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1、病史特点,男性，59岁反复胸痛4个月，加重1个月。胸痛呈压榨性与劳力有关。有高血压，吸烟史。有心脑血管病阳性家族史。查体：体胖，无明显其他阳性发现。ECG：V4V6，I，aVL ST 0.5-1mm.,思考,胸痛的鉴别心绞痛的特点心绞痛的分级心绞痛的分类不同类型心绞痛的病理基础进一步检查冠心病的易患因素,心绞痛的鉴别(1),Non-ischemic CVAortic dissectionPericarditisPulmonaryPulmonary embolusPneumothoraxPneumoniaPleuritis,GastrointestinalEsophagealEsophagiti
2、s,Spasm,RefluxBiliaryColicCholecystitisCholedocholithiasisCholangitisPeptic ulcerPancreatitis,心绞痛的鉴别(2),Chest WallCostochondritisFibrositisRib fractureSternoclavicular arthritisHerpes zoster(before the rash),PsychiatricAnxiety disordersHyperventilationPanic disorderPrimary anxietyAffective disorders
3、(e.g.,depression)Somatiform disordersThought disorders(e.g.,fixed delusions),心绞痛特点,SAVES U：Sudden onset;Anterior chest;Vague sensation;Exercise precipitated;Short duration;Unanimous attack.,Grading of Angina Pectoris by CCSC,Class I:日常体力活动不引起心绞痛.Class II:日常体力活动轻度受限.Class III:日常体力活动明显受限.Class IV:任何体力
4、活动都引起症状，可以有休息时心绞痛。,UAP 的主要临床表现,Rest angina:Occurring at rest,usu.20min,occurring within a week of presentation.New onset angina:At least CCSC III severity,2 months of initial presentation.Increasing angina:Distinctly more frequent,longer in duration,lower in Threshold.(ie.Increased by at least one C
5、CSC class in 2 months,to at least CCSC III severity),Noninvasive Testing:ECG/Chest X-ray,ECG:Normal in 50%stable angina.Abnormal in 50%angina(normal rest ECG).Equivocal:QIII,QS in V1,V2.Pseudonormalization of ST depression or T inversion.Chest X-ray,ECHO,本例:左室肥厚，左室舒张功能减低。室间隔增厚：13mm(7-11mm),左室后壁10mm(
6、7-11mm)。室壁运动正常，各瓣膜结构及功能正常，无心包积液。二尖瓣血流频谱示左室功能减低，E/A=0.5,冠状动脉造影,本例冠状动脉造影：前降支中段99狭窄，回旋支近段90狭窄，远段50狭窄。Definition of Significant CAD 70%diameter stenosis of 1 major epicardial artery segment.50%diameter stenosis of left main.Although lesions of less stenosis can cause angina,they have much less prognosti
7、c significance.,Noninvasive Testing:Ultrafast Computed Tomography,Ultrafast(electron beam)computed tomography(EBCT)for the detection and quantification of coronary calcification:Sensitivity(detection of calcium):85-100%.Specificity:41-76%.Positive predictive value:55-84%.Negative predictive value:84
8、-100%.,Noninvasive Testing:Exercise ECG(1),Absolute contraindications:MI in 2 days;Significant arrhythmias;Severe AS;Symptomatic HF;Acute PE;Acute myocarditis or pericarditis;Acute aortic dissection.,Noninvasive Testing:Exercise ECG(2),Relative contraindication:Left main coronary stenosis;Moderate A
9、S;Electrolyte abnormalities;SBP 200mmHg;DBP 110mmHg;Tachy-or Brady-arrhythmias;High degree AVBHCMP or other forms of OT obstruction;Mental or physical impairment;,Noninvasive Testing:Exercise ECG(3),Risk:MI and death 1/2500 tests.A standard percentage(often 85%)of age-predicated maximum heart rate i
10、s targeted.Reported 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 ECG(4)(Absolute indication for stopping):,SBP drop 10mmHg with ischemia;Moderat
11、e 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 ECG(5)(Relative indication for stopping):,SBP drop 10mmHg without ischemia;SBP 250 or DBP 115mmHg;ST depressio
12、n 2mm;Marked axis deviation;Multifocal PVCs,triplets PVCs,SVT,heart block or bradyarrhythmias,BBB or IVCBIncreasing chest pain;Serious symptoms.,Noninvasive Testing:Exercise ECG(6),Sensitivity:68%;Specificity:77%Influence of other factors on test:Digoxin:25-40%abnormal ST depression.Beta blockers:Gr
13、adually withheld 48hrs.Anti-HBP,vasodilators,nitrates,flacainide.LBBB:RBBB:LV hypertrophy:More false-positive.Rest ST depression:Additional ST significant.,Stress Imaging Studies,Good candidates for stress imaging,as opposed to exercise ECG:CLBBB,Paced rhythm,WPW etc.ST 1mm at rest,Unable to exercis
14、e,Angina with prior Revascularization.,Pharmacologic Modalities(Vasodilators)Used in Stress Imaging,Dipyridamole(DIP)inhibiting cellular uptake of adenosine(a potent coronary vasodilators).The flow increase by adenosine is of lesser magnitude through stenostic arteries,creating heterogeneous myocard
15、ial perfusion.Side effects of both DIP and ADE are rare,but may cause severe bronchospasm in patients with asthma or COPD.,Pharmacologic Modalities(Dobutamine)Used in Stress Imaging,In high doses(20 to 40g/kg/min)increases HR,SBP and myocardial contractility.The flow increase(2-3 times)is less than
16、that elicited by adenosine or dipyridamole.Side effects are frequent,but the test appears to be safe even in the elderly,including nausea,anxiety,headache,tremor,VPC,APC,SVT,nonsust-VT,chest pain and angina(8%).,Invasive Testing-Angiography(Indications),Chest pain,possible ischemic,coexisting COPD n
17、ot a candidate forExercise test because of dyspnea;Perfusion imaging with dipyridamole or adenosine because of bronchospasm and theophylline therapy;Stress ECHO because of poor images.,Invasive Testing-Angiography(Indications),Typical or atypical symptoms and a high clinical probability of sever CAD
18、.Most appropriate for a patient 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.,RISK STRATIFICATION,A.Clinical AssessmentB.ECG/Chest X-RayNoninvasive TestingCoronary
19、Angiography and Left Ventriculography,Risk 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 diseased vessels.A recent coronary plaque
20、rupture:worsening clinical symptoms with unstable feature;General health and noncoronary comorbidity.,Risk Stratification(Clinical Assessment),Clinical Parameters Predictive of Severe(left main or three vessel)CADAge,Gender,Typical angina,Previous MI,DM and use of insulin,Risk Stratification(ECG/Che
21、st 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 calcification,Risk Stratification(Noninvasive Testing),Resting LV FunctionImportance of assessmentGlobal LV FunctionSWMAMR,LV An
22、eurysm,LV Thrombosis,TREATMENT,Pharmacologic TherapySuccessful and Initiating TreatmentEducation of Patients with CSARisk FactorsRevascularization for CSA,Overview of Treatment,Stable angina-Two purposes:To prevent MI and death.To reduce symptoms of angina and occurrence of ischemia.,稳定心绞痛的A，B，C，D，E
23、治疗,A=Aspirin and Antianginal B=Beta-blocker and Blood pressureC=Cigarette smoking and CholesterolD=Diet and DiabetesE=Education and Exercise,To Prevent MI and Death（1,抗血小板药物阿斯匹林抑制环氧化酶和 TXA2合成。抵克力得（Ticlopidine a thienopyridine derivative抑制血小板聚集副作用：中心粒细胞减少,TTPClopidogrel:如上潘生丁（Dipyridamole口服增加运动性缺血，不能
24、用做抗血小板药。,To Prevent MI and Death（2,抗血栓治疗用于稳定型心绞痛的资料极有限。降脂药物胆固醇降低1使心血管事件下降2。抗心绞痛和抗缺血治疗 受体阻滞剂钙拮抗剂硝酸甘油和硝酸盐类,UAP的治疗,阿斯匹林肝素 阻滞剂硝酸甘油积极治疗24小时无效时需冠状动脉造影,PTCA和CABG,CABG：左主干病变。三支病变。二支病变，但其中一支病变在前降支近段。一或二支，无前降支病变，但有SCD或持续VT史。PTCA：二或三支病变，包括前降支近端，但病变适合导管治疗，LV功能正常，无需用药的DM。,Conditions Provoking or Exacerbating Isc
25、hemia(Increased Oxygen Demand),Non-CardiacHyperthermiaHyperthyroidismSympathomimetic toxicity(e.g.,cocaine use)HypertensionAnxietyArteriovenous fistulae,CardiacHCMAortic stenosisDilated CMTachycardiaVentricularSuperventricular,Conditions Provoking or Exacerbating Ischemia(Decreased Oxygen Supply),Non-CardiacAnemiaHypoxemiaPneumoniaAsthmaCOPDPul-hypertensionInterstitial Pul-fibrosisOSASSickle cell diseaseSympathomimetictoxicity(e.g.,cocaine use),HyperviscosityPolycythemiaLeukemiaThrombocytosisHypergammaglobuli-nemiaCardiacAortic stenosisHCM,
