1、 Coronary Artery Disease 冠状动脉疾病冠状动脉疾病Coronary Artery DiseasenAtherosclerosis动脉粥样硬化动脉粥样硬化is often referred to as“hardening of the arteries”.Although this condition can occur in any artery in the body,the atheromas血管硬化血管硬化(fatty deposits)have a preference for the coronary arteries.nAteriosclerotic Hea
2、rt Disease(ASHD)动脉粥样硬化性心脏病动脉粥样硬化性心脏病,Cardiovascular Heart Disease(CHD)心血管心脏病心血管心脏病,and Coronary Artery Disease(CAD)冠状动脉疾病冠状动脉疾病are synonymous terms used to describe this disease process.Etiology and pathophysiology病因和病理生理病因和病理生理 nAtherosclerosis动脉粥样硬化动脉粥样硬化is the major cause of CAD.n It is character
3、ized by a focal deposit of cholesterol胆固醇胆固醇and lipids血脂血脂,primarily within the intimal wall of the artery.nThe concept of endothelial injury内皮损伤内皮损伤is central to current theories of atherogensis.nThe genesis of plague斑块斑块 formation is the result of complex interactions between the components of the
4、 blood and the elements forming the vascular wall.Etiology and pathophysiology病因和病理生理病因和病理生理 Development stages 发展过程发展过程nCAD takes many years to develops.When it becomes symptomatic,the disease process is usually well advanced.nThe states of development in atherosclerosis are:Fatty streak脂肪条纹脂肪条纹Rai
5、sed fibrous plaque resulting from smooth muscle cell proliferation纤维斑块增加纤维斑块增加Complicated lesion复杂病变复杂病变Risk factors风险因素Three most significant risks are:elevated serum lipids血脂血脂,hypertension and cigarette smoking.Risk factors can be categorized as unmodifiable and modifiableUnmodifiable factors:nAg
6、e,gender and racenFamily history and heredityModifiable major risk factorsnElevated serum lipids血脂nHypertensionnSmokingnPhysical inactivityModifiable minor risk factorsnObesitynDiabetes mellitus糖尿病nStress and behavior patterns Health promotion and maintenance健康促进和维护nIdentification of high-risknManag
7、ement of high-risknPhysical fitnessnHealth educationnNutritional management nPharmacologic managementDrugs that increase lipoprotein removalDrugs that restrict lipoprotein productionClinical manifestation of CAD临床表现There are three major clinical manifestation of CAD:n angina心绞痛心绞痛n acute MI心肌梗死心肌梗死n
8、 sudden cardiac death猝死猝死Angina pectoris心绞痛nMyocardial ischemia心肌缺血心肌缺血is expressed symptomatically as angina心绞痛心绞痛.More specifically,angina pectoris is transient短暂短暂的的chest pain caused by myocardial ischemia心肌缺血心肌缺血.nAngina usually lasts for only a few minutes(3 to 5 minutes)and commonly subsides解除
9、解除when the precipitating factor(usually exertion)is relieved.Pathophysiology of Angina pectoris病理生理病理生理nMyocardial ischemia develops when the demand for myocardial oxygen exceeds the ability of the coronary arteries to supply it.nThe primary reason for insufficient flow is narrowing of coronary arte
10、ries by atherosclerosis.nFor ischemia as a result of atherosclerosis to occur,the artery is usually 75%or more stenosed狭窄狭窄.Pathophysiology of Angina pectoris病理生理病理生理nWith the total occlusion of the coronary arteries,contractility ceases after several minutes,depriving the myocardial cells of glucos
11、e葡萄糖for aerobic metabolism有氧代谢.nAnaerobic metabolism无氧代谢 begins and lactic acid乳酸accumulates.nMyocardial nerves fibers are irritated by the increased lactic acid and transmit a pain message to the cardiac nerves and upper thoracic posterior roots上部胸椎神经后根(the reason for referred cardiac pain to the l
12、eft shoulder and arm).Precipitating factors激发因素 Extracardiac factors my precipitate myocardial ischemia and anginal pain including:nPhysical exertionnStrong emotionnConsumption of a heavy mealnTemperature extremesnCigarette smokingnSexual activitynStimulantsnCircadian rhythm patterns 昼夜节律模式Types of
13、angina 1.Stable angina稳定型心绞痛稳定型心绞痛nStable angina(classic)refers to chest pain occurring intermittently间歇性间歇性over a long period with the same pattern of onset,duration,and intensity of symptoms.nStable angina is usually exercise induced.Pain at rest is unusual.nAn ECG usually reveals ST segment depre
14、ssion ST段压低，段压低，indicating subendocardial ischemia.nStable angina can be controlled with medications on an outpatient basis.Medication can be timed to provided peak effects during the time of day when angina is liking to occur.Types of angina 2.Unstable angina不稳定型心绞痛不稳定型心绞痛nUnstable angina(progressi
15、ve进展的进展的,cresendo渐强的渐强的,or preinfarction angina心肌心肌梗死前心绞痛梗死前心绞痛)may be the first manifestation of CAD.nThe patient with previously diagnosed stable angina will describe a significant change in the pattern of angina.It will be occurring with increasing frequency,easily provoked by minimal or no exerc
16、ise,during sleep or even at total rest.Types of angina 3.Prinzmetals angina 变异型的心绞痛变异型的心绞痛nPrinzmetals angina(variant angina),is a rare form of angina,often occurs at rest,usually in response to spasm of a major coronary artery.nFactors precipitate coronary spasm includes increased myocardial oxygen
17、 demand and increased levels of a variety of substances(e.g.,histamine组胺组胺,angiotensin血管紧张素血管紧张素,epinephrine肾上腺素肾上腺素,norepinephrine去甲肾上腺素去甲肾上腺素,prostaglandins前列腺素前列腺素)nWhen spasm occurs,the patient experience pain and marked,transient ST segment elevation.nThe pain may occur during rapid eye movemen
18、t(REM)sleep快快速眼动睡眠速眼动睡眠 when myocardial oxygen consumption increases.Cyclical周期性的周期性的,short bursts of pain at a usual time each day may also occur with this type of angina.Clinical manifestation临床表现 nThe most common initial symptom is chest pain or discomfort.Patient may had a vague sensation,an unp
19、leasant feeling,often described as a constrictive缩窄缩窄,squeezing压缩压缩,heavy,choking,or suffocating sensation.nAlthough most of the person with angina experience discomfort substernally,the sensation may occur in the neck or radiate放射放射to various locations including jaw下巴下巴,shoulders and down the arms.
20、Often people will complaint of pain between the shoulder blades肩胛骨之间肩胛骨之间and dismiss it as not being heart pain.nAssociated symptoms may includes:shortness of breath,cool sweat,weakness,or paresthesia 感觉异常感觉异常 of the arm(s).nRelief of classic angina is usually obtained with rest or cessation of acti
21、vity.Diagnostic studies辅助检查辅助检查nChest X-raynSerum lipidnCardiac enzyme valuesnECGnNuclear imagingnAngiographynEchocardiography Emergency management chest pain1.Establish and maintain airway2.Administer oxygen by nasal cannula if not in respiratory distress;otherwise use high flow(100%)by nonbreather
22、 mask.Anticipate need for intubation if respiratory distress evident3.Start 2 IV lines with large-gauge needles4.Remove clothing;comfort and reassure patient5.Monitor cardiac rate and rhythm;monitor vital signs including level of consciousness6.Be prepared to perform cardiopulmonary resuscitation心肺复
23、苏,defirbillation电除颤,external pacing or cardioversion外部起搏或电复律7.Assess severity and location of pain,medicate for pain as order8.Assess for indications and contraindications for thrombolytic therapy9.Prepare to initiate thrombolytic therapy溶栓治疗溶栓治疗if indicatedTherapeutic management Pharmacologic manag
24、ement药理管理nAntiplatelet aggregation therapy抗血小板聚集治疗:is the first line of pharmacologic intervention in the treatment of angina.Aspirin阿司匹林阿司匹林is the drug of choice.nNitrates硝酸盐:which are commonly classified as vasodilators,are the next step in the treatment of angina.Nitroglycerin硝酸甘油硝酸甘油:it is given
25、 sublingually for acute angina attacks,usually relieve pain in approximately 3 minutes and has a duration of approximately 20 to 45 minutes.Nitrates produce their principle effects by the following:nDilating peripheral blood vesselsnDilating coronary arteries and collateral侧支侧支vesselsPharmacologic m
26、anagementNitrates硝酸盐硝酸盐nThe usual recommended dose is 1 tablet taken sublingually(SL)舌下舌下,which can be followed at 5-minute intervals with two more doses.If relief from anginal pain has not been obtained after 3 tables and 15 minutes,the patient should be instructed to seek medical attention.nThe pr
27、edominant side effect of nitrate drugs is headache from the dilatation of cerebral blood vessels.nOther complications of the vasodilator drugs are orthostatic hypotension体位性低血压体位性低血压(nitrate syncope硝酸晕厥硝酸晕厥)and an aggravation of cerebral vascular insufficiency.Thus,monitor BP and pulse prior to long
28、-acting nitrates administration(if BP is 30 mm Hg below baseline or 90 mm Hg,withhold medication and notify the doctors)。Nitrates硝酸盐硝酸盐nThe patient needs to be instructed in the proper use of sublingual nitroglycerin1.It should be easily accessible to the patient at all time.2.For protection from de
29、gradation退化,it should be kept in a tightly closed dark glass bottle with metal caps.3.The patient should be instructed to place a nitroglycerin table beneath the tongue and allow it to dissolve.This should cause a fizzing or slightly warm feeling locally.4.The patient should be warned that HR may in
30、crease and a pounding headache,dizziness头晕,or flushing脸红may occur.5.The patient should be cautioned against quickly rising to a standing position because postural hypotension may occur after nitroglycerin ingestion.6.if the pain has not been relieved after 5 minutes,the patient should be told to tak
31、e another nitroglycerin tablet.This procedure may be repeated for pain relief every 5 minutes,not to exceed the ingestion of 3 tablets.If pain persist after three doses,the patient should seek immediate medical treatment.Therapeutic management Pharmacologic management n-adrenergic blocking agents:pr
32、opranolol普奈洛尔,metoprolol美托洛尔,nadolol钠多洛而,atenolol阿替洛尔.nThese drugs produce a direct decrease in myocardial contractility,HR,SVR and BP,all of which reduce the myocardial oxygen demand.nSide effect of these drugs includes brachycardia心动过缓,hypotension,wheezing and GI complaints,weight gain,depression
33、and sexual dysfunction.nThe-adrenergic blockers should not be discontinued abruptly without medical supervision.Pharmacologic managementnCalcium-channel blocking agents:nifedipine硝本地平硝本地平,verapimil维拉帕米维拉帕米,diltiazem地尔硫卓地尔硫卓 and nicardipine 尼卡地平尼卡地平are the next step in the management of angina.nThe t
34、hree primary effects of these drugs are:Systemic vascular vasodilatation with decreased SVRDecreased myocardial contractilityCalcium-channel blockersnCalcium-channel blockers have a depressant effect on the sinoatrial(SA)node窦房结rate of discharge and the conduction velocity传导速度through AV node房室结is de
35、creased,thus slowing the HR.n Calcium-channel blocking agents地高辛potentiate the action of digoxin地高辛by increasing serum digoxin levels during the early part(first week)of therapy.Therefore serum digoxin levels should be closely monitored upon institution of this therapy,and the patient should be taug
36、ht the signs and symptoms of digoxin toxicity洋地黄中毒.Nursing diagnosis护理诊断 nPain related to ischemia myocardiumnAnxiety related to diagnosis and awareness of being a vitim of heart disease,pain and limited activity tolerance,uncertainties about the future,diagnostic tests,pending surgerynDecreased CO
37、related to myocardial ischemia affecting contractilitynActivity intolerance related to myocardial ischemiaAcute intervention1.Establish and maintain airway2.Administer oxygen by nasal cannula if not in respiratory distress;otherwise use high flow(100%)by nonbreather mask.Anticipate need for intubati
38、on if respiratory distress evident3.Start 2 IV lines with large-gauge needles4.Remove clothing;comfort and reassure patient5.Monitor cardiac rate and rhythm;monitor vital signs including level of consciousness6.Be prepared to perform cardiopulmonary resuscitation心肺复苏,defirbillation电除颤,external pacin
39、g or cardioversion外部起搏或电复律7.Assess severity and location of pain,medicate for pain as order8.Assess for indications and contraindications for thrombolytic therapy9.Prepare to initiate thrombolytic therapy溶栓治疗溶栓治疗if indicatedChronic and home managementnThe patient needs to be reassured that a long,pr
40、oductive life is possible.nThe patient needs to be educated regarding CAD and angina,precipitating factors,risk factors,and medication.nEducating the patient and the family about diets that are low in sodium and reduced in saturated fat may be appropriated.nIts important to educate the patient and their family in the use of nitroglycerin.Nitroglycerin硝酸甘油片硝酸甘油片tablets or ointments may be used prophylactically预防预防before an emotionally stressful situation,sexual intercourse or physical exertion.
