1、冠状动脉粥样硬化性心脏病 (coronary atherosclerotic heart disease),大连医科大学附属二院心内科牛 楠,动脉粥样硬化 atherosclerosis,Introduction,Arteriosclerosis 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 Bee
2、n Surgically Removed from Coronary Artery,Courtesy Ronald D. Gregory and John Riley, MD.,Non Modifiable Risk Factors,AgeA dominant influenceAtherosclerosis begins in the young, but does not precipitate organ injury until later in life GenderMen more prone than women, but by age 60-70about equal freq
3、uency Family HistoryFamilial cluster of risk factorsGenetic differences,Modifiable Risk Factors (potentially controllable),Hyperlipidemia Hypertension Cigarette smoking Diabetes Mellitus Elevated Homocysteine Factors that affect hemostasis and thrombosis Infections: Herpes virus; Chlamydia pneumonia
4、e Obesity, sedentary lifestyle, stress,Pathogenesis of Atherosclerosis,Response 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 accumul
5、ation,Response to injury,Endothelia dysfunction,Initiation of Fatty Streak,Fatty Streak,Fibro-fatty Atheroma,Atherosclerosis Timeline,Foam Cells,Fatty Streak,Intermediate Lesion,Atheroma,Fibrous Plaque,Complicated Lesion/ Rupture,Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104).,From First D
6、ecade,From Third Decade,From Fourth Decade,AHA Classification of atherosclerosis,动脉粥样硬化血栓形成: 具共同病理基础的进展性过程,正常,脂肪条纹,纤维斑块,粥样硬化斑块,斑块破溃/ 裂隙和血栓形成,心肌梗死,缺血性中风/TIA,严重的 下肢缺血,临床无症状,心血管死亡,年龄增长,稳定性心绞痛 间歇性跛行,不稳定性 心绞痛,ACS,*ACS, 急性冠脉综合征; TIA, 一过性脑缺血发作,缺血性肾病 缺血性肠病,Coronary Artery Disease,冠心病,Clinical classification
7、(1979 WHO),Asymptomatic CHD(隐匿型） Angina pectoris CHD（心绞痛型） Myocardial infarction CHD(心肌梗死型） Ischemic cardiomyopathy CHD（缺血性心肌病型） Sudden death CHD（猝死型）,Classification of IHD,Chronic ischemic syndrome: stable anginaasymptomatic CHDischemic cardiomyopathy CHD Acute coronary syndrome:unstable anginaSTEM
8、I/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 et al. Circulation. 1990;82(Suppl II):II-38, II-46.,不稳定血栓(UA/NSTEMI),脂肪池 巨噬细胞 内在的压力，张力 外部的剪切力,裂缝,大裂缝,小裂缝,闭合血栓 (STEMI),动脉粥样硬化斑块,斑块破裂,血栓,No ST Elevation,ST Elevation,Acute Coronary Syndrome,Unstable Angina,NQMI,Qw MI,NSTEMI,My
9、ocardial Infarction,Davies MJ Heart 83:361, 2000,Ischemic Discomfort,Presentation,Working Dx,ECG,Biochem. Marker,Final Dx,Hamm Lancet 358:1533,2001,ANGINA PECTORIS,Definition of Angina,A pain or discomfort in the chest or adjacent areas caused by insufficient blood flow to the heart muscle.,Clinical
10、 classification and pathology,Stable angina:fixed atheromatous stenosis Unstable angina:dynamic obstruction by plaque rupture with superimposed thrombosis and spasm,斑块破裂引起急性严重事件,不稳定 心绞痛,心肌梗死,猝死,稳定性 (劳力性) 心绞痛,不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,斑块破裂,血栓形成,稳定斑块,斑块
11、体积增加,管腔狭窄,Stable angina pectoris,ETIOLOGY,.Ischemia is secondary to coronary artery disease in 95% of patients. 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 i
12、n patients with normal coronary arteries,Clinical menifestation chest discomfort,Quality - “squeezing,“ “griplike,“ “pressurelike,“ “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. Duratio
13、n - anginal episode is typically minutes in duration. Fleeting discomfort or a dull ache lasting for hours is rarely angina Location - usually 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 are
14、a over the left lateral chest wall is rarely anginal. Provocation - angina is generally precipitated by exertion or emotional stress and commonly relieved by rest. Sublingual nitroglycerin also relieves angina, usually within 30 seconds to several minutes.,Categorize the Severity of Angina,Clinical
15、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 complete physical exam is crucial in making an assessment of risk.
16、 Most pt:(-),Alternative Diagnoses to Angina for Patients with Chest Pain,Non-Ischemic CV aortic dissection pericarditis Pulmonary pulmonary embolus pneumothorax pneumonia pleuritis Chest Wall costochondritis fibrositis rib fracture sternoclavicular arthritis herpes zoster,Gastrointestinal Esophagea
17、l esophagitis spasm reflux Biliary colic cholecystitis choledocholithiasis cholangitis Peptic ulcer Pancreatitis,Psychiatric Anxiety disorders hyperventilation panic disorder primary anxiety Affective disorders depression Somatiform disorders Thought disorders fixed occlusions,Investigation,12 Lead
18、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 prognosis,CHD,At rest:,ECG,冠心病,Episode of angina:ST-segment depression,ECG,CHD,Holte
19、r,Exercise testing,Angina: Exercise Testing High Risk Patients,Significant ST-segment depression at low levels of exercise and/or heart rate130 Fall in systolic blood pressure Diminished exercise capacity Complex ventricular ectopy at low level of exercise,Exercise Testing Contraindications,MIimpend
20、ing or acute Unstable angina Acute myocarditis/pericarditis Acute systemic illness Severe aortic stenosis Congestive heart failure Severe hypertension Uncontrolled cardiac arrhythmias,Investigation,Echocardiography. The stress echocardiogram is a widely performed test used to assess patients for cor
21、onary 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) and compared with those at rest. Regional wall-motion abnormalities wit
22、h 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,Investigation,Coronary angiography. Used to identify foci of coronary
23、 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,Coronary angiography,冠心病,冠状动脉造影,冠心病,LAD:stenosis LAD:normal,冠心病,RCA:stenosis LCX:
24、stenosis,Chronic Stable Angina Treatment Objectives,Prevent progression of coronary artery disease and optimise life expectancy Relieve symptoms,Management,Aspirin beta-adrenoreceptor blocking agents (-blockers) calcium antagonists Nitrates,NCEP Primary CHD Risk Goals for Lowering LDL-C,LDL-C Goal,N
25、o CHD 2 RF,160 mg/dL,No CHD 2 RF,130 mg/dL,CHD,100 mg/dL,The NCEP recommends lowering LDL-C even further than these goals, if possible.,Risk Category,NHLBI; September 1993,Coronary revascularisation,Invasive treatment: coronary angioplasty (PTCA); coronary artery bypass grafting (CABG),冠心病,CABG,冠心病,
26、PTCA,冠心病,PTCA,Before PTCA after PTCA,冠心病,PTCA/S,Acute coronary syndrome,Unstable angina Non-ST elevation myocardial infarction (NSTEMI) ST elevation myocardial infarction(STEMI),Unstable Angina/NSTEMI,Unstable Angina Clinical Presentation and Classification,Diagnosis of unstable angina refers to new
27、 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,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)* 多个大型数据库中验证其有效性 (c-indices分别为 0.84*和0.75*)评价死亡/再发心梗的长期风险,网络版可下载www.outcomes-umassmed.org/GRACE,*Granger CB, et al. Arch intern M
28、ed. 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 infarction by CK, CK-MB, or Troponin,NSTEMI,Chest pain syndrome,
29、 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 Troponin,Unstable Angina/NSTEMI,Significant likelihood of occurrence of major cardiac eventsA. Incidence of MI: 8 to 10%B. Mort
30、ality: 2 to 5%,Unstable Angina/NSTEMI: Pathophysiology,Acute plaque fissuring and rupture Superimposed thrombus Transient occlusion Mediator-induced vasospasm may be present,Determinants of Plaque Vulnerability,Lipid-rich core size Cap thickness Cap inflammation and repair,斑块破裂引起急性严重事件,不稳定 心绞痛,心肌梗死,
31、猝死,稳定性 (劳力性) 心绞痛,不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,斑块破裂,血栓形成,稳定斑块,斑块体积增加,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 regurgitation from papillary muscle dysfunction,Investigation,
32、ECG Cardiac Enzyme or Troponin Coronary angiography,Acute Coronary Syndromes,评估住院期间和出院后长期缺血风险,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)* 多个大型数据库中验证其有效性 (c-indices分别为 0.84*和0.75*)评价死亡/再发心梗的长期风险,网络版可下载www.outcomes-umassmed.org/GRACE,*Granger CB, et al. Arch intern Med. 2003;163:2345-2353.*
33、Eagle K, at al. JAMA. 2004;291:2727-2733.,management,Admitted to hospital Best rest,Oxygen Anti-platelet:asprin, Clopidogrel , GP IIb/IIIa inhibitorsAnticoagulant: UFH or LMWH B-blocker Nitrates (intravenous) CCB Statins ACEI Coronary revascularisation,Definite ACS,Possible ACS,() ECG; Normal biomar
34、kers,Observe; repeat ECG,markers at 4-8 hrs,No recurrent pain; () follow-up studies,Recurrent pain; (+) follow-up studies,Stress test; LV function if ischemia,() test: outpt follow-up,(+) test,Admit, Use Acute Ischemia Pathway,ST ,Use MIGuidelines,No ST ,ST-T s, chest pain, markers,Initial Chest Pai
35、n Evaluation,Symptoms Suggestive of ACS,Acute Coronary Syndromes,Preparation 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
36、 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,No ST Elevation,ST Elevation,Acute Coronary Syndrome,Unstable Angina,NQMI,Qw MI,NSTEMI,Myocardial Infarction,Davies MJ Heart 83:361, 2000,Ischemic Discomfort,Presentation,Working Dx,ECG,Biochem. Marker,Final Dx,Hamm Lancet 358:1533,2001,Thank you,
