冠狀動脈粥樣硬化性心臟病英文212/24/2024ContentsAtherosclerosisStableAnginaPectorisAcuteCoronarySyndromeUAandNSTEMIAMI(STEMI)312/24/2024Self-study

VariantAnginaCardiacSyndromeXSilentMyocardialIschemiaMyocardialBridging412/24/2024WhatIsAtherosclerosis?Atherosclerosisisthedescriptivetermforthickenedandhardenedlesionsofthemediumandlargemuscularandelasticarteries.512/24/2024WhatIsCoronaryHeartDisease?612/24/2024CoronaryheartdiseaseatherosclerosisCoronarystenosiscoronaryspasmMyocardialischemia,necrosisIschemicheartdisease712/24/2024812/24/2024Atherosclerosis912/24/2024FoamcellFattysteak

atheromatousplaquerupturedplaquesFibrousplaqueEndothelialdamagefirstdecadeThirddecadeForthdecadeAdaptedfromStaryHCetal.Circulation1995;92:1355-1374.mediumdamage12/24/202410Whatdamagedoesatherosclerosiscause?

1112/24/2024CommonlocationCoronaryHeartDiseaseCarotidArteryDiseasePeripheralArterialDiseaseChronicKidneyDisease1212/24/2024Howdoesatherosclerosisstartandprogress?1312/24/2024ElevatedlevelsofcholesterolandtriglyceridesinthebloodHighbloodpressureCigarettesmoking1412/24/2024BiologicalprocessesAccumulationofintimalcellssmoothmusclecellsMacrophagesT-lymphocytes1512/24/2024BiologicalprocessesProliferatedconnectivetissuematrixcollagenelasticfibersproteoglycans

1612/24/2024Biologicalprocesses3.Accumulationoflipid1712/24/2024Atherosclerosis-Hypothesis

HypothesisoflipoproteininfiltrationAggregationofplateletsandthrombosisClonaltheoryTheresponse-to-injuryhypothesis1812/24/2024Highbloodpressure,bacterium,virus,toxin,ox-LDL,immunefactor,vasoactivesubstance.Plateletsareactivated,

adhesionandaggregationofplatelets.Lipidoses,growthfactor,proliferationofsmoothmuclecells,collagen,lipolyticenzyme.Response-to-injury

1912/24/2024Pathologyandpathophysiology

FattysteakFibrousplaqueComplicatedlesion2012/24/2024InitiationofAtherosclerosis

Fattysteakformation2112/24/2024InitiationofAtherosclerosis2212/24/2024fibrousplaque2312/24/20242412/24/2024

2512/24/2024ThinCapVulnerablePlaqueThrombusUnstable“ActiveVolcano”ThickCapCalcifiedPlaqueFlow-limitingLesionStableAngina“DormantVolcano”SAPACSpressureorasqueezingpain!!!2612/24/2024UnstableandStablePlaques薄的纖維帽炎性細胞少的平滑肌細胞內(nèi)皮細胞不完整巨噬細胞較厚的纖維帽沒有炎性細胞泡沫細胞完整的內(nèi)皮細胞較多平滑肌細胞LibbyP.Circulation.1995;91:2844-2850.unstablestable12/24/202428Atherosclerosis

ClinicalstagesAbsenceofsymptomorstageofincubationischemianecrosis(target

organ)fibrosis2912/24/2024clinicalmanifestation

GeneralmanifestationAorticatherosclerosisCoronaryarteryatherosclerosisCerebral

atherosclerosisRAatherosclerosisMesentericatherosclerosisPeripheral

arteryatherosclerosis3012/24/2024Laboratory

ExaminationLackofsensitiveandspecificmethodsforearlydiagnosisDyslipidemiaX-ray：DSAshowseverityofstenosisDopplerultrasound:bloodflow3112/24/2024Laboratory

Examinationradionuclide：detectionofischemiaEchocardiogram：CHDECGandstresstest:CHDAngiography:themostdirectwayIntravascularultrasound,angioscopeCT,MRI3212/24/2024Riskfactors

1.Lipiddisorders(Dyslipidemia)Increasedcholesterol:TcandLDL-c,TG,ApoB,Lp(a)Decreasedcholesterol:HDL-capoA2.Hypertension3312/24/2024Riskfactors3.DM,MetabolicsyndromeorinsulinresistancesyndromeMorediffuselesionCADequivalent75-80%causeofdeathinadultDMarevasculardiseases:CAD,cerebrovasculardisease,orperipheralvasculardisease3412/24/20247yearsincidenceofdeath/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:CADequivalent3512/24/2024Riskfactors

4.

Cigarettesmoking：morethrombogenic5.

Familyhistory6.

Aging：>40yrsadults，4/5fatalmyocardialinfarctionoccuredinpatiens>65yrs7.Malegender/postmenopausalstate：male:female=2：1,mendevelopCHD10-15yrsearlierthanwomen8.alcohol9.Others:diet,homocysteine,hemostaticfactorsinflammation/infection3612/24/2024

Drugtherapy

anti-platelet：

aspirin,clopidogrel,GPIIb/IIIainhitibor,Dipyridamole,cilostazolLipid-loweringHMG-CoAreductaseinhibitors（statins）3712/24/2024DoubtsofpatientsQuest1：Mybloodpressureisonlyabout100/60mmHg,Whygivemehypotensorlotensin?3812/24/2024DoubtsofpatientsQuestion2：Myshapeisnotfat,lipidisnothigh,whygivemelipid-loweringdrugs,madeamistake?3912/24/2024DoubtsofpatientsQuestion3：Ihavecoronaryheartdisease,thenshouldIdolessactivities

inordertoprotecttheheart?4012/24/2024

CoronaryHeartDisease(CHD)

12/24/202441ClinicalTypeSilentmyocardialischemiaAnginapectorisMyocardialinfarctionIschemiccardiomyopathySuddencardiacdeath12/24/202442SilentMyocardialIschemiaDefinedasdocumentedepisodesofischemianotassociatedwithanytypicaloratypicalsymptomsthatamongpatientswithobstructivecoronaryarterydisease.TypeI:myocardialischemiaisdetectedonroutineECG,24hambulatoryECGmonitoring(Holter),etc.butnotexperienceanginaatanytime;TypeII:patientsaremostfrequentlyencounteredinclinicalpractice.Someepisodesofischemiaareassociatedwithchestdiscomfortandotherepisodesareasymptomatic.12/24/202443IschemicCardiomyopathySymptomsofheartfailure,causedbyischemicmyocardialdysfunction,diffusefibrosis,andmultipleinfarction,aloneorincombination.Manifestations:ventriclesenlargement(dominantleftventricle),heartfailureandarrhythmias.12/24/202444SuddenCardiacDeathSCDisnaturaldeathduetocardiaccauses,heraldedbyabruptlossofconsciousnesswithin1houroftheonsetofacutesymptoms.Thetimeandmodeofdeathareunexpected.WHOdefinition:unexpecteddeathwithin6hours.Thisdefinitionincorporatesthekeyelementsofnatural,

rapidandunexpected.OnehalfofSCDduetocoronaryheartdisease，causedbyseverearrhythmias,suchasventricularfibrillationandcardiacarrest.12/24/202445AcuteCoronarySyndromeACSrepresentsaspectrumofconditions.Acuteplaquechangecharacterizedbyplaqueruptureandexposureofsubstancesthatpromoteplateletactivationandthrombingeneration.12/24/202446STABLEANGINAPECTORIS4712/24/2024Definition

Acuteandtransientmyocardialischemiaandanoxaemia.Usuallycausedbycoronaryinsufficiencyduringexertion.4812/24/2024Characteristicsparoxysmalprecordialsqueezing-likechestpain,behindthemidsternumradiatedtoleftshoulderandupperarmprecipitatedbystressorexertionrelievedrapidlybyrestornitrates4912/24/2024

hypoxiaCoronarystenosis(others:aorticvalvedisease,HOCM)+Myocardialoxygendemand（HRXSBP）increased

myocardialhypoxiaacumulationofmetabolicproduct,stimulateC1-5tocausethesensationofchestpain

mechanism5012/24/2024inangiographySignificantcoronarylesionwithdiameterstenosis>70%in75%ptsNosignificantstenosisinabout5-10%pts,Ischemiamayberelatedtocoronaryspasmormicrovasculardysfunction.PathologyStableanginapectoris5112/24/2024pathophysiology1.MetabolicandelectrophysiologyATPreduced,accumulationofacidsubstancesDysfunctionofionpump(Na+-K+,andNa+-Ca++)Earlydepolarization(STdeviation)2.LVfunctionandhemodynamicsituationLVcontractility,systolicBP,strokevolume,cardiacoutputdecreasedLVEDpressureandvolumeStunningofmyocardiumStableanginapectoris5212/24/2024symptom：chestpainlocation

behindorslightlytotheleftofthemidsternumnodefiniteborderlineradiatedtotheleftshoulderandupperarmAtypicallocation:lowerjaw,thebackofneckClinicalmanifestationStableanginapectoris5312/24/2024character：tightness,squeezing,burning,pressing,choking,bursting,rarelysharpduration：3－5minsprecipitatingfactor

exertionoremotionalagitationpainrelief:withinseveralminsafterrestorusingnitroglycerinClinicalmanifestationStableanginapectoris5512/24/2024PhysicalexaminationincreasedHR,elevatedBPanxietycoolandsweatyskinoccasionally

galloprhythm，transientsystolicmurmurClinicalmanifestationStableanginapectoris5612/24/2024

Auxiliaryexamination1.ECG：Resting

ECGECGduringchestpain:ST-Tchangefoundin95%ptsHolter:detectofslientischemiaStresstesting:Criteriaforpositive:STsegmentdepression

0.1mV，last2minscontraindication：AMI,UAP,myocarditis,Hypertension,heartfailure,aorticstenosis,HOCM,severarrhythmia,aorticaneurysmEndofthetest：STor≥0.2mV，APattacks，BP>220mmHg，BPdrop，ventriculararrhythmiaStableanginapectoris5712/24/2024StresstestrestExersciseStableanginapectoris5812/24/2024

2.Echocardiography:3.Scintigraphyassessment:CandetectfillingdefectofInfarctionarea4.X-rayofheart 5.coronaryangiography：finaldiagnose6.others:IVUSAuxiliaryexaminationStableanginapectoris5912/24/2024CoronaryAngiography6012/24/2024StableAnginaPectorisDiagnosisChestpainriskfactorsECGevidenceofischemiaduringchestpainangiography6112/24/2024Cardiovascular

causesNoncardiaccausesStableAnginaPectorisDifferentialdiagnosis6212/24/2024Cardiovascular

cause

MyocardialinfarctionPericarditisAorticdissectionPulmonaryembolismPulmonaryhypertension6312/24/2024Noncardiac

cause

PneumoniawithpleurisySpontaneouspneumothoraxMusculoskeletaldisordersHerpeszosterEsophagealrefluxPepticulcer6412/24/2024Generaltreatment：riskfactorscontrol2.Drugtherapy3.Coronaryrevascularization:percutaneouscoronaryintervention(PCI)Coronaryarterybypasssurgery(CABG)SVG,IMAGTreatmentStableAnginaPectoris6512/24/2024BloodandoxygensupplytotheheartMyocardial

bloodflowMyocardialoxygen

consumption4%oftotal

cardiacoutput

suppliedtothe

myocardium12%oftotalbodyoxygen,

usedatrestby

myocardium12/24/202466CoronaryReserveMyocardial

bloodflow

increasesupto

4times...…tomeet

increased

myocardialoxygen

demand12/24/202467Myocardialoxygen

supplyanddemandO2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2supplyO2demand12/24/202468AimsofmedicaltherapyArterialvasodilatationReducesarterial

resistanceReducesafterloadDecreases

sympatheticdriveReduceheartrate

andcontractileforceReducescardiacworkLVRVDilatationof

coronaryarteriesImprovescoronary

supplyVenodilatationReduces

venousreturnReducespreload12/24/202469antianginalandanti-ischemictherapyDrugtherapyOxygensupplyOxygendemanda.Nitratesb.Betablockersc.Calciumantagonistsd.DrugsimprovingmetabolismStableAnginaPectoris7012/24/2024Drugtherapya.Nitratesloweroxygendemand:decreasearteriolarandvenoustone,reducepreloadandafterloadincreasecoronarysupply:CoronarydilatationNitroglycerinIsosorbidedinitrateisosorbide5-mononitrate(long-actingnitrates)StableAnginaPectoris7112/24/2024NitratesinanginaReducepreload

through

venodilatationReduceafterloadby

loweringarterialresistanceReduceplateletaggregationIncreasecoronaryperfusion,includingischaemicareasReversalofcoronaryspasm12/24/202472b.?－blockers:reducemyocardialoxygen:reduceHR,myocardialcontractility,BP,theLVwallstressAbslutecontraindications：severbradycardia:high-degreeA-Vblock,SSS,severeunstableLVfailureRelativecontraindications:asthmaandbronchospasticdiseaseperipheralvasculardisease?1-selective：metoprolol,atenolol,bisoprololDrugtherapyStableAnginaPectoris7312/24/2024c.Calciumantagonists：Increaseoxygensupply:dilateconduitandresistancevessels,releasespasm,improvemicrovascularfunctionDecreaseoxygendemand:negativeinotropiceffect,decreaseBPAntiplateleteffectd.DrugsimprovingmetabolismDrugtherapyStableAnginaPectoris7412/24/2024preventMIanddeaththerapya.antiplateletangents：ASAclopidogrelCilostazolb.Lipid-loweringangents:statinsc.Angiotesin-convertingenzymeinhibitor(ACEI)DrugtherapyStableAnginaPectoris7512/24/2024stentingStableAnginaPectoris7612/24/2024UnstableAngina(UA)andnon-STEMI7712/24/2024ACSNon-STelevationSTelevationUnstableanginaNon-QwaveAMIQwaveAMI*positiveserumcardiacmarkers****##occasionallyvariantanginaAcuteCoronarySyndrome(ACS)7812/24/2024PathophysiologyofACS

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-antithrombincomplexesUAandnon-STEMI7912/24/2024Occuringatrest(orwithmininalexertion):last>20minsseverandofnew-onset:within1-2months,CCSIIIOccuringwithacrescendopattern:DeteriorationofCCSclassfication,atleastCCSIIIDefinition

UAandnon-STEMIAnginapectorisorequivalentischemicdiscomfortwithatleastoneofthethreefeatures8012/24/2024BraunwaldclassificationofunstableanginaSeverity：ClassI：New-onset,oracceleratedsevereanginanorestpainwithin2monthsClassII：Anginaatrest,subacuteanginaatrest(withintheprecedingmonthbutnotwithin48h)ClassIII：Anginaatrest,acute(withinthepreceding48h)UAandnon-STEMI8112/24/2024BraunwaldclassificationofunstableanginaClinicalCircumstancesClassA：SecondaryUAPaclearlyidentifiedconditionextrinsictothecoronaryvascularbedthathasintensifiedmyocardialischemia,e.g.anemia,hypotension,tachy-arrhythmiaClassB：PrimaryunstableanginaClassC：Post-infarctionUAP(within2weeksofadocumentedMI)UAandnon-STEMI8212/24/2024mechanism：

1.plaqueruptureanderosion,withnonocclusivethrombus2.dynamicobstruction:Vasoconstruction3.progressivemechnialobstruction(rapidlyadvancingorISRfollowingstenting)4.secondaryUAInflammationThrombogenesisUAandnon-STEMI8312/24/2024

ECG:Non-STEMI:STdepressionlast>12hrCardiacbiomarkersofmyocardiumdamage:cTnT,cTnICK-MBUAPandnon-STEMICoronaryangiographyAngioscopyandIVUSOtherlaboratorytests8412/24/2024Treatment1.Genearlmanagement:rest,oxygen,CCU2.DrugtherapyA.Anti-ischemicdrug:intravenously,orallynitrates

-blockerCalcium

antagnoist:firstchoiceforvariantanginaMorphinesulfateUAandnon-STEMI8512/24/2024Treatment

2.Drugtherapy:B.antithrombotictherapya.Anti-plateletAspirin:early,300mgloadingdoseADP-receptorantagonist:clopidogrel300mg-600mgloadingdose,75mg/dGPIIb/IIIareceptorinhibitor:usedinptsplannedtoPCIb.Anticoagulationtherapy:HeparinLowmolecularweightheparin(LMWH)Directanti-thrombindrug:bivalirudin,hirudin

UAandnon-STEMI8612/24/2024Treatment2.Drugtherapy:C.othermedicaltherapya.lipid-loweringdrugs:

sta