1、冠狀動脈粥樣硬化性心臟病 (coronary atherosclerotic heart disease),大連醫(yī)科大學附屬二院心內科 牛 楠,動脈粥樣硬化 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 Be

2、en Surgically Removed from Coronary Artery,Courtesy Ronald D. Gregory and John Riley, MD.,Non Modifiable Risk Factors,Age A dominant influence Atherosclerosis begins in the young, but does not precipitate organ injury until later in life Gender Men more prone than women, but by age 60-70 about equal

3、 frequency Family History Familial cluster of risk factors Genetic differences,Modifiable Risk Factors (potentially controllable),Hyperlipidemia Hypertension Cigarette smoking Diabetes Mellitus Elevated Homocysteine Factors that affect hemostasis and thrombosis Infections: Herpes virus; Chlamydia pn

4、eumoniae 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

5、accumulation,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

6、First Decade,From Third Decade,From Fourth Decade,AHA Classification of atherosclerosis,動脈粥樣硬化血栓形成: 具共同病理基礎的進展性過程,正常,脂肪條紋,纖維斑塊,粥樣硬化斑塊,斑塊破潰/ 裂隙和血栓形成,心肌梗死,缺血性中風/TIA,嚴重的 下肢缺血,臨床無癥狀,心血管死亡,年齡增長,穩(wěn)定性心絞痛 間歇性跛行,不穩(wěn)定性 心絞痛,ACS,*ACS, 急性冠脈綜合征; TIA, 一過性腦缺血發(fā)作,缺血性腎病 缺血性腸病,Coronary Artery Disease,冠心病,Clinical classif

7、ication(1979 WHO),Asymptomatic CHD(隱匿型） Angina pectoris CHD（心絞痛型） 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 angina asymptomatic CHD ischemic cardiomyopathy CHD Acute coronary syndrome: unstable

8、angina STEMI/NSTEMI,急性冠脈綜合癥的病理生理學,Fuster et al. N Engl J Med. 1992;326:310-318. Davies et al. Circulation. 1990;82(Suppl II):II-38, II-46.,不穩(wěn)定血栓(UA/NSTEMI),脂肪池 巨噬細胞 內在的壓力，張力 外部的剪切力,裂縫,大裂縫,小裂縫,閉合血栓 (STEMI),動脈粥樣硬化斑塊,斑塊破裂,血栓,No ST Elevation,ST Elevation,Acute Coronary Syndrome,Unstable Angina,NQMI,Qw M

9、I,NSTEMI,Myocardial 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 muscl

10、e.,Clinical classification and pathology,Stable angina:fixed atheromatous stenosis Unstable angina:dynamic obstruction by plaque rupture with superimposed thrombosis and spasm,斑塊破裂引起急性嚴重事件,不穩(wěn)定 心絞痛,心肌梗死,猝死,穩(wěn)定性 (勞力性) 心絞痛,不穩(wěn)定斑塊的進展過程,穩(wěn)定斑塊的進展過程,Nissen SE. Am J Cardiol. 2000;86(suppl):12H-17H,不穩(wěn)定斑塊,斑塊破裂,血

11、栓形成,穩(wěn)定斑塊,斑塊體積增加,管腔狹窄,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

12、can occur in 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. Duration

13、- 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 area

14、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 fe

15、atures,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. M

16、ost 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 Esophageal

17、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 Re

18、sting 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,Holter,

19、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,MIimpendin

20、g 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 coron

21、ary 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 with

22、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 d

23、isease. 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,冠狀動脈造影,冠心病,LAD:stenosis LAD:normal,冠心病,RCA:stenosis LCX:st

24、enosis,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,No

25、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,PT

26、CA,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 o

27、r worsening symptoms of myocardial ischemia: rest angina new-onset severe angina increasing angina,評估住院期間和出院后長期缺血風險,評估住院期間死亡風險 (c-index 0.83)* 及出院后6個月死亡風險 (c-index 0.81)* 多個大型數據庫中驗證其有效性 (c-indices分別為 0.84*和0.75*) 評價死亡/再發(fā)心梗的長期風險,網絡版可下載 /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 events A. Incidence of MI: 8 to 10% B. M

30、ortality: 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,斑塊破裂引起急性嚴重事件,不穩(wěn)定 心絞痛,心肌

31、梗死,猝死,穩(wěn)定性 (勞力性) 心絞痛,不穩(wěn)定斑塊的進展過程,穩(wěn)定斑塊的進展過程,Nissen SE. Am J Cardiol. 2000;86(suppl):12H-17H,不穩(wěn)定斑塊,斑塊破裂,血栓形成,穩(wěn)定斑塊,斑塊體積增加,管腔狹窄,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,Investigati

32、on,ECG Cardiac Enzyme or Troponin Coronary angiography,Acute Coronary Syndromes,評估住院期間和出院后長期缺血風險,評估住院期間死亡風險 (c-index 0.83)* 及出院后6個月死亡風險 (c-index 0.81)* 多個大型數據庫中驗證其有效性 (c-indices分別為 0.84*和0.75*) 評價死亡/再發(fā)心梗的長期風險,網絡版可下載 /GRACE,*Granger CB, et al. Arch intern Med. 2003;163:2345-2353. *Eagle K, at al. JAMA. 2004;291:2727-2733.,management,Admitted to hospital Best rest,Oxygen Anti-platelet:asprin, Clopidogrel , GP IIb/IIIa inhibitors Anticoagulant: UFH or LMWH B-blocker Nitrates (intraveno