冠心病

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1、Coronary Artery DiseaseDepartment of CardiologyWest China Hospital, Sichuan UniversityYuan-ning Xu Definition of Coronary Artery DiseaseCoronary Artery Disease (CAD) is most commonly caused by obstruction of the coronary arteries by atheromatous plaque and secondary thrombosis. Anatomy of coronary a

2、rtery Atherosclerosis is the condition in which an artery wall thickens as the result of a build-up of fatty materials such as cholesterol.Definition of atherosclerosis From endothelial dysfunction to atherosclerosis Endothelial Dysfunction Fatty-Streak Formation Atheroma Unstable Atheroma A BDC 7 A

3、therosclerosis: from Egyptian mummies High Prevalence of Coronary Atherosclerosis in Asymptomatic Teenagers and Young Adults. Evidence From Intravascular Ultrasound. Circulation. 2001;103:2705. Prevalence of coronary atherosclerosis by age 9 Different stage of atherosclerosis Oxygen requirements (he

4、art rate; contractility; wall tension) Oxygen supply(coronary blood flow and coronary arterial O2 content )BalanceThe fragility of balanceProduce myocardial ischemia with contractile cardiac dysfunction,arrythmias,infarction,and possibly death Stable angina pectoris is characterized by a deep, poorl

5、y localized chest or arm discomfort (rarely described as pain) that is reproducibly associated with physical exertion or emotional stress and relieved within 5 to 15 minutes by rest and/or sublingual nitroglycerin.Definition of stable angina Checklist for history taking Location Radiation Quality Wh

6、at causes and relieves it Duration and frequency Associated symptoms Location and radiation of typical angina 15 Quality of angina Stangling pressing squeezing constricting burning crushing heavy 16 Precipitation and aggravating factors exertion walking in the cold heavy meal strong emotion or frigh

7、t 17 Relief of Pain rest nitroglycerin sweating: angina profuse sweating: AMI nausea and vomiting: AMI shortness of breath palpitation syncopeAccompanying Symptoms Gastroesophageal Types of chest pain 21 A Aspirin and Anti-ischemia B Blood pressure and Beta-blocker C Cholesterol and Cigarette smokin

8、g D Diabetes and Diet E Exercise and EducationThe general principles of non-invasive therapy Antiplatelets AspirinCholesterol modulation StatinsAnti-ischemia Beta-blocker, Calcium Blocker and NitratesACEI/ARBsDrug treatments 稳 定 性 心 绞 痛 的 本 质 是 什 么 ？ Thin cap fibroatheroma (TCFA) 25 Vulnerable and s

9、table plaqueVulnerable Plaque Stable plaque Different progress types of vulnerable plaque 1 Adhesion 3 Aggregation2 Activation 4 ThrombosisPlatelets Coagulation system 斑 块 破 裂 血 小 板 粘 附 血 小 板 聚 集 血 管 腔 部 分 堵 塞 -不 稳 定 心 绞 痛血 栓 脱 落 ， 微 血 管 栓 塞 -非 ST段 抬 高 心 梗 血 管 腔 因 血 栓 形 成 ， 急 性 闭 塞 -ST段 抬 高 心 梗 Acut

10、e coronary syndromeACSNon-ST ELEVATION ACS ST ELEVATION ACS 非 ST段 抬 高 心 梗（ NSTEMI） ST段 抬 高 心 梗（ STEMI）不 稳 定 心 绞 痛(UA) Unstable angina is defined as angina pectoris (or equivalent type of ischemic discomfort) with at least one of four features: (1) it occurs at rest (or with minimal exertion) usually

11、 lasting more than 20 minutes (if not interrupted by nitroglycerin); (2) it is severe and described as frank pain and of new onset (i.e., within 1 month); (3) it occurs with a crescendo pattern (i.e., more severe, prolonged, or frequent than previously);(4) and post-MI angina. Types of unstable angi

12、na severe and intolerable. prolonged, usually lasting for more than 30 minutes and frequently for a number of hours. described as constricting, crushing, oppressing, or compressing; a sensation of a heavy weight or a squeezing in the chest. retrosternal in location, radiates down the ulnar aspect of

13、 the left arm not relieved by rest and nitroglycerin. accompanied by diaphoresis, nausea, and vomiting. Characteristics of chest pain in ACS Arrhythmia, even sudden death (About 50 percent of the deaths associated with AMI occur within 1 hour of the event and are attributable to arrhythmias, most of

14、ten ventricular fibrillation) Acute heart failure Shock (including cardiogenic shock, hypovolumic shock, et al.)Severe complications in ACS ECG in ACSThe dynamic changes of ECG (especially ST-T) have the importance to assess ischmia. 36 ECG Example in Non-STEMI ACS 37 ECG Example in STEMI ECG Non ST

15、 elevation ST elevationBiomarkerUnstable angina Non-STEMI STEMIACSBiomarkerThe level of serum biomarker (Troponin I,T and CK-MB) is used to evaluate the extent of cardiomyocyte injury and necrosis Short-term mortality of ACS Eur Heart J, 2002; 23: 11901201.024681012 In hospital Mortality 30-d Mortal

16、ity UANon-QMIQMI Long-term mortality of ACS Circulation.2009;119:3110-3117. Treatment of ACS Anti-thrombotic therapyAnti-platelet therapy Aspirin ADP receptor antagonist (Clopidogrel) GP b/ a antagonist Anti-coagulation therapy unfractionated heparin low-molecular weight heparin (LMWH) a inhibitor D

17、irect thrombosis antagonist Class I1. In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours and ST elevation greater than 0.1 mV in at least 2 contiguous precordial leads or at least 2 adjacent limb leads. (Lev

18、el of Evidence: A)2. In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours and new or presumably new LBBB. (Level of Evidence: A)Recommendations for Thrombolysis Contraindications for Thrombolysis Thrombolysis

19、for STEMI The Lancet 1994;343:311-22. 47 Coronary Artery Bypass Surgery(CABG) Percutaneous coronary intervention (PCI) 49 病 案 一 老 年 男 性 ， 劳 力 性 胸 痛 半 年 ； 高 血 压 15年 ， 未 正 规 服 药 。 吸 烟 30年 ，戒 烟 3月 ； 高 血 脂 3年 ， LDL-C:3.8mmol/L BP： 156/90mmHg， 心 率 ： 86bpm 心 电 图 临 床 诊 断 冠 心 病 劳 力 性 心 绞 痛 或 稳 定 性 心 绞 痛 高 血

20、 压 高 血 脂 诊 治 方 案 阿 司 匹 林 100mg Qd 美 托 洛 尔 25mg Tid 单 硝 酸 异 山 梨 醇 脂 60mg Qd 阿 托 伐 他 汀 钙 20mg Qn 硝 酸 甘 油 0.5mg 舍 下 含 化 prn. Case 1 (Stable angina) Case 1 Case 1 病 案 二 中 年 男 性 ， 突 发 剧 烈 持 续 性 胸 痛 4小 时 ，伴 大 汗 淋 漓 、 呼 吸 急 促 就 诊 吸 烟 10年 BP： 114/60mmHg， HR： 98bpm， 双 肺未 闻 及 湿 罗 音 及 干 鸣 肌 钙 蛋 白 、 CKMB升 高 心 电 图 临 床 诊 断 冠 心 病 急 性 前 间 壁 心 梗 主 要 诊 治 方 案 阿 司 匹 林 嚼 服 300mg， 100mg Qd维 持 氯 吡 格 雷 顿 服 300mg， 75mg Qd维 持 静 脉 推 注 肝 素 钠 4000IU， 持 续 静 脉 泵 入肝 素 500IU/H 其 余 二 级 预 防 治 疗 （ Beta受 体 阻 滞 剂 、ACEI或 ARB、 他 汀 等 ） 考 虑 再 灌 注 治 疗 ： 静 脉 溶 栓 急 诊 冠 脉 介 入 （ 直 接 PCI） Case 2 (Anterior STEMI) Case 2 Case 2