1、冠心病课件(大医英)动脉粥样硬化atherosclerosisIntroductionArteriosclerosis Thickening and loss of elasticity of arterial walls Hardening of the arteries Greatest morbidity and mortality of all human diseases via Narrowing Weakening Plaque That Has Been Surgically Removed from Coronary ArteryCourtesy Ronald D.Grego
2、ry and John Riley,MD.Non Modifiable Risk FactorsAge A dominant influence Atherosclerosis begins in the young,but does not precipitate organ injury until later in lifeGender Men more prone than women,but by age 60-70 about equal frequencyFamily History Familial cluster of risk factors Genetic differe
3、ncesModifiable Risk Factors(potentially controllable)Hyperlipidemia Hypertension Cigarette smoking Diabetes Mellitus Elevated Homocysteine Factors that affect hemostasis and thrombosis Infections:Herpes virus;Chlamydia pneumoniae Obesity,sedentary lifestyle,stress Pathogenesis of AtherosclerosisResp
4、onse to injury hypothesis Injury to the endothelium(dysfunctional endothelium)Chronic inflammatory response Migration of SMC from media to intima Proliferation of SMC in intima Excess production of ECM Enhanced lipid accumulationResponse to injuryEndothelia dysfunctionInitiation of Fatty StreakFatty
5、 StreakFibro-fatty AtheromaAdapted from Pepine CJ.Am J Cardiol.1998;82(suppl 104).From FirstDecadeFrom ThirdDecadeFrom FourthDecadeAHA Classification of atherosclerosis动脉粥样硬化血栓形成动脉粥样硬化血栓形成:具具共同病理基础的进展性过程共同病理基础的进展性过程正常正常脂肪条纹脂肪条纹纤维斑块纤维斑块 粥样硬化斑块粥样硬化斑块斑块破溃斑块破溃/裂隙和血栓形成裂隙和血栓形成心肌梗死心肌梗死 缺血性中缺血性中风风/TIATIA 严重
6、的严重的下肢缺血下肢缺血临床无症状临床无症状心血管死亡心血管死亡年龄增长年龄增长稳定性心绞痛稳定性心绞痛间歇性跛行间歇性跛行不稳定性不稳定性心绞痛心绞痛ACSACS*ACS,ACS,急性冠脉综合征急性冠脉综合征;TIA,;TIA,一过性脑缺血发作一过性脑缺血发作缺血性肾病缺血性肾病缺血性肠病缺血性肠病Coronary Artery Disease冠心病冠心病Clinical classification(1979 WHO)Asymptomatic CHD(隐匿型）隐匿型）Angina pectoris CHD（心绞痛型）（心绞痛型）Myocardial infarction CHD(心肌梗死型
7、）心肌梗死型）Ischemic cardiomyopathy CHD（缺血性心肌病型）（缺血性心肌病型）Sudden death CHD（猝死型）（猝死型）Classification of IHD Chronic ischemic syndrome:stable angina asymptomatic CHD ischemic cardiomyopathy CHD Acute coronary syndrome:unstable angina STEMI/NSTEMI急性冠脉综合症的病理生理学Fuster et al.N Engl J Med.1992;326:310-318.Davies
8、et al.Circulation.1990;82(Suppl II):II-38,II-46.ANGINA PECTORISDefinition of AnginaA pain or discomfort in the chest or adjacent areas caused by insufficient blood flow to the heart muscle.Clinical classification and pathology Stable angina:fixed atheromatous stenosis Unstable angina:dynamic obstruc
9、tion by plaque rupture with superimposed thrombosis and spasm斑块破裂引起急性严重事件不稳定斑块的进展过程不稳定斑块的进展过程稳定斑块的进展过程稳定斑块的进展过程Nissen SE.Am J Cardiol.2000;86(suppl):12H-17H不稳定斑块不稳定斑块斑块破裂斑块破裂血栓形成血栓形成稳定斑块稳定斑块斑块体积增加斑块体积增加管腔狭窄管腔狭窄Stable angina pectorisETIOLOGY.Ischemia is secondary to coronary artery disease in 95%of p
10、atients.The leading cause is certainly atherosclerotic coronary artery disease.A decreased oxygen supply or an increase in oxygen demand can lead to a worsening of symptoms.Ischemia can occur in patients with normal coronary arteries Clinical menifestationchest discomfortQuality-squeezing,griplike,p
11、ressurelike,suffocating and heavy”;or a discomfort but not pain.Angina is almost never sharp or stabbing,and usually does not change with position or respiration.Duration-anginal episode is typically minutes in duration.Fleeting discomfort or a dull ache lasting for hours is rarely anginaLocation-us
12、ually substernal,but radiation to the neck,jaw,epigastrium,or arms is not uncommon.Pain above the mandible,below the epigastrium,or localized to a small area over the left lateral chest wall is rarely anginal.Provocation-angina is generally precipitated by exertion or emotional stress and commonly r
13、elieved by rest.Sublingual nitroglycerin also relieves angina,usually within 30 seconds to several minutes.Categorize the Severity of AnginaCCS ClassificationClass 0 asymptomaticClass Ion strenuous activityClass IIon moderate activity 2 blocks or 2 flights of stairsClass IIIon mild activity 2 blocks
14、 or 2 flights of stairs Class IVrest or minimal activity Clinical features Physical examination An S4 gallop may be transiently present during an episode,and the patient may be dyspneic or diaphoretic or have a new heart murmur.High-risk features of angina include heart failure and hypotension.A com
15、plete physical exam is crucial in making an assessment of risk.Most pt:(-)Alternative Diagnoses to Angina for Patients with Chest PainNon-Ischemic CVaortic dissectionpericarditisPulmonarypulmonary emboluspneumothoraxpneumoniapleuritisChest Wallcostochondritisfibrositisrib fracturesternoclavicular ar
16、thritisherpes zosterGastrointestinalEsophagealesophagitisspasmrefluxBiliarycoliccholecystitischoledocholithiasischolangitisPeptic ulcerPancreatitisPsychiatricAnxiety disordershyperventilationpanic disorderprimary anxietyAffective disordersdepressionSomatiform disordersThought disordersfixed occlusio
17、nsInvestigation 12 Lead Resting ECG should be recorded in all patients with symptoms suggestive of angina pectoris normal in 50%of patients a normal ECG does not exclude severe CAD;however,it does imply normal LV function with favorable prognosisCHD CHD At rest:At rest:ECGECG冠心病冠心病 Episode of angina
18、:ST-segment Episode of angina:ST-segment depressiondepressionECGECGCHD CHD HolterHolterExercise testing Angina:Exercise TestingHigh Risk Patients Significant ST-segment depression at low levels of exercise and/or heart rate130 Fall in systolic blood pressure Diminished exercise capacity Complex vent
19、ricular ectopy at low level of exerciseExercise TestingContraindications MIimpending or acute Unstable angina Acute myocarditis/pericarditis Acute systemic illness Severe aortic stenosis Congestive heart failure Severe hypertension Uncontrolled cardiac arrhythmiasInvestigation Echocardiography.The s
20、tress echocardiogram is a widely performed test used to assess patients for coronary disease.Baseline echocardiographic images are obtained at rest to evaluate left ventricular function,wall motion,and valve function.Images are then acquired during peak stress(that is,during a GXT or with dobutamine
21、)and compared with those at rest.Regional wall-motion abnormalities with stress indicate areas of hypoperfusion or ischemia.Investigation Isotope scanning:obtaining scintiscans of the myocardium at rest and during stress after administration of an intravenous radioactive isotope such as thallium 201
22、Investigation Coronary angiography.Used to identify foci of coronary disease.It is the evaluation of choice in patients with angina that is(1)poorly responsive to medication,or(2)unstable.It is also indicated in patients with test results consistent with a high risk for CAD.冠心病冠心病 Coronary angiograp
23、hyCoronary angiography冠心病冠心病 冠状动脉造影冠状动脉造影冠心病冠心病 LAD:stenosis LAD:normal冠心病冠心病 RCA:stenosis LCX:stenosisChronic Stable Angina Treatment Objectives Prevent progression of coronary artery disease and optimise life expectancy Relieve symptomsManagement Aspirin beta-adrenoreceptor blocking agents(-blocke
24、rs)calcium antagonists NitratesNCEP Primary CHD Risk Goals for Lowering LDL-CLDL-C GoalNo CHD 2 RF160 mg/dLNo CHD 2 RF130 mg/dLCHD 100 mg/dLThe NCEP recommends lowering LDL-C even further than these goals,if possible.Risk CategoryNHLBI;September 1993Coronary revascularisation Invasive treatment:coro
25、nary angioplasty(PTCA);coronary artery bypass grafting(CABG)冠心病冠心病 CABG冠心病冠心病 PTCA冠心病冠心病 PTCABefore PTCA after PTCA冠心病冠心病 PTCA/SAcute coronary syndrome Unstable angina Non-ST elevation myocardial infarction(NSTEMI)ST elevation myocardial infarction(STEMI)Unstable Angina/NSTEMIUnstable AnginaClinical
26、 Presentation and Classification Diagnosis of unstable angina refers to new or worsening symptoms of myocardial ischemia:rest angina new-onset severe angina increasing angina评估住院期间和出院后长期缺血风险n 评估住院期间死亡风险(c-index 0.83)*及出院后6个月死亡风险(c-index 0.81)*n 多个大型数据库中验证其有效性(c-indices分别为 0.84*和0.75*)n 评价死亡/再发心梗的长期风
27、险网络版可下载 www.outcomes-umassmed.org/GRACE*Granger CB,et al.Arch intern Med.2003;163:2345-2353.*Eagle K,at al.JAMA.2004;291:2727-2733.Unstable Angina Chest pain syndrome,either new onset or progressive angina Transient ST-segment depression on the electrocardiogram(ECG)Without evidence of myocardial in
28、farction by CK,CK-MB,or TroponinNSTEMI Chest pain syndrome,either new onset or progressive angina Transient or persistent ST-segment depression on the electrocardiogram(ECG)With evidence of myocardial infarction by CK,CK-MB,or TroponinUnstable Angina/NSTEMI Significant likelihood of occurrence of ma
29、jor cardiac eventsA.Incidence of MI:8 to 10%B.Mortality:2 to 5%Unstable Angina/NSTEMI:Pathophysiology Acute plaque fissuring and rupture Superimposed thrombus Transient occlusion Mediator-induced vasospasm may be presentDeterminants of Plaque Vulnerability Lipid-rich core size Cap thickness Cap infl
30、ammation and repair斑块破裂引起急性严重事件斑块破裂引起急性严重事件不稳定斑块的进展过程不稳定斑块的进展过程稳定斑块的进展过程稳定斑块的进展过程Nissen SE.Am J Cardiol.2000;86(suppl):12H-17H不稳定斑块不稳定斑块斑块破裂斑块破裂血栓形成血栓形成稳定斑块稳定斑块斑块体积增加斑块体积增加管腔狭窄管腔狭窄Physical Examinaton Not that helpful May have evidence of CHF:JVD,rales,edema May have S4 May have murmur of mitral regu
31、rgitation from papillary muscle dysfunctionInvestigation ECG Cardiac Enzyme or Troponin Coronary angiographyAcute Coronary Syndromes评估住院期间和出院后长期缺血风险n 评估住院期间死亡风险(c-index 0.83)*及出院后6个月死亡风险(c-index 0.81)*n 多个大型数据库中验证其有效性(c-indices分别为 0.84*和0.75*)n 评价死亡/再发心梗的长期风险网络版可下载 www.outcomes-umassmed.org/GRACE*Gr
32、anger CB,et al.Arch intern Med.2003;163:2345-2353.*Eagle K,at al.JAMA.2004;291:2727-2733.management Admitted to hospital Best rest,Oxygen Anti-platelet:asprin,Clopidogrel,GP IIb/IIIa inhibitors Anticoagulant:UFH or LMWH B-blocker Nitrates(intravenous)CCB Statins ACEI Coronary revascularisationDefini
33、te ACSPossible ACS()ECG;Normal biomarkersObserve;repeat ECG,markers at 4-8 hrsNo recurrent pain;()follow-up studiesRecurrent pain;(+)follow-up studiesStress test;LVfunction if ischemia()test:outpt follow-up(+)testAdmit,Use AcuteIschemia PathwayST Use MI GuidelinesNo ST ST-T s,chest pain,markersSympt
34、oms Suggestive of ACSAcute Coronary SyndromesManagementST Elevation MIThrombolytic therapyPrimary interventionNon ST Elevation MI and USALMWHPlatelet inhibitorsRole of catheterizationASAAntithrombinBeta blockerNitratesPreparation for Discharge After UA/NSTEMI Antiplatelet Rx ASA 75-162 mg/day Clopidogrel 75 mg/day Beta Blocker ACEI/ARB Especially if DM,HF,EF 40%,HTN Statin LDL 100 mg/dL(ideally 70 mg/dL)Secondary Prevention Measures Smoking Cessation BP 140/90 mm HG or 130/80 mm HG for DM or chronic kidney disease HbA1C 7%BMI 18.5-24.9 Physical Exercise 30-60 min at least 5 days/wk
