitratesIsosorbide dinitrate (nitrate)Nifed
10、ipine Nifedipine( slow-release)Nifedipine (controlled-release)Felodipine)AmlodipineLacidipineVerapamil Bisoprolol (Beta1 blockers, the highest selectivity)Betaloc (Beta1 blocker)Atenolol (Beta1 blocker)Propranolol (Beta blocker)Fosinopril (ACEI), Nuodikang (Medicine)Trimetazidine ( changes in myocar
11、dial metabolism)Bisoprolol ( Bisoprolol, Beta1 blockers, high selectivity )Metoprolol ( Beta1blockers )Atenolol ( Beta1 blockers )Propranolol ( Beta blockers )3 Beta-R Blockers 1. To lower heart rate, V-pressure and contractility2. To slow fat decomposition3. To increase V-volume 4. To contract coro
12、nary arteries( Propranolol) -blockers is effective against the stable angina pectoris not in variant angina pectoris. 和硝酸之类的区别?和硝酸之类的区别?For Angina Pectoris:Beta Blockers + GTN?Contraindications of Beta-Blockers: 1. Asthma2. Heart Failure3. Bradycardia4. Hyperlipidemia5. Variant Angina4 Ca2+ Channel
13、Blockers 1. Reduction of myocardial oxygen demand? 2. Dilation of coronary vessels 3. Protection of ischemic myocardial cell4. Inhibition of platelet aggregation 1. Nifidipine: variant angina2. Nifedipine + -blockers?3. Verapamil, diltiazem: variant, stable, and unstable angina pectoris. Summary 1.
14、Acute attacks of angina are treated with: Sublingual nitrates Nifedipine 2. Acute anginal pain is treated with morphine 3. Stable angina is treated with Long-lasting nitrates -adrenergic receptor blockers Ca2+ channel blockers 4. Unstable angina is treated with: Aspirin Heparin 疏血通,金纳多等疏血通,金纳多等病例病例
15、高血压合并心绞痛高血压合并心绞痛一职业高中教师,男一职业高中教师,男7676岁(退休)。当年岁(退休)。当年4545岁时候,岁时候,患高血压,主要靠复方降压片治疗。随着时间的推移,患高血压,主要靠复方降压片治疗。随着时间的推移,药物逐渐失效,并患有冠心病。某药物逐渐失效,并患有冠心病。某“地方小医院地方小医院”处处方卡托普利、复方降压片(北京方卡托普利、复方降压片(北京0 0号类似)和心痛定号类似)和心痛定(硝苯地平片)。后来发生脑梗塞,经治疗,基本恢(硝苯地平片)。后来发生脑梗塞,经治疗,基本恢复。最近感到头疼,血压升高,来到中国医大一院心复。最近感到头疼,血压升高,来到中国医大一院心血管内
16、科。患者及其家属,告诉大夫上述降压药物已血管内科。患者及其家属,告诉大夫上述降压药物已经使用多年,效果不理想,希望换药。大夫将如何处经使用多年,效果不理想,希望换药。大夫将如何处方?方?早晨:替米沙坦(早晨:替米沙坦(35h),阿替罗尔(),阿替罗尔(24h)晚上:贝尼地平(晚上:贝尼地平(24h,抗心绞痛),小剂量阿司匹林(间隔半小时),抗心绞痛),小剂量阿司匹林(间隔半小时),饭后。你认为处方是否合理,为什么?饭后。你认为处方是否合理,为什么?复方降压片:复方降压片:本品为复方制剂,其成分为每片含:利血平本品为复方制剂,其成分为每片含:利血平0.032mg0.032mg,氢氯噻嗪氢氯噻嗪3
17、.1mg3.1mg,维生素,维生素B61.0mgB61.0mg,混旋泛酸钙,混旋泛酸钙1.0mg1.0mg,三硅酸镁三硅酸镁30mg30mg,氯化钾,氯化钾30mg30mg,维生素,维生素B11.0mgB11.0mg,硫酸,硫酸双肼屈嗪双肼屈嗪4.2mg4.2mg,盐酸异丙嗪,盐酸异丙嗪2.1mg2.1mg,辅料适量。,辅料适量。 患者女性,患者女性,8282岁,有典型的劳力型心绞痛发作史,口含硝岁,有典型的劳力型心绞痛发作史,口含硝酸甘油均可以迅速缓解。患者于酸甘油均可以迅速缓解。患者于20062006年年7 7月月1515日日5 pm5 pm呕血呕血约约400 ml400 ml后突发心前区
18、剧烈疼痛,经查是胃底静脉曲张破后突发心前区剧烈疼痛,经查是胃底静脉曲张破裂,查心电图示:心房纤颤,伴快速心室率,普遍导联裂,查心电图示:心房纤颤,伴快速心室率,普遍导联STST压低,反复含服硝酸甘油无效,即刻输血压低,反复含服硝酸甘油无效,即刻输血800 ml800 ml后患者心后患者心前区疼痛症状缓解,复查心电图示:窦性心律,心肌缺血前区疼痛症状缓解,复查心电图示:窦性心律,心肌缺血较前好转。患者病情稳定后于较前好转。患者病情稳定后于20062006年年7 7月月2727日出院。出院日出院。出院后随访后随访3 3个月,患者未再发呕血及出现持续剧烈心绞痛症个月,患者未再发呕血及出现持续剧烈心绞
19、痛症 。硝酸甘油为何无效?硝酸甘油为何无效?止血剂的应用:止血剂的应用:酌情选用安络血止血敏或止血芳酸,加入补酌情选用安络血止血敏或止血芳酸,加入补液中滴注;液中滴注;自胃管灌注浓度为自胃管灌注浓度为80mg80mgL L去甲肾上腺素或凝血酶;去甲肾上腺素或凝血酶;胃镜下局部止血可选用喷洒止血剂,如胃镜下局部止血可选用喷洒止血剂,如80mg80mgL L去甲肾上腺素或去甲肾上腺素或凝血酶;或者注射止血剂,如凝血酶;或者注射止血剂,如1 12mg2mg肾上腺素加入肾上腺素加入1010盐水盐水10ml10ml,作分点注射;或高频电凝止血;或微波止血;或激光止血。作分点注射;或高频电凝止血;或微波止
20、血;或激光止血。 病例病例女女,68,68岁岁. .因劳累、情绪波动等诱因致心绞痛发作入院因劳累、情绪波动等诱因致心绞痛发作入院. .经经过检查过检查, ,诊断为高血压病诊断为高血压病期、冠心病、不稳定型心绞痛期、冠心病、不稳定型心绞痛. .予抗凝、扩张冠状动脉、降压等药物治疗予抗凝、扩张冠状动脉、降压等药物治疗, ,病情好转病情好转. .于第于第3 3日晨患者进食油条时突然出现胸闷、气短、心前区针刺日晨患者进食油条时突然出现胸闷、气短、心前区针刺样疼痛样疼痛, ,被迫停止进餐被迫停止进餐. .急查心电图急查心电图:、aVFaVF导联中导联中T T波压低波压低,S-T,S-T段斜形下移段斜形下移, ,心率心率54/min54/min,确诊为心绞痛发作。,确诊为心绞痛发作。如何用药物治疗?如何用药物治疗?即给予吸氧、吗啡静脉注射、舌下含服速效救心丸即给予吸氧、吗啡静脉注射、舌下含服速效救心丸1010粒等粒等治疗治疗,4,4分钟后缓解分钟后缓解. .之后连续之后连续2 2日均在进食馒头、馄饨过程日均在进食馒头、馄饨过程中出类似症状中出类似症状. .改流质膳食配合治疗后改流质膳食配合治疗后, ,心绞痛未再发作心绞痛未再发作,1,1周后出院周后出院