1、病史特点病史特点 男性，男性，59岁岁 反复胸痛反复胸痛4个月，加重个月，加重1个月。个月。胸痛呈压榨性与劳力有关。胸痛呈压榨性与劳力有关。有高血压，吸烟史。有高血压，吸烟史。有心脑血管病阳性家族史。有心脑血管病阳性家族史。查体：体胖，无明显其他阳性发现。查体：体胖，无明显其他阳性发现。ECG：V4V6，I，aVL ST 0.5-1mm.思考思考 胸痛的鉴别胸痛的鉴别 心绞痛的特点心绞痛的特点 心绞痛的分级心绞痛的分级 心绞痛的分类心绞痛的分类 不同类型心绞痛的病理基础不同类型心绞痛的病理基础 进一步检查进一步检查 冠心病的易患因素冠心病的易患因素心绞痛的鉴别心绞痛的鉴别(1)Non-isch
2、emic CV Aortic dissection Pericarditis Pulmonary Pulmonary embolus Pneumothorax Pneumonia Pleuritis Gastrointestinal Esophageal Esophagitis,Spasm,Reflux Biliary Colic Cholecystitis Choledocholithiasis Cholangitis Peptic ulcer Pancreatitis心绞痛的鉴别心绞痛的鉴别(2)Chest Wall Costochondritis Fibrositis Rib fract
3、ure Sternoclavicular arthritis Herpes zoster(before the rash)Psychiatric Anxiety disorders Hyperventilation Panic disorder Primary anxiety Affective disorders(e.g.,depression)Somatiform disorders Thought disorders(e.g.,fixed delusions)心绞痛特点心绞痛特点 SAVES U：Sudden onset;Anterior chest;Vague sensation;Ex
4、ercise precipitated;Short duration;Unanimous attack.Grading of Angina Pectoris by CCSC Class I:日常体力活动不引起心绞痛.Class II:日常体力活动轻度受限.Class III:日常体力活动明显受限.Class IV:任何体力活动都引起症状，可以有休息时心绞痛。UAP 的主要临床表现的主要临床表现 Rest angina:Occurring at rest,usu.20min,occurring within a week of presentation.New onset angina:At l
5、east CCSC III severity,200mmHg;DBP 110mmHg;Tachy-or Brady-arrhythmias;High degree AVB HCMP or other forms of OT obstruction;Mental or physical impairment;Noninvasive Testing:Exercise ECG(3)Risk:MI and death 1/2500 tests.A standard percentage(often 85%)of age-predicated maximum heart rate is targeted
6、.Reported in estimated METs of exercise(One MET is the standard basal oxygen uptake of 3.5ml/kg per min.)ST depression 1mm for 60-80ms after the end of QRS,during or after exercise.Noninvasive Testing:Exercise ECG(4)(Absolute indication for stopping):SBP drop 10mmHg with ischemia;Moderate to severe
7、angina;Increasing ataxia;Dizziness or near syncope;Sign of poor perfusion;Technical difficulties;Sustained VT;ST elevation in leads without Q waves.Noninvasive Testing:Exercise ECG(5)(Relative indication for stopping):SBP drop 10mmHg without ischemia;SBP 250 or DBP 115mmHg;ST depression 2mm;Marked a
8、xis deviation;Multifocal PVCs,triplets PVCs,SVT,heart block or bradyarrhythmias,BBB or IVCB Increasing chest pain;Serious symptoms.Noninvasive Testing:Exercise ECG(6)Sensitivity:68%;Specificity:77%Influence of other factors on test:Digoxin:25-40%abnormal ST depression.Beta blockers:Gradually withhel
9、d 48hrs.Anti-HBP,vasodilators,nitrates,flacainide.LBBB:RBBB:LV hypertrophy:More false-positive.Rest ST depression:Additional ST significant.Stress Imaging Studies Good candidates for stress imaging,as opposed to exercise ECG:CLBBB,Paced rhythm,WPW etc.ST 1mm at rest,Unable to exercise,Angina with pr
10、ior Revascularization.Pharmacologic Modalities(Vasodilators)Used in Stress Imaging Dipyridamole(DIP)inhibiting cellular uptake of adenosine(a potent coronary vasodilators).The flow increase by adenosine is of lesser magnitude through stenostic arteries,creating heterogeneous myocardial perfusion.Sid
11、e effects of both DIP and ADE are rare,but may cause severe bronchospasm in patients with asthma or COPD.Pharmacologic Modalities(Dobutamine)Used in Stress Imaging In high doses(20 to 40g/kg/min)increases HR,SBP and myocardial contractility.The flow increase(2-3 times)is less than that elicited by a
12、denosine or dipyridamole.Side effects are frequent,but the test appears to be safe even in the elderly,including nausea,anxiety,headache,tremor,VPC,APC,SVT,nonsust-VT,chest pain and angina(8%).Invasive Testing-Angiography(Indications)Chest pain,possible ischemic,coexisting COPD not a candidate for E
13、xercise test because of dyspnea;Perfusion imaging with dipyridamole or adenosine because of bronchospasm and theophylline therapy;Stress ECHO because of poor images.Invasive Testing-Angiography(Indications)Typical or atypical symptoms and a high clinical probability of sever CAD.Most appropriate for
14、 a patient with a high-risk treadmill outcome.Symptoms suggestive but not characteristic,special occupation,eg.Pilots,firefighters etc.A low threshold angiography is appropriate for diabetics.RISK STRATIFICATION A.Clinical Assessment B.ECG/Chest X-Ray Noninvasive Testing Coronary Angiography and Lef
15、t VentriculographyRisk Stratification(Clinical Assessment)Prognosis of CAD for Death or Nonfatal MI:LV function:the strongest predictor,EF is the most commonly used;Anatomic extent and severity of coronary tree involvement.The number of diseased vessels.A recent coronary plaque rupture:worsening cli
16、nical symptoms with unstable feature;General health and noncoronary comorbidity.Risk Stratification(Clinical Assessment)Clinical Parameters Predictive of Severe(left main or three vessel)CAD Age,Gender,Typical angina,Previous MI,DM and use of insulinRisk Stratification(ECG/Chest X-ray)ECG Evidence o
17、f 1 previous MI,Persistent ST-T inversion,LBBB,LAB+RBBB,II or III AVB,Af,VT,LV hypertrophy,Chest X-ray Cardiomegaly,LV aneurysm,PV congestion Coronary calcificationRisk Stratification(Noninvasive Testing)Resting LV Function Importance of assessment Global LV Function SWMA MR,LV Aneurysm,LV Thrombosi
18、sTREATMENT Pharmacologic Therapy Successful and Initiating Treatment Education of Patients with CSA Risk Factors Revascularization for CSAOverview of Treatment Stable angina-Two purposes:To prevent MI and death.To reduce symptoms of angina and occurrence of ischemia.稳定心绞痛的稳定心绞痛的A，B，C，D，E治疗治疗 A=Aspir
19、in and Antianginal B=Beta-blocker and Blood pressure C=Cigarette smoking and Cholesterol D=Diet and Diabetes E=Education and ExerciseTo Prevent MI and Death（1 抗血小板药物抗血小板药物 阿斯匹林阿斯匹林 抑制环氧化酶和抑制环氧化酶和 TXA2合成。合成。抵克力得抵克力得（Ticlopidine a thienopyridine derivative 抑制血小板聚集抑制血小板聚集 副作用：中心粒细胞减少副作用：中心粒细胞减少,TTP Clo
20、pidogrel:如上如上 潘生丁潘生丁（Dipyridamole 口服增加运动性缺血，不能用做抗血小板药。口服增加运动性缺血，不能用做抗血小板药。To Prevent MI and Death（2 抗血栓治疗抗血栓治疗 用于稳定型心绞痛的资料极有限。用于稳定型心绞痛的资料极有限。降脂药物降脂药物 胆固醇降低胆固醇降低1使心血管事件下降使心血管事件下降2。抗心绞痛和抗缺血治疗抗心绞痛和抗缺血治疗 受体阻滞剂受体阻滞剂 钙拮抗剂钙拮抗剂 硝酸甘油和硝酸盐类硝酸甘油和硝酸盐类UAP的治疗的治疗 阿斯匹林阿斯匹林 肝素肝素 阻滞剂阻滞剂 硝酸甘油硝酸甘油 积极治疗积极治疗24小时无效时需冠状动脉造影
21、小时无效时需冠状动脉造影PTCA和和CABG CABG：左主干病变。三支病变。左主干病变。三支病变。二支病变，但其中一支病变在前降支近段。二支病变，但其中一支病变在前降支近段。一或二支，无前降支病变，但有一或二支，无前降支病变，但有SCD或持续或持续VT史。史。PTCA：二或三支病变，包括前降支近端，但病变适二或三支病变，包括前降支近端，但病变适合导管治疗，合导管治疗，LV功能正常，无需用药的功能正常，无需用药的DM。Conditions Provoking or Exacerbating Ischemia(Increased Oxygen Demand)Non-Cardiac Hyperth
22、ermia Hyperthyroidism Sympathomimetic toxicity(e.g.,cocaine use)Hypertension Anxiety Arteriovenous fistulae Cardiac HCM Aortic stenosis Dilated CM Tachycardia Ventricular SuperventricularConditions Provoking or Exacerbating Ischemia(Decreased Oxygen Supply)Non-Cardiac Anemia Hypoxemia Pneumonia Asthma COPD Pul-hypertension Interstitial Pul-fibrosis OSAS Sickle cell disease Sympathomimetic toxicity(e.g.,cocaine use)Hyperviscosity Polycythemia Leukemia Thrombocytosis Hypergammaglobuli-nemia Cardiac Aortic stenosis HCM
