1、病史特點男性，59歲反復(fù)胸痛4個月，加重1個月。胸痛呈壓榨性與勞力有關(guān)。有高血壓，吸煙史。有心腦血管病陽性家族史。查體：體胖，無明顯其他陽性發(fā)現(xiàn)。ECG：V4V6，I，aVL ST 0.5-1mm.病史特點男性，59歲思考胸痛的鑒別心絞痛的特點心絞痛的分級心絞痛的分類不同類型心絞痛的病理基礎(chǔ)進一步檢查冠心病的易患因素思考胸痛的鑒別心絞痛的鑒別 (1)Non-ischemic CVAortic dissectionPericarditisPulmonaryPulmonary embolusPneumothoraxPneumoniaPleuritisGastrointestinalEsophage

2、alEsophagitis,Spasm, RefluxBiliaryColicCholecystitisCholedocholithiasisCholangitisPeptic ulcerPancreatitis心絞痛的鑒別 (1)Non-ischemic CVGastr心絞痛的鑒別 (2)Chest WallCostochondritisFibrositisRib fractureSternoclavicular arthritisHerpes zoster (before the rash)PsychiatricAnxiety disordersHyperventilationPanic

3、disorderPrimary anxietyAffective disorders(e.g., depression)Somatiform disordersThought disorders(e.g., fixed delusions)心絞痛的鑒別 (2)Chest WallPsychiatri心絞痛特點SAVES U：Sudden onset; Anterior chest; Vague sensation; Exercise precipitated; Short duration; Unanimous attack.心絞痛特點SAVES U：Grading of Angina Pec

4、toris by CCSCClass I: 日常體力活動不引起心絞痛.Class II: 日常體力活動輕度受限.Class III: 日常體力活動明顯受限.Class IV: 任何體力活動都引起癥狀，可以有休息時心絞痛。Grading of Angina Pectoris by UAP 的主要臨床表現(xiàn)Rest angina: Occurring at rest, usu. 20min, occurring within a week of presentation.New onset angina: At least CCSC III severity, 200mmHg; DBP 110mmH

5、g; Tachy- or Brady-arrhythmias; High degree AVBHCMP or other forms of OT obstruction;Mental or physical impairment; Noninvasive Testing: Exercise 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.Rep

6、orted 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 Noninvasive Testing: Exercise ECG(4)(Absolute indication for stopping):SBP drop 10mmHg with

7、 ischemia;Moderate to severe 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 Noninvasive Testing: Exercise ECG(5)(Relative indication for stopping):SBP drop 10mmHg with

8、out ischemia;SBP 250 or DBP 115mmHg;ST depression 2mm;Marked axis deviation;Multifocal PVCs, triplets PVCs, SVT, heart block or bradyarrhythmias, BBB or IVCBIncreasing chest pain; Serious symptoms.Noninvasive Testing: Exercise Noninvasive Testing: Exercise ECG(6)Sensitivity: 68%; Specificity: 77%Inf

9、luence of other factors on test:Digoxin: 25-40% abnormal ST depression.Beta blockers: Gradually withheld 48hrs.Anti-HBP, vasodilators, nitrates, flacainide.LBBB:RBBB: LV hypertrophy: More false-positive.Rest ST depression: Additional ST significant.Noninvasive Testing: Exercise Stress Imaging Studie

10、sGood candidates for stress imaging, as opposed to exercise ECG:CLBBB, Paced rhythm, WPW etc.ST 1mm at rest,Unable to exercise,Angina with prior Revascularization.Stress Imaging StudiesGood canPharmacologic Modalities (Vasodilators) Used in Stress ImagingDipyridamole(DIP) inhibiting cellular uptake

11、of adenosine (a potent coronary vasodilators). The flow increase by adenosine is of lesser magnitude through stenostic arteries, creating heterogeneous myocardial perfusion.Side effects of both DIP and ADE are rare, but may cause severe bronchospasm in patients with asthma or COPD. Pharmacologic Mod

12、alities (VasoPharmacologic Modalities (Dobutamine) Used in Stress ImagingIn 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 adenosine or dipyridamole.Side effects are frequent, but the test appears to be safe e

13、ven in the elderly, including nausea, anxiety, headache, tremor, VPC, APC, SVT, nonsust-VT, chest pain and angina(8%).Pharmacologic Modalities (DobuInvasive Testing - Angiography(Indications)Chest pain, possible ischemic, coexisting COPD not a candidate forExercise test because of dyspnea;Perfusion

14、imaging with dipyridamole or adenosine because of bronchospasm and theophylline therapy;Stress ECHO because of poor images.Invasive Testing - AngiographyInvasive Testing - Angiography(Indications)Typical or atypical symptoms and a high clinical probability of sever CAD.Most appropriate for a patient

15、 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.Invasive Testing - AngiographyRISK STRATIFICATIONA. Clinical AssessmentB. ECG/Chest X-RayNoninvasive TestingCorona

16、ry Angiography and Left VentriculographyRISK STRATIFICATIONA. ClinicalRisk 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 disease

17、d vessels.A recent coronary plaque rupture: worsening clinical symptoms with unstable feature;General health and noncoronary comorbidity.Risk Stratification(Clinical Risk Stratification(Clinical Assessment)Clinical Parameters Predictive of Severe (left main or three vessel) CADAge, Gender, Typical a

18、ngina, Previous MI,DM and use of insulinRisk Stratification(Clinical Risk Stratification(ECG/Chest X-ray)ECGEvidence of 1 previous MI, Persistent ST-T inversion,LBBB, LAB+RBBB, II or III AVB, Af, VT,LV hypertrophy,Chest X-rayCardiomegaly, LV aneurysm, PV congestionCoronary calcificationRisk Stratifi

19、cation(ECG/ChestRisk Stratification(Noninvasive Testing)Resting LV FunctionImportance of assessmentGlobal LV FunctionSWMAMR, LV Aneurysm, LV ThrombosisRisk Stratification(NoninvasiTREATMENTPharmacologic TherapySuccessful and Initiating TreatmentEducation of Patients with CSARisk FactorsRevasculariza

20、tion for CSATREATMENTPharmacologic TherapyOverview of TreatmentStable angina-Two purposes:To prevent MI and death.To reduce symptoms of angina and occurrence of ischemia.Overview of TreatmentStable an穩(wěn)定心絞痛的A，B，C，D，E治療A=Aspirin and Antianginal B=Beta-blocker and Blood pressureC=Cigarette smoking and

21、CholesterolD=Diet and DiabetesE=Education and Exercise穩(wěn)定心絞痛的A，B，C，D，E治療A=Aspirin andTo Prevent MI and Death（1抗血小板藥物阿斯匹林抑制環(huán)氧化酶和 TXA2合成。抵克力得 （Ticlopidine a thienopyridine derivative抑制血小板聚集副作用：中心粒細(xì)胞減少, TTPClopidogrel: 如上潘生丁 （Dipyridamole口服增加運動性缺血，不能用做抗血小板藥。To Prevent MI and Death（1抗血小板To Prevent MI and Death（2抗血栓治療用于穩(wěn)定型心絞痛的資料極有限。降脂藥物膽固醇降低1使心血管事件下降2?？剐慕g痛和抗缺血治療 受體阻滯劑鈣拮抗劑硝酸甘油和硝酸鹽類To Prevent MI and Death（2抗血栓治UAP的治療阿斯匹林肝素 阻滯劑硝酸甘油積極治療24小時無效時需冠狀動脈造影UAP的治療阿斯匹林PTCA和CABGCABG：左主干病變。三支病變。二支病變，但其中一支病變在前降支近段。一或二支，無前