冠心病课件(大医英)
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• 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 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.
Response to injury
Endothelia dysfunction
Initiation of Fatty Streak
Fatty Streak
Fibro-fatty Atheroma
Atherosclerosis Timeline
Foam Cells Complicated Lesion/ Fatty Intermediate Fibrous Rupture Streak Lesion Atheroma Plaque
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 accumulation
斑块破裂引起急性严重事件
不稳定斑块的进展过程
不稳定 心绞痛
心肌梗死
不稳定斑块
斑块破裂
血栓形成
猝死
稳定斑块的进展过程
稳定性 (劳力性) 心绞痛
稳定斑块 斑块体积增加 管腔狭窄
Nissen SE. Am J Cardiol. 2000;86(suppl):12H-17H
Stable angina pectoris
Clinical classification and pathology
• Stable angina:fixed atheromatous stenosis • Unstable angina:dynamic obstruction by plaque rupture with superimposed thrombosis and spasm
Байду номын сангаас
Hamm Lancet 358:1533,2001
Presentation Working Dx
Ischemic Discomfort
Acute Coronary Syndrome
Davies MJ Heart 83:361, 2000
ECG
No ST Elevation NSTEMI
ST Elevation
Plaque That Has Been 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 frequency Family History Familial cluster of risk factors Genetic differences
急性冠脉综合症的病理生理学
大裂缝
脂肪池 巨噬细胞 内在的压力，张力 外部的剪切力 裂缝 小裂缝
闭合血栓 (STEMI)
不稳定血栓(UA/NSTEMI)
动脉粥样硬化斑块
斑块破裂
血栓
Fuster et al. N Engl J Med. 1992;326:310-318. Davies et al. Circulation. 1990;82(Suppl II):II-38, II-46.
Biochem. Marker Final Dx Unstable Angina
Myocardial Infarction NQMI Qw MI
ANGINA PECTORIS
Definition of Angina
A pain or discomfort in the chest or adjacent areas caused by insufficient blood flow to the heart muscle.
Coronary Artery Disease
冠心病
Clinical classification(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）
Clinical 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. • Most pt:(-)
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 - anginal episode is typically minutes in duration. Fleeting discomfort or a dull ache lasting for hours is rarely angina
Sudden death CHD（猝死型）
Classification of IHD
• Chronic ischemic syndrome: stable angina asymptomatic CHD ischemic cardiomyopathy CHD • Acute coronary syndrome: unstable angina STEMI/NSTEMI
Alternative Diagnoses to Angina for Patients with Chest Pain
• Non-Ischemic CV
– aortic dissection – pericarditis
Gastrointestinal • Esophageal
– esophagitis – spasm – reflux
Psychiatric • Anxiety disorders
– hyperventilation – panic disorder – primary anxiety
•
Pulmonary
– – – – pulmonary embolus pneumothorax pneumonia pleuritis
Endothelial Dysfunction From First Decade From Third Decade From Fourth Decade
Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104).
AHA Classification of atherosclerosis
•
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
•
• •
Affective disorders
– depression
•
Biliary
– colic – cholecystitis – choledocholithia sis – cholangitis
Somatiform disorders Thought disorders
– fixed occlusions
Modifiable Risk Factors (potentially controllable)
• • • • • • • Hyperlipidemia Hypertension Cigarette smoking Diabetes Mellitus Elevated Homocysteine Factors that affect hemostasis and thrombosis Infections: Herpes virus; Chlamydia pneumoniae • Obesity, sedentary lifestyle, stress
动脉粥样硬化血栓形成: 具共同病理基础的进展性过程
斑块破溃/ 裂隙和血栓形成 正常 脂肪条纹 纤维斑块 粥样硬化斑块
不稳定性 心绞痛
心肌梗死
}ACS
缺血性中 风/TIA
临床无症状 稳定性心绞痛 间歇性跛行
严重的 下肢缺血
缺血性肾病 缺血性肠病
心血管死亡
年龄增长
*ACS, 急性冠脉综合征; TIA, 一过性脑缺血发作
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 in patients with normal coronary arteries
Response to injury
Endothelia dysfunction
Initiation of Fatty Streak
Fatty Streak
Fibro-fatty Atheroma
Atherosclerosis Timeline
Foam Cells Complicated Lesion/ Fatty Intermediate Fibrous Rupture Streak Lesion Atheroma Plaque
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 accumulation
斑块破裂引起急性严重事件
不稳定斑块的进展过程
不稳定 心绞痛
心肌梗死
不稳定斑块
斑块破裂
血栓形成
猝死
稳定斑块的进展过程
稳定性 (劳力性) 心绞痛
稳定斑块 斑块体积增加 管腔狭窄
Nissen SE. Am J Cardiol. 2000;86(suppl):12H-17H
Stable angina pectoris
Clinical classification and pathology
• Stable angina:fixed atheromatous stenosis • Unstable angina:dynamic obstruction by plaque rupture with superimposed thrombosis and spasm
Байду номын сангаас
Hamm Lancet 358:1533,2001
Presentation Working Dx
Ischemic Discomfort
Acute Coronary Syndrome
Davies MJ Heart 83:361, 2000
ECG
No ST Elevation NSTEMI
ST Elevation
Plaque That Has Been 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 frequency Family History Familial cluster of risk factors Genetic differences
急性冠脉综合症的病理生理学
大裂缝
脂肪池 巨噬细胞 内在的压力，张力 外部的剪切力 裂缝 小裂缝
闭合血栓 (STEMI)
不稳定血栓(UA/NSTEMI)
动脉粥样硬化斑块
斑块破裂
血栓
Fuster et al. N Engl J Med. 1992;326:310-318. Davies et al. Circulation. 1990;82(Suppl II):II-38, II-46.
Biochem. Marker Final Dx Unstable Angina
Myocardial Infarction NQMI Qw MI
ANGINA PECTORIS
Definition of Angina
A pain or discomfort in the chest or adjacent areas caused by insufficient blood flow to the heart muscle.
Coronary Artery Disease
冠心病
Clinical classification(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）
Clinical 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. • Most pt:(-)
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 - anginal episode is typically minutes in duration. Fleeting discomfort or a dull ache lasting for hours is rarely angina
Sudden death CHD（猝死型）
Classification of IHD
• Chronic ischemic syndrome: stable angina asymptomatic CHD ischemic cardiomyopathy CHD • Acute coronary syndrome: unstable angina STEMI/NSTEMI
Alternative Diagnoses to Angina for Patients with Chest Pain
• Non-Ischemic CV
– aortic dissection – pericarditis
Gastrointestinal • Esophageal
– esophagitis – spasm – reflux
Psychiatric • Anxiety disorders
– hyperventilation – panic disorder – primary anxiety
•
Pulmonary
– – – – pulmonary embolus pneumothorax pneumonia pleuritis
Endothelial Dysfunction From First Decade From Third Decade From Fourth Decade
Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104).
AHA Classification of atherosclerosis
•
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
•
• •
Affective disorders
– depression
•
Biliary
– colic – cholecystitis – choledocholithia sis – cholangitis
Somatiform disorders Thought disorders
– fixed occlusions
Modifiable Risk Factors (potentially controllable)
• • • • • • • Hyperlipidemia Hypertension Cigarette smoking Diabetes Mellitus Elevated Homocysteine Factors that affect hemostasis and thrombosis Infections: Herpes virus; Chlamydia pneumoniae • Obesity, sedentary lifestyle, stress
动脉粥样硬化血栓形成: 具共同病理基础的进展性过程
斑块破溃/ 裂隙和血栓形成 正常 脂肪条纹 纤维斑块 粥样硬化斑块
不稳定性 心绞痛
心肌梗死
}ACS
缺血性中 风/TIA
临床无症状 稳定性心绞痛 间歇性跛行
严重的 下肢缺血
缺血性肾病 缺血性肠病
心血管死亡
年龄增长
*ACS, 急性冠脉综合征; TIA, 一过性脑缺血发作
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 in patients with normal coronary arteries