Atherosclerosis&CoronaryheartdiseasesZhengzhouUniversity,FirstaffiliatedHospitalDept.ofCardiologyHaiyuLi,M.D.第一頁，共一百一十五頁。編輯課件CardiovascularDiseases第二頁，共一百一十五頁。編輯課件Atherosclerosis第三頁，共一百一十五頁。編輯課件leadingcauseofdeathanddisabilityCommonlocation:Coronarycirculation:Proximalleftanteriordescending

coronaryartery(LAD)ProximalportionofrenalarteriesExtracranial

circulationtothebrainCarotidbifurcationAtherosclerosis第四頁，共一百一十五頁。編輯課件CoronaryheartdiseaseatherosclerosisCoronarystenosiscoronaryspasmMyocardialischemia,anoxaemiaCoronaryheartdisease,CHDIschemicheartdisease第五頁，共一百一十五頁。編輯課件AtherosclerosisStableanginapectoris(SAP)AcutecoronarysyndromeUnstableangina(UAP)andnon-STEMI(UA/NSTEMI)STelevationmyocardialinfarction(STEMI)第六頁，共一百一十五頁。編輯課件ThreefundamentalbiologicalprocessesofatherosclerosisAccumulationofintimalcells:smoothmusclecellsMacrophagesT-lymphocytesProliferatedconnectivetissuematrix

:collagenelastic

fibersproteoglycans3.Accumulationoflipid:cholesterolestersfreecholesterol第七頁，共一百一十五頁。編輯課件HypothesisoflipoproteininfiltrationAggregationofplateletsandthrombosisClonaltheorytheresponse-to-injuryhypothesisAtherosclerosis-Hypothesis第八頁，共一百一十五頁。編輯課件Response-to-injuryAtherosclerosis:hypothesisHighbloodpressure,bacterium,virus,toxin,ox-LDL,immunefactor,vasoactivesubstanceendotheliumdamageanddysfunction(vasoactivesubstance,adhesionandaggregationofmonocytes-foamcell,platelets)Lipidosis,growthfactor,proliferationofsmoothmuclecells,collagen,lipolyticenzyme,atherosclerosis第九頁，共一百一十五頁。編輯課件PathologyandpathophysiologyFattysteakFibrousplaqueComplicatedlesionAtherosclerosis第十頁，共一百一十五頁。編輯課件InitiationofAtherosclerosisFattysteakformation第十一頁，共一百一十五頁。編輯課件InitiationofAtherosclerosisFattysteakformation

Lipoprotein

oxidationNonenzymatic

glycationLeukocyterecruitmentFoamcellformation第十二頁，共一百一十五頁。編輯課件Atheromaevolution:fibrousplaqueAtheromaevolutionandcomplicationsVascularremodeling:compensatoryenlargement第十三頁，共一百一十五頁。編輯課件Atheromaevolution:Involvementofarterialsmooth-musclecellsBloodcoagulationmicrovesselsAtheromaevolutionandcomplications第十四頁，共一百一十五頁。編輯課件炎癥細胞少量平滑肌細胞激活的巨噬細胞血栓Complicatedlesion:thrombosisAtheromaevolutionandcomplications第十五頁，共一百一十五頁。編輯課件AtheromaevolutionandcomplicationsVulnerableplaque:ThinfibrouscapRelativelylargelipidcoreHighcontentofmacrophagesInflammatorymediators第十六頁，共一百一十五頁。編輯課件Intravascularultrasound

第十七頁，共一百一十五頁。編輯課件ClassicificationofatheroscleroticlesionusingIVUS第十八頁，共一百一十五頁。編輯課件CliniclstagesandclassificationAbsenceofsymptomorstageofdelitescenceischemianecrosis(targetorgan)fibrosisAtherosclerosis第十九頁，共一百一十五頁。編輯課件GeneralmanifestationAorticatherosclerosisCoronaryarteryatherosclerosisCerebralatherosclerosisMesentericatherosclerosisPeripheralarteryatherosclerosisAtherosclerosisclinicalmanifestation第二十頁，共一百一十五頁。編輯課件

laboratoryexaminationLackofsensitiveandspecificmethodsforearlydiagnosisDyslipidemia：X-ray：DSAshowseverityofstenosisDopplerultrasound:bloodflowradionuclide：detectionofischemiaEchocardiogram：CHDECGandstresstest:CHDNewtechniques:intravascularultrasound,angioscopeCT,MRIAtherosclerosis第二十一頁，共一百一十五頁。編輯課件Riskfactorsandprevention1.Lifestylemodification2.Lipiddisorders(Dyslipidemia):cholesterolscreeninginall>20yrsElevated:cholesterol(TcandLDL-c),TG,ApoB/ApoA,Lp(a),Low:HDL-cLDLloweringbyHMG-CoAreductase(statins):cardiovascularevents30%，riskofMI62%3.Hypertension：4.DM,Metabolicsyndromeorinsulinresistancesyndrome:

BP,BMI,TG,seruminsulin

HDL-c

第二十二頁，共一百一十五頁。編輯課件Diabetesmellitus(DM):RR1.9formale,3.3forfemalemorediffuselesion.CADequivalent

75-80%causeofdeathinadultDMarevasculardiseases:CAD,cerebrovasculardisease,orperipheralvasculardiseaseRiskfactorsandprevention第二十三頁，共一百一十五頁。編輯課件7yearsincidenceofdeath/non-fatalMI

(EastWestStudy)*ThesepatientshadnohistoryofmyocardialinfarctionHaffnerSM,etal.NEnglJMed.1998;339:229–234.05101520253035404550EventsofMIin7yearsNohistoryofMIOMINohistoryofMI*OMInon-diabetics diabetics n=1373 n=1059P<0.001P<0.0014%19%20%45%DM:CADequivalent第二十四頁，共一百一十五頁。編輯課件5.

Cigarettesmoking：morethrombogenic6.

Familyhistory：geneticfactor7.

Aging：>40yrsadults，4/5fatalmyocardialinfarctionoccuredinpatiens>65yrs8.Malegender/postmenopausalstate：male:female=2：1,mandevelopCHD10-15yrsearlierthanwoman9.alcohol10.Others:diet,homocysteine,hemostaticfactorsinflammation/infectionRiskfactorsandprevention第二十五頁，共一百一十五頁。編輯課件

Drugtherapy：anti-platelet：

aspirin,clopidogrel,GPIIb/IIIainhitibor,Dipyridamole,cilostazolLipid-loweringRiskfactorsandprevention第二十六頁，共一百一十五頁。編輯課件HMG-CoAreductaseinhibitors（statins）Atorvastatin,Fluvastatin,Lovastatin,Pravastatin,Simvastatin,Cerivastatin,Rosuvastatin：

*elevationofaminopherase,rhabdomyolysis2.Bileacid-bindingResinscholestyramine，colestipol3.NicotinicAcid：4.Fibricacidderivatives（fibrates）

Gemifibrozil,clofibrate,Fenofibrate5.Cholesterolabsorptioninhibitors:ezetimibe6.ProbucolLipid-loweringdrugs第二十七頁，共一百一十五頁。編輯課件PreventionofCADA:aspirin,ACEIB:bloodpressure,β-blocker,C:cigarettesmoking,CholesterolD:diet,diabetesE:exercise,education第二十八頁，共一百一十五頁。編輯課件ThirdReportoftheNationalCholesterolEducationProgram(NCEP)ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults

ATPIII(adulttreatmentpanelIII)Circulation200217/24:3144-3373Atherosclerosis第二十九頁，共一百一十五頁。編輯課件Coronaryheartdisease(CHD)第三十頁，共一百一十五頁。編輯課件Coronaryheartdisease(CHD)mostcommoncause:obstructionofatheromatousplaqueothercauses:spasmarterialthrombicoronaryemboliostialnarrowingduetolueticaortitiscongenitalabnormalitiessevereLVhypertrophy第三十一頁，共一百一十五頁。編輯課件FactorseffectmyocardialoxygensupplyanddemandOxygensupplyOxygendemandHeartrateMyocardialcontractilitySystolicwallstressoxygencarryingcapacityofbloodCoronarybloodflowVascularresistanceExtravascularcompressiveforcesautoregulationMetabolicregulationHumoralfactorNeuralregulationDurationofdiastolePressuregradientEndothelialcontrol第三十二頁，共一百一十五頁。編輯課件Coronaryheartdisease

Type：slientischemia:delitescence：(ECGchange)Anginapectoris：angina,causedbymyocardialischemia

myocardialinfarction：acutemyocardialischemicnecrosiscausedbytheocclusionofcoronaryarteryIschemiacardiomyopathy(Heartfailureandarrhythmia)：cardiacenlargement,heartfailure,arrhythmia,causedbythemyocardialfibrosisastheconsequenceofchronicmycardialischemiaSuddendeath：suddencardiacarrestcausedbyventricularfibrillation/flutter第三十三頁，共一百一十五頁。編輯課件Coronaryheartdisease(CHD)

Type：

slientischemia:delitescenceAnginapectoris：myocardialinfarction：Ischemiccardiomyopathy(Heartfailureandarrhythmia)Suddendeath第三十四頁，共一百一十五頁。編輯課件AcuteCoronarySyndrome(ACS)RestingischemiaNon-STelevationSTelevationUnstableanginaNon-QwaveAMIQwaveAMI*positiveserumcardiacmarkers****##occasionallyvariantangina第三十五頁，共一百一十五頁。編輯課件Stableanginapectoris(SAP)第三十六頁，共一百一十五頁。編輯課件definition:acuteandtransientmyocardialischemiaandanoxaemiausuallycausedbycoronaryinsufficiencyduringexertionoremotionalstressCharacteristics:paroxysmalprecordialsqueezing-likechestpain,behindthemidsternum，radiatedtoleftshoulderandupperarmprecipitatedbystressorexertionduration:2-5mintypically

relievedrapidlybyrestornitratesStableanginapectoris第三十七頁，共一百一十五頁。編輯課件Coronarystenosis(others:aorticvalvedisease,HOCM,MB)+Myocardialoxygendemand（HR

X

SBP）increased

myocardialhypoxiaacumulationofmetabolicproduct,stimulateC1-5nervetocausethesensationofchestpain

Stableanginapectorismechanism第三十八頁，共一百一十五頁。編輯課件inangiographySignificantcoronarylesionwithdiameterstenosis>70%in75%ptsNosignificantstenosisinabout5-10%pts,Ischemiamayberelatedtocoronaryspasmormicrovasculardysfunction.PathologyStableanginapectoris第三十九頁，共一百一十五頁。編輯課件pathophysiology1.MetabolicandelectrophysiologyATPreduced,accumulationofacidsubstancesDysfunctionofironpump(Na+-K+,andNa+-Ca++)Earlydepolarization(STdeviation)2.LVfunctionandhemodynamicsituationLVcontractilityandspeed,systolicBP,strokevolume,cardiacoutputdecreasedLVEDpressureandvolumeStunningofmyocardiumStableanginapectoris第四十頁，共一百一十五頁。編輯課件symptom：chestpainoroppressionlocation

behindorslightlytotheleftofthemidsternumnodefiniteborderlineradiatedtotheleftshoulderandupperarmAtypicallocation:lowerjaw,thebackofneckClinicalmanifestationStableanginapectoris第四十一頁，共一百一十五頁。編輯課件chestpaincharacteristics：tightness,squeezing,burning,pressing,choking,bursting,rarelysharp,notspasmodicforcethepatientstoptheactivitytillthesymptomrelievedprecipitationexertionoremotionalagitation。duration：3－5minspainrelief:withinseveralminsafterrestorusingnitroglycerinClinicalmanifestationStableanginapectoris第四十二頁，共一百一十五頁。編輯課件PhysicalexaminationincreasedHR,elevatedBPanxietysweatingoccasionallygalloprhythm，transientsystolicmurmurClinicalmanifestationStableanginapectoris第四十三頁，共一百一十五頁。編輯課件Laboratory1.ECG：atrestDuringchestpain:ST-Tchangefoundin95%ptsHolter:detectofslientischemiaStresstest:indication：suspectionofCHD,pre-andpost-CABGandPCI,ptswithOMIcontraindication：AMI,UAP,myocarditis,Hypertension,heartfailure,aorticstenosis,HOCM,severarrhythmia,aorticaneurysmEndofthetest：STor≥0.2mV，APattacks，BP>220mmHg，BPdrop，ventriculararrhythmiaCriteriaforpositive:STsegmentdepression0.1mV，last2minsStableanginapectoris第四十四頁，共一百一十五頁。編輯課件StresstestrestExersciseStableanginapectoris第四十五頁，共一百一十五頁。編輯課件

2.Echocardiography:3.Radionuclideimagingassessment:TL201，Tc99m-sestamibimyocardialperfusionscintigraphy4.X-rayofheart 5.coronaryangiography：finaldiagnose6.others:IVUS、intracoronaryDopplerflow、intracoronarypressureLaboratoryStableanginapectoris第四十六頁，共一百一十五頁。編輯課件CoronaryAngiography第四十七頁，共一百一十五頁。編輯課件1.Cardiogenicpain：aorticdissection,HOCM,aorticstenosis2.Respiratory：PE,pneumothorax,pleuritis

3.Gastrointestinal:gastro-esophagealdiseases,Hiatalhernia,cholecystitis,pepticulceration,pancreatitis4.Neuromuscular/skeletal：TietzeSyndrome(Costochondritis),intercostalneuralgia,Herpeszoster5.Psychologic:anxiety,depression,panicattacks

StableanginapectorisDiagnosisChestpain,riskfactors,ECGevidenceofischemiaduringchestpain,angiographyDifferentiation第四十八頁，共一百一十五頁。編輯課件FunctionalclassificationofSAP(CCS)CCSI：nochestpainatordinaryactivity.AnginaatstrenuousorrapidorprolongedexertionCCSII：Slightlimitationofordinaryactivity.Walkingorclimbingstairsrapidly,aftermeals,incold,inwind.Walkingmorethan2blocks,climbingmorethanstairsof3rdfloor.CCSIII：Markedlimitationofordinaryactivity.Walking1to2blocks,climbingstairsof3rdfloor

CCSIV：Inabilitytocarryonanyactivitywithoutdiscomfortanginalsymdromemaybepresentatrest.Stableanginapectoris第四十九頁，共一百一十五頁。編輯課件Generalconsideration：rest，avoidprovocativefactors,riskfactorscontrol2.Drugtherapy:

preventMIanddeathsymptomreliefandqualityoflifeimprovment3.Coronaryrevascularization:percutaneouscoronaryintervention(PCI)Coronaryarterybypasssurgery(CABG)SVG,LIMAPreventionandtreatmentStableanginapectoris第五十頁，共一百一十五頁。編輯課件antianginalandanti-ischemictherapyDrugtherapyOxygensupplyOxygendemanda.nitratesb.beta-adrenergicblockersc.Calciumantagonistsd.DrugsimprovingmetabolismStableanginapectoris第五十一頁，共一百一十五頁。編輯課件Drugtherapya.nitratesloweroxygendemand:decreasearteriolarandvenoustone,reducepreloadandafterloadincreasecoronarysupply:CoronarydilatationNitroglycerinIsosorbidedinitrateisosorbide5-mononitrate(long-actingnitrates)Stableanginapectoris第五十二頁，共一百一十五頁。編輯課件b.?－blockers:reducemyocardialoxygen:reduceHR,myocardialcontractility,BP,theLVwallstressAbslutecontraindications：severbradycardia:high-degreeA-Vblock,SSS,severeunstableLVfailureRelativecontraindications:asthmaandbronchospasticdiseaseperipheralvasculardisease?1-selective：metoprolol,atenolol,bisoprololDrugtherapyStableanginapectoris第五十三頁，共一百一十五頁。編輯課件c.Calciumantagonists：Increaseoxygensupply:dilateresistancevessels,releasespasm,improvemicrovascularfunctionDecreaseoxygendemand:negativeinotropiceffect,decreaseBPAntiplateleteffectd.Drugsimprovingmetabolism：trimethazine（vasorel），selectivelyinhibit3-KAT（3-酮酰輔酶(fǔméi)A硫解酶），partlyinhibitFAoxidationDrugtherapyStableanginapectoris第五十四頁，共一百一十五頁。編輯課件preventMIanddeaththerapya.antiplateletangents：ASA，75-325mg/dclopidogrel;ticlopidine:ADPreceptor-antagonists:Cilostazol:phosphodiesteraseinhititor,50-100mgbidb.Lipid-loweringangents:statinsc.Angiotesin-convertingenzymeinhibitor(ACEI)DrugtherapyStableanginapectoris第五十五頁，共一百一十五頁。編輯課件stentingStableanginapectoris第五十六頁，共一百一十五頁。編輯課件Unstableangina(UAP)andnon-STEMI第五十七頁，共一百一十五頁。編輯課件RestingischemiaNon-STelevationSTelevationUnstableanginaNon-QwaveAMIQwaveAMI*positiveserumcardiacmarkers****##occasionallyvariantanginaAcuteCoronarySyndrome(ACS)第五十八頁，共一百一十五頁。編輯課件PathophysiologyofACS

stableangina UAP&non-Q-wAMI Q-wAMIAngiographicthrombus

0-1% 75% >90%IncreasedFPA/TAT 0-5% 60-80% 80-90%Activatedplatelets 0-5% 70-80% 80-90%Acutecoronaryocclusion 0-1% 10-25% >90%mortality 1-2% 3-8% 6-15%FPA：fibrinopeptideATAT：thrombin-antithrombincomplexesUAPandnon-STEMI第五十九頁，共一百一十五頁。編輯課件Occuringatrest(orwithmininalexertion):last>20minssevereandofnew-onset:within1-2months,CCSIIIOccuringwithadeteriorativepattern:atleastCCSIIIvariantanginapectoris(Prinzmetalangina):transientSTelevation,causedbythecoronaryspasmDefinitionUAPandnon-STEMIAnginapectorisorequivalentischemicdiscomfortwithatleastoneofthethreefeatures第六十頁，共一百一十五頁。編輯課件BraunwaldclassificationofunstableanginaSeverity：ClassI：New-onset,oracceleratedsevereanginanorestpainwithin2monthsClassII：Anginaatrest,subacuteanginaatrest(withintheprecedingmonthbutnotwithin48h)ClassIII：Anginaatrest,acute(withinthepreceding48h)UAPandnon-STEMI第六十一頁，共一百一十五頁。編輯課件BraunwaldclassificationofunstableanginaClinicalCircumstancesClassA：SecondaryUAPaclearlyidentifiedconditionextrinsictothecoronaryvascularbedthathasintensifiedmyocardialischemia,e.g.anemia,hypotension,tachy-arrhythmiaClassB：PrimaryunstableanginaClassC：Post-infarctionUAP(within2weeksofadocumentedMI)UAPandnon-STEMI第六十二頁，共一百一十五頁。編輯課件mechanism：

1.plaqueruptureanderosion,withnonocclusivethrombus2.dynamicobstruction:Vasoconstruction3.progressivemechnialobstruction(rapidlyadvancingorISRfollowingstenting)4.secondaryUAInflammationThrombogenesisUAPandnon-STEMI第六十三頁，共一百一十五頁。編輯課件ECG:Non-STEMI:STdepressionlast>12hrCardiacbiomarkersofmyocardiumdamage:cTnT,cTnICK-MBUAPandnon-STEMICoronaryangiographyAngioscopyandIVUSOtherlaboratorytests第六十四頁，共一百一十五頁。編輯課件Riskstratification：TIMIRiskScoreAge>=65yrsMorethan3coronaryriskfactorsPriorangiographiccoronaryobstructionST-segmentdeviation0.5mmMorethan2anginaeventswithin24hoursDevelopmentofUA/NSTEMIwhileonaspirinElevatedcardiacmarkersAntaman,JAMA2000;284:835-42TIMIIIB,ESSENCE,PRISM-PLUS,TACTICS-TIMI18UAPandnon-STEMI第六十五頁，共一百一十五頁。編輯課件Treatment1.Genearlmanagement:rest,oxygen,CCU2.DrugtherapyA.Anti-ischemicdrug:intravenously,orallynitrates-blockerCalciumantagnoist:firstchoiceforvariantanginaMorphineUAPandnon-STEMI第六十六頁，共一百一十五頁。編輯課件Treatment2.Drugtherapy:B.antithrombotictherapya.Anti-plateletAspirin:early,300mgloadingdoseADP-receptorantagonist:clopidogrel300mg-600mgloadingdose,75mg/dGPIIb/IIIareceptorinhibitor:usedinptsplannedtoPCIb.Anticoagulationtherapy:HeparinLowmolecularweightheparin(LMWH)Directanti-thrombindrug:bivalirudin,hirudin

UAPandnon-STEMI第六十七頁，共一百一十五頁。編輯課件Treatment2.Drugtherapy:C.othermedicaltherapya.lipid-loweringdrugs:

statins,earlyuse(infirst24hrs)LDL-ctarget:<70mg/dl

b.ACEI:

long-termsecondarypreventionUAPandnon-STEMI第六十八頁，共一百一十五頁。編輯課件Treatment3.Invasiveversusconservativestrategyearlyinvasivestrategyindicatedforhighriskpatients:within48-72hrs,Followingbycoronaryrevascularization(PCIorCABG)4.Long-termmanagement

?-blockers,Statin,ACEI,aspirinclopidegrel(12m)UAPandnon-STEMI第六十九頁，共一百一十五頁。編輯課件PatientwithischemictypediscomfortRapidtriageto“urgentcare”roomAspirin160-325mgObtainbaselineserumcardiacmarkerlevelGoal=10minsAssessinitial12-leadsECGECGstronglysuspiciousforischemia(STdepression,T-waveinversion)STelevationNondiagnosticECGyesInitiateantiischemictherapyAssesscontraindicationstothrombolysisInitiatereperfusionstrategyContinueevaluationinEDorshort-termobservationunitObtainfollow-upserumcardiacmarkerConsider2DEchoEvidenceofischemia/infarctionRoutinebloodtesttobeobtainedonadmission:CBCLipidprofileElectrolytelevelsadmitnoadmitInitiatereperfusionstrategyIfSTelevationdevelopsDischargegoal=8-12h第七十頁，共一百一十五頁。編輯課件SYMPTOMSSUGGESTIVEOFACSNoncardiacDiagnosisChronicStableAnginaPossibleACSDefiniteACSTreatmentasindicatedbyalternativediagnosisACC/AHAChronicStableAnginaGuidelinesNoST-ElevationST-ElevationNondiagnosticECGNormalinitialserumcardiacbiomarkersSTand/orTwavechangesOngoingpainPositivecardiacbiomarkersHemodynamicabnormalitiesEvaluateforreperfusiontherapyACC/AHASTEMIGuidelinesObserve≥12hfromsymptomonsetNorecurrentpain;negativefollow-upstudiesRecurrentischemicpainorpositivefollow-upstudiesDiagnosisofACSconfirmedStressstudytoprovokeischemiaConsiderevaluationofLVfunctionifischemiaispresent(testsmaybeperformedeitherpriortodischargeorasoutpatient)NegativePotentialdiagnoses:nonischemicdiscomfort;low-riskACSArrangementsforoutpatientfollow-upPositiveDiagnosisofACSconfirmedorhighlylikelyAdmittohospitalManageviaacuteischemiapathwayAlgorithmforevaluationandmanagementofpatientssuspectedofhavingACS.AndersonJL,etal.JAmCollCardiol2007;50:e1–e157,Figure2.第七十一頁，共一百一十五頁。編輯課件STelevationmyocardialinfarctionSTEMI第七十二頁，共一百一十五頁。編輯課件AcuteCoronarySyndrome(ACS)RestingischemiaNon-STelevationSTelevationUnstableanginaNon-QwaveAMIQwaveAMI*positiveserumcardiacmarkers****##occasionallyvariantangina第七十三頁，共一百一十五頁。編輯課件ischemicnecrosisofmyocardiumresultsfromtheprolongedmyocardialischemiaprecipitated

byanocclusivecoronarythrombusatthesiteofapreexistingatheroscleroticplaque。WithtypicalandserialECGchangesRepresenttheserioussituationofcoronaryarterydiseaseSTEMIDefinition第七十四頁，共一百一十五頁。編輯課件1.incidence

：inUSA,71‰inmalebetween35-84yrs,22‰infemale,1attackinabout20second2.mortality：decreasedin30%recent10yearsstill1/3ofthepatientsdied50%ofthedeathoccuredwithin1haftertheonsetMImostdeathes

resultfromventricularfibrillationepidemiologySTEMI第七十五頁，共一百一十五頁。編輯課件Causeofthedecreasedmortalitynewdrugtherapy?-blocker,anti-thromboticLMWHnitratesACEIStatinsSTEMI第七十六頁，共一百一十五頁。編輯課件Changeofconcept1960-80s:Transmural,non-transmuralorsub-endocardium1980s:QwaveMI，non-QwaveMI1990s:STEMI,non-STEMISTEMI第七十七頁，共一百一十五頁。編輯課件Possiblemechanism

ofthechronicCADtoACS炎癥細胞少量平滑肌細胞激活的巨噬細胞血栓第七十八頁，共一百一十五頁。編輯課件Pathology:CoronarydiseasesOcclusionofLAD:anteriorwallMISTEMI第七十九頁，共一百一十五頁。編輯課件Pathology:myocardiummyocardialnecrosis(coagulationnecrosis)coronaryocclusionnecroticmusclefibresdissolvedgranulationtissueremovalofnecrosistissuecollagenzationfirmconnectivetissuescarOMI1-2hr2-3d1-2weeks6－8weeksSTEMI第八十頁，共一百一十五頁。編輯課件STEMIPathology:myocardialdiseases第八十一頁，共一百一十五頁。編輯課件Ventricularremodelingconcept:thechangesinLVsize,shape,andthicknessinvolvingboththeinfarctedandnoninfarctedsegmentsDeterminants:thesizeofinfarctionVentricularloadingconditionsInfarctrelatedarterypatencySTEMI第八十二頁，共一百一十五頁。編輯課件Infarctexpansion:anincreaseinthesizeoftheinfarctedsegment.“acutedilatationandthinningoftheareaofinfactionnotexplainedbyadditional

myocardialnecrosis”..ventriculardilatation：shiftofpressure-volumecurveofLVtotherightlargerLVvolumeatanygivendiastolicpressureCompensatory

mechanismsformaintainingstokevolumeAssociatedwithnon-uniformrepolarizationofmyocardium,predisposetolife-threateningventriculararrhythmias.STEMIVentricularremodeling第八十三頁，共一百一十五頁。編輯課件Systolicfunction:dyssynchrony:dissociationinthetimecourse

ofcontractionofadjacentsegmenthypokinesis:reductionintheextentofshorteningakinesis:cessationofshorteningdyskinesis:paradoxicalexpansion,systolicbulgingDiastolicfunction:reductioninLVcompliance:decreaseinthepeakrate

ofdeclineinLVpressure(dP/dt)riseinLVend-diastolicpressureandvolumeSTEMIpathophysiologyLVfunction第八十四頁，共一百一十五頁。編輯課件Predisposingfactor：heavyexercise,mentalstress:surgicalproceduresfever,tachycardia,respiratoryinfection,hypoxemia,hypoglycemiaPrinzmental’sanginaProdromalsymptoms：weakness,chestdiscomfort,restlessness

,newonsetAPandacceleratingAPCircadianperiodicity

peakincidence:6-12amSTEMIClinicalmanifestation第八十五頁，共一百一十五頁。編輯課件SymptomChestpain

severe,sometimesintolerable,prolonged,usuallylastingfor>30mins，lesseffectiveofsublingualnitroglycerin,retrosternalinlocation,sweating,scared,andfeelingofimpendingdeathinsomepatients,AMIismanifestedbyshockandacuteLVfailure,notbychestpain(theelderly)alerttheepigastrium

painandabdominaldisordersSTEMIClinicalmanifestation第八十六頁，共一百一十五頁。編輯課件symptomsGeneral：fever、HRincrease、WBC，ESRfastingGastrointestinalsymptom：nausea,vomiting

,arrhythmias：VPs、AVblock,atrialarrhythmiasoccurredmoreofteninpatientswithHFHeartfailure:mainlyacuteLVfailure,maydevelopeRVfailure.InitialRVfailureoccureinpatientswithRVinfarction,associatedwithhypotensionHypotensionandshock：SBP<80mmHgafterpainrelease,RVinfarctionSTEMIClinicalmanifestation第八十七頁，共一百一十五頁。編輯課件PumpfailureClassificationbasedonclinicalexamination(Killip)ClassI：noHF,ralesandS3absent；ClassII:mildHF，ralesover<50%oflung,withorwithouts3；ClassIII:acutepulmonaryedema,ralesover50%oflungfieldsClassIV:cardiogenicshockClassificationbasedoninvasivehemodynamicmonitoringClassI：Normal,PCWPpulmonarycapillarywedgepressure

<18.CI>2.2；ClassII:Pulmonarycongestion,PCWP>18.CI>2.2；ClassIII:peripheralhypoperfusion,PCWP<18,CI<2.2;ClassIV:pulmonarycongestionandperipheralhypoperfusion,PCWP>18,CI<2.2STEMIClinicalmanifestation第八十八頁，共一百一十五頁。編輯課件physicalexaminationGeneralappearance:anxious

,distress,coldperspiration,skinpallorCardiacexamination:HR:bradycardia,tachycardia,irregularheartsound:S1muffled,galloprhythmcardiacmurmurs:systolicpericardialfrictionrubsBP:previouslyhypertensivebecomenormotensiveothersSTEMIClinicalmanifestation第八十九頁，共一百一十五頁。編輯課件1.ruptureofapapillarymuscle：rarebutfatalcomplicationcauseacutemassivemitralregurgitation,pulmonaryedema2.ruptureofventricularwall：occursmostcommonlywithin1weekfreewallrupture;ruptureofinterventricularseptum3.embolization：LVmural

thrombuscausearterialembolizationDVT(deepveinthrombus)causepulmonaryembolization4.cardiacaneurysm：persistantSTelevationcausemural

thrombus,heartfailure,andarrhythmias5.post-MIsyndrome(Dresslersyndrome)：fever,chestpain,repeatedpericarditis,pleuritis,pneumoniaSTEMIClinicalmanifestationcomplications第九十頁，共一百一十五頁。編輯課件ECG：Typical：pathologicalQwave,STelevation,invertedTwaveSerial：

peakedTwave(hyperacute),STelevation(acute),Qwave,Twaveinversion(old)STEMILaboratorytest第九十一頁，共一百一十五頁。編輯課件AnteriorAMISTEMILaboratory第九十二頁，共一百一十五頁。編輯課件InferiorAMISTEMILaboratory第九十三頁，共一百一十五頁。編輯課件LocalizationLADSTEMILaboratory第九十四頁，共一百一十五頁。編輯課件STEMILaboratoryLocalizationLAD第九十五頁，共一百一十五頁。編輯課件STEMILaboratoryLocalizationLCX第九十六頁，共一百一十五頁。編輯課件STEMILaboratoryLocalizationRCA第九十七頁，共一百一十五頁。編輯課件2.vectorcardiography3.radionuclideangiography：4.Echocardiology：distinctregionofdisorderedcontraction,LVfunction,detectioncomplication5.laboratoryexamination:bloodroutineserumcardiacmarkersSTEMILaboratory第九十八頁，共一百一十五頁。編輯課件markerRangeoftimestoinitialelevation（h）Meantimetopeakelevations（nonthrombolysis）TimetoreturntonormalrangeMyoglobin1-46-7h24hcTnI*3-624h7-9dcTnT*3-612h-2d7-14dCK-MB3-616-24h3-4dCK-MM1-612h38hLDH8-1024-48h10-14dCardiacmarkers*MostsensitiveandspecificmarkerofmyocardialdamageSTEMILaboratory第九十九頁，共一百一十五頁。編輯課件Differentialdiagnosis1.anginapectoris：chestpain,complication,generalsymptoms,elevationofcardiamarkers,ECGchanges2.acutepericarditis：