Atherosclerosis & Coronary heart diseases,Fudan University, Zhongshan Hospital Dept. of Cardiology, Shanghai Institute of CVD Juying Qian, M.D. qian.juyingzs-hospital.sh.cn,2009,Cardiovascular Diseases,Coronary heart disease,atherosclerosis,Coronary stenosis,coronary spasm,Myocardial ischemia, anoxaemia,Coronary heart disease, CHD Ischemic heart disease,Atherosclerosis Stable angina pectoris(SAP) Acute coronary syndrome Unstable angina(UAP) and non-STEMI(UA/NSTEMI) ST elevation myocardial infarction(STEMI) elevation .elivein ,Atherosclerosis.rusklirusis,leading cause of death and disability Common location: Coronarykr.neri circulation: Proximalprksiml left anteriorntiri descendingdisendi coronary artery(LAD) Proximal portion of renal arteries Extracranial.ekstrkreini:l 颅外的circulation to the brain Carotid颈动 krtid bifurcation,Atherosclerosis,Three fundamental biological processes of atherosclerosis,Accumulation of intimalintml cells: smooth muscle cells Macrophagesmkrfeid T-lymphocyteslimfsait Proliferatedprlif.reit connective tissue matrixmeitriks 结缔组织基质增生 : collagenkldn elasticilstik fibers proteoglycans.prutiuglaikns蛋白聚糖 3. Accumulation of lipid: cholesteryl estersist free cholesterolklst,rol,Hypothesis of lipoprotein infiltration Aggregation of platelets and thrombosis Clonal theory克隆(选择)学说the response-to-injury hypothesis,Atherosclerosis-Hypothesis,Response-to-injury,Atherosclerosis: hypothesis,High blood pressure,bacterium,virus,toxin,ox-LDL, immune factor,vasoactive substanceendothelium damage, metergasis (vasoactive substance, adhesion and aggregation of monocytes-foam cell, platelets)Lipidoses, growth factor, proliferation of smooth mucle cells, collagen, lipolytic enzyme,atherosclerosis,Pathology and pathophysiology Fatty steak Fibrous plaque Complicated lesionli:n,Atherosclerosis,Initiation of Atherosclerosis,Fatty steak formation,Initiation of Atherosclerosis,Fatty steak formationLipoprotein.lippruti:n oxidationNonenzymaticnnenzaimtik glycation Leukocyte recruitment rikru:tmnt Foam cell formation,Atheroma evolution: fibrous plaquepl:k,Atheroma evolution and complications,Vascular remodeling: compensatory enlargement,Atheroma evolution: Involvement of arterial smooth-muscle cells Blood coagulationkugjulein microvesselsmaikruvesl,Atheroma evolution and complications,Intimaintim,Complicated lesionli:n: thrombosis,Atheroma evolution and complications,Atheroma evolution and complications,Vulnerable plaque: Thin fibrous cap Relativelyreltivli large lipid core High content of macrophages,Inflammatory mediatorsmi:di.eit,Intravascular ultrasoundltr.saund,Classicification of atherosclerotic lesion using IVUS,Clinicl stages and classification Absence of symptom or stage of delitescencedeilitesns潜伏 ischemia necrosis(targett:git organ ) fibrosis,Atherosclerosis,General manifestation Aortic atherosclerosis Coronary artery atherosclerosis Cerebralseribrl atherosclerosis RA atherosclerosis Mesentericmesnterik atherosclerosis Peripheralprifrl artery atherosclerosis,Atherosclerosis,clinical manifestation,laboratory lbrtri examination Lack of sensitive and specific methods for early diagnosis.daignusis Dyslipidemiadislipidemi： X-ray：DSA show severity of stenosis Doppler ultrasound: blood flow radionuclide： detection of ischemia Echocardiogram： CHD ECG and stress test: CHD New techniques: intravascular ultrasound, angioscope CT, MRI,Atherosclerosis,Risk factors and prevention,1.Lifestyle modification 2.Lipid disorders (Dyslipidemia): cholesterol screening in all 20yrs Elevated: cholesterol (Tc and LDL-c), TG, ApoB/ApoA,Lp(a), Low: HDL-c LDL lowering by HMG-CoA reductase(statins): cardiovascular events 30%，risk of MI 62% 3.Hypertension： 4.DM,Metabolic syndrome or insulin resistance syndrome:BP, BMI ,TG, serum insulinHDL-c, OGTT,Diabetes mellitus(DM): RR 1.9 for male, 3.3 for female more diffuse lesion. CAD equivalent75-80% cause of death in adult DM are vascular diseases: CAD, cerebrovascular disease, or peripheral vascular disease,Risk factors and prevention,7 years incidence of death/non-fatal MI (East West Study),* These patients had no history of myocardial infarction Haffner SM, et al. N Engl J Med. 1998;339:229234.,0,5,10,15,20,25,30,35,40,45,50,Events of MI in 7 years,No history of MI OMI No history of MI* OMI,non-diabetics diabetics n = 1373 n = 1059,P 0.001,P 40yrs adults ，4/5 fatal myocardial infarction occured in patiens 65 yrs 8. Male gender/ postmenopausal state： male:female = 2：1, man develop CHD 10-15 yrs earlier than woman 9. alcohol 10. Others: diet,homocysteine, hemostatic factorsinflammation/infection,Risk factors and prevention,