1、1Analysis of Coronary Heart DiseaseCadre WardLi Hui2Case 1vSubjective Data:A 68-year-old woman with type diabetes(5 years)and mild hypertension(10 years)was admitted for evaluation of dyspnea and precordialgia on exertion in 6 months.vObjective Data:T:37.0,P:96bpm,BP:150/92mmHg Height:160cm,Weight:8
2、2kg,BIM:32kg/3Preliminary AssessmentvThe possible reason of precordialgia：Coronary Heart Disease,Gastroesophageal Reflux,Pulmonary Embolism,Spontaneous Pneumothorax,Aortic Dissection,Pericarditis,Ventricular Aneurysm,Rib Cartilage Pain,Hyperventilation and so on.vThis patient had no symptoms of acut
3、e severe chest.coronary heart disease may be assessed first for the high incidence and mortality4Supplementary DataBiological aspects1、HPIthe duration and cause shortness of breathcause and mitigating factors of dyspnea and precordialgia(1)whether there are related injuries.5Supplementary DataBiolog
4、ical aspects2、PMH(1)the risk factors,the existence of cardiovascular diseases such as hypertension,diabetes and other chronic diseases.(2)the time of diagnosis of hypertension and diabetes(3)whether an ulcer or biliary tract disease.3、MedsWhether the use of other drugs in addition to the treatment o
5、f hypertension,diabetes.6Supplementary Data Social aspect1.FHxFamily members who had suffered from hypertension or diabetes,and cardiovascular disease such as stroke.Record age of the illness,clinical course and treatment2.Smoking Status3.Drinking situation 4.Relationship between family members5.Die
6、tary habits7Supplementary DataPsychological aspect1.The patients feelings and concern degree to the disease with years of chronic disease history,2.Her family factors have what kind of influence to her3.The patients expectations.82.Does the patient suffered from anxiety and fear for the chest discom
7、fort?1.What is the patient most want to solve through this visit?9Supplementary DataLab data:Blood Lipid:Total Cholesterol:4.82mmol/L HDL-C:1.04mmol/L LDL-C:3.00mmol/L Triglyceride:1.73mmol/L，Blood RT,TSH,Liver and kidney function：all normal，Fasting blood glucose：8.0mmol/LGlycosylated hemoglobin：7.6
8、%ECG:Sinus rhythm,heart rate 90 beats/min,PR and normal QRS interval,V3 V6 ST segment of 0.05mV,left ventricular high voltage and suggest that left ventricular hypertrophy with strain,no pathological Q wave10Evidence-based MedicineApplication of evidence-based medicine theory and method to construct
9、 and answer the clinical questionWhat is significant to the patient of coronary heart disease risk factors?Coronary artery disease is the most common cardiovascular disease,is the main cause of death in Chinese.According to a research report from Circulation;Cardiovascular Quality and Outcomes magaz
10、ineDue to aging,smoking,hypertension and other risk factors,to 2030,in China,the morbidity and the mortality rate of cardiovascular disease would be increased to 73%.The main risk factors for coronary artery disease is smoking,diabetes and hypertension.The world will have to face the enormous pressu
11、re to the increase of cardiovascular disease morbidity and mortality.So the general practitioners should pay more attention to the prevention and treatment of coronary heart disease11Evidence-based MedicineThe risk factors of coronary heart disease:1.Age(male45，female55）2.Smoking Status（smoking or s
12、moked in 6 months）3.FHx（AMI Or MI on first-degree relatives before the age of 55）4.Hhypertension（systolic pressure 140mmHg And(or)diastolic pressure 90mmHg）5.Hyperlipidemia(total cholesterol5.2mmo1/L,LDL-C3.4mmol/L,HDL-C 7.0mmol/L)7.Obesity(BMI28kg/，or waist90cm)8.Sedentary lifestyle(Do not meet the
13、 minimum requirements of physical activity)12The most suitable examinationCoronary heart disease refers to coronary artery plaque formation in the inner layer,which lead to coronary artery stenosis or occlusion,and block the blood supply of coronary artery to myocardium.Some experts think that more
14、than 50%of the diameter of the lumen of coronary artery stenosis can be defined as coronary heart disease.On the other,some experts believe that it is 70%.Study confirmed that the nature of the plaque is more important than the degree of stenosis.Because of these vulnerable plaque increased the risk
15、 of rupture and thrombosis.Therefore,for the general practitioner,take effective measures to found significant patients with coronary heart disease is very important.Evidence-based Medicine13In China,there are several noninvasive can be used to assess suspected patients with coronary heart disease.T
16、hese checks have different sensitivity and specificity,also has its own unique advantages,disadvantages and risks.Including:Exercise load test(with or without the use of drugs)EchocardiographyRadionuclide perfusion(SPECT or Myocardial Scintigraphy)Evidence-based Medicine14Searching PICO on the Natio
17、nal Library of Medicine website.PICO is not only used to evaluate the effect of treatment,can also be used for the evaluation of diagnostic test value and comparison.Coronary artery disease input as the research problem,Stress echo as the intervention,Nuclear stress test as a control,The type is met
18、a analysis.Then we got five articles.Conclusion:echocardiography may be more suitable for female patients,because it has a higher specificity for diagnosis.Is this evidence applicable to the case of the patient?6 in 14 of the studies compared the female stress echocardiography and 99mTc MIBI myocard
19、ial perfusion scan,display echocardiography has higher specificity.Evidence-based Medicine15Evidence-based MedicineThe next step to change the PICO search strategy.Comparison of echocardiography(stress echo)and SPECT scanning with single photon emission computed tomography(single photo emission CT)a
20、nd CT image.16In summary:It should be provided to patients that a diagnostic test can not only sensitively diagnose but also specifically exclude the coronary heart disease.High sensitivity test is helpful to find the patients need further examination(such as cardiac catheterization),Test of high sp
21、ecificity is helpful to correctly identify patients without coronary heart disease.There are risks due to cardiac catheterizationThe patient should avoid unnecessary cardiac catheterization,We need a diagnostic test for high specificity(low false positive rate).Echocardiography is the best examinati
22、on(87.1%specificity),And also has a very high sensitivity(79.1%).Echocardiography costs less than SPECT and EBCTFor patients at their own expense,it has obvious advantages.So we can come to the conclusion:The diagnosis of coronary heart disease,echocardiography is accurate,and cost-effective means o
23、f diagnosis.And it is more suitable for female patients.Evidence-based Medicine17For the patients with coronary heart disease risk factors,should focus on primary prevention patients.The risk factors of the patient can be changed is hypertension,diabetes and obesity.HOT(Hypertension Optimal Treatmen
24、t)shows that,when diastolic pressure is 82.6 mmHg,the incidence of cardiovascular events is the lowest.Therefore,the majority of hypertension guidelines recommend blood pressure under 130/80mmHg.There is evidence that ACE inhibitors have renal protective effect on diabetic patients.This patients wit
25、h hypertension and diabetes,will be benefit from the use of ACEI or ARB drugs to control blood pressure.For the patients with diabetes,according to the test results of ACCORD(the action to control cardiovascular risk in diabetes),The patient HbA1c should be controled in 7%or a little higher.Another
26、experiment in HOT is that aspirin can reduce 29%major cardiovascular events(P=0.03)and 36%myocardial infarction(P=0.002),some of the patients in the study also suffered from diabetes.Todays research shows that obesity increases the incidence rate and mortality rate of various diseases,so encourage p
27、atients to lose weight is also very important.Finally,due to the low activity/sedentary of this patient,and sedentary lifestyle is independent risk factors of coronary heart disease,so it is recommended that the patient should make some regular,moderate exercise.Comprehensive Analysis181.Metformin i
28、ncreased to 1000 mg/times,2 times a day,oral(glycated hemoglobin control in about 7%).2.Hydrochlorothiazide,25 mg/times,once a day,oral.3.Lisinopril,10mg/times,once a day,oral.4.Aspirin 75 mg/times,once a day,oral.5.Reducing the weight of 10%.6.regular exercise.7.low salt low fat,eat more vegetables
29、 and fruits.8.two weeks after the treatment of renal function,blood pressure,body weight and fasting blood glucose.Treatment19As primary health care workers,the general practitioner should provide clinical preventive services for patients.This 68 year old diabetic patient should be recommended to in
30、fluenza vaccination,pneumococcal vaccine every year.And every 1 to 2 years,this patient should accept a mammography and bone scan in screening for osteoporosis,and we recommend her to regularly screening for colorectal cancer.Here is an acute coronary events after the diagnosis of coronary heart dis
31、ease patients with evidence-based treatment.Treatment20 CASE 2vSubjective Data:A 61-year-old man,who was recently hospitalized for non ST segment elevation myocardial infarction,came to the general out-patient clinic.During hospitalization,due to the inferior wall myocardial infarction,this patient
32、had the PTCA and two stents implanted into the right coronary artery and left circumflex coronary artery Echocardiography at discharge showed that part of the left ventricular anterior wall motioned abnormally while the ejection fraction was 50%.Patients felt good after discharged.There was no chest
33、 pain or shortness of breath at rest or walk,no nocturnal paroxysmal dyspnea and no orthopnea.21 CASE 2vObjective Data:No obvious respiratory distress.BP:150/92mmHg，P:66bpm，T:37 Height:175cm，Weight:78kg BIM:25.5 kg/。22Preliminary Assessment1.AMI2.After PCI23Supplementary DataBiological aspects1、HPI(
34、1)whether there is a symptoms of shortness of breath?(2)whether there is a chest discomfort?2、PMHWhether there is a risk factor for cardiovascular disease,such as high blood pressure,diabetes and other chronic diseases.3、MedsWhether taking other drugs.24Supplementary Data Social aspect1.FHxFamily me
35、mbers who had suffered from hypertension or diabetes,and cardiovascular disease such as stroke.Record age of the illness,clinical course and treatment2.Smoking Status3.Drinking situation 4.Relationship between family members5.Dietary habits25Supplementary DataPsychological aspect1.The patients feeli
36、ngs and concern degree to the disease with years of chronic disease history,2.Her family factors have what kind of influence to her3.The patients expectations.262.Does the patient suffered from anxiety and fear for the chest discomfort?1.What is the patient most want to solve through this visit?27Ev
37、idence-based MedicineCould cardiac rehabilitation which is based on exercise reduce the morbidity and mortality of angina pectoris?Compared with ordinary medical care,cardiac rehabilitation can reduce for all-cause mortality,heart rate,and significantly lower levels of total cholesterol,triglyceride
38、 level,systolic blood pressure and lower self-reported smoking rates.Regular exercise can increase exercise tolerance,Treat other possible risk factors,and improve the quality of life.Therefore,it is clear that the patient will benefit from the cardiac rehabilitation programs or other regular exerci
39、se program28Evidence-based MedicineWhich antihypertensive drugs were proved that can reduce the morbidity and mortality of patients after myocardial infarction?Firstly，look for the research evidence of CADs secondary prevention:receptor antagonist can reduce the incidence of recurrent myocardial inf
40、arction,sudden cardiac death and the mortality of patient after myocardial infarction.In the first two years after MI,the receptor antagonist，compared with other antihypertensive agents,can double reduce cardiovascular events29Evidence-based MedicineACC recommended that receptor antagonist is the ch
41、oice durg of all secondary prevention at starting and maintaining to CHD patients after MI，EXCEPT:1.Asthma patients who need to use the bronchi relaxation and(or)hormone 2.cardiogenic shock3.Heart rate is lower than 50-60 bpm4.atrioventricular block(-)5.Heart failure which is serious enough to requi
42、re using intravenous diuretics or cardiac medicine6.Systolic pressure is lower than 90-100 mmHg30Evidence-based MedicineThe patient also can consider to use ACEI.Studies have shown that ramipril therapy can reduce the mortality of cardiovascular disease,and reduce the occurrence of cardiovascular de
43、ath and myocardial infarction to the patients with high-risk or existing cardiovascular disease without heart failure.31Evidence-based MedicineTherefore,in this case,the patient using the receptor antagonist medicine is safe and useful.Because the patients blood pressure is still higher than normal
44、after oral metoprolol，in order to control blood pressure and reduce the risk of cardiovascular disease，combination with ACEI is appropriate32Evidence-based MedicineFor this patient,whats the goal to lower cholesterol?Statins can reduce the recurrence of cardiovascular events of acute coronary syndro
45、me patients of and all cause mortality.Recent research shows:compared with standard therapy,the treatment to lower lipid can reduce all-cause mortality of acute coronary syndrome patients.As a result,some experts claim that all of the CHD patients should use statins.In the study of LIPID,compared wi
46、th the placebo group,pravastatin reduced CHD and all cause mortality,and also reduced the incidence of cardiovascular events to the different starting lipid levels of myocardial infarction or unstable angina patients33Evidence-based Medicinev For the secondary prevention of CHD：LDL-C100mg/dl(2.59mmo
47、l/L)v For high risk patients，LDL-C 130mg/dl，in addition to lifestyle changes,lipid-lowering drugs also should be addedv According to the above evidence,the patients treatment goals:changing lifestyle and statin treatment.LDL-C70mg/dl is required)34Evidence-based MedicineAfter PTCA or stent implanted
48、,how long should continue taking clopidogrel?ACC recommended that combination of clopidogrel and aspirin should keep over 12 months after acute cardiac events or PCIIn this case,the patient,who is similar to the patients in the study,recently had a heart attack and will benefit from the use of clopi
49、dogrel.Moreover,the patient has implanted the two stents,clopidogrel is indications for the treatment of 12 months after surgery.35Evidence-based MedicineIn the treatment of the patient,what is the role of aspirin?Aspirin therapy(81-162 mg a day)can make the recurrence rate of patients with cardiova
50、scular events to reduce 1/4.For occult cardiovascular events,including acute myocardial infarction(ami)or ischemic stroke,unstable,or stability of angina pectoris and old myocardial infarction,cerebral ischemic lesion,peripheral artery disease or an increased risk of atrial fibrillation patients,app
