Coronary Atherosclerotic Heart Disease (CHD),Definition,Coronary atherosclerotic heart disease: Coronary heart disease: Ischemic heart disease:,Clinical Type,Silent myocardial ischemia Angina pectoris Myocardial infarction Ischemic cardiomyopathy Sudden cardiac death,Silent Myocardial Ischemia,Defined as documented episodes of ischemia not associated with any typical or atypical symptoms that among patients with obstructive coronary artery disease. Type I: myocardial ischemia is detected on routine ECG, 24h ambulatory ECG monitoring (Holter), etc. but not experience angina at any time; Type II: patients are most frequently encountered in clinical practice. Some episodes of ischemia are associated with chest discomfort and other episodes are asymptomatic.,Ischemic Cardiomyopathy,Symptoms of heart failure, caused by ischemic myocardial dysfunction (hibernation), diffuse fibrosis, and multiple infarction, alone or in combination. Manifestations: ventricles enlargement (dominant left ventricle), heart failure and arrhythmias.,Sudden Cardiac Death,SCD is natural death due to cardiac causes, heralded by abrupt loss of consciousness within 1 hours of the onset of acute symptoms. The time and mode of death are unexpected. WHO definition: unexpected death within 6 hours. This definition incorporates the key elements of natural, rapid and unexpected. One half of SCD due to coronary heart disease，caused by severe arrhythmias, such as ventricular fibrillation and cardiac arrest.,Acute Coronary Syndromes（ACS）,ACS represents a spectrum of conditions: including: acute MI, unstable angina and sudden cardiac death. Acute plaque change characterized by plaque rupture and exposure of substances that promote platelet activation and thrombin generation.,Risk Factor,Age, gender and family history Hypertension Dislipidmia Diabetes mellitus Tobacco use Obesity,Candidate Risk Factor,Homocystein Fibrinogen LP(a) Fibrinolytic activity（tPA） Plasminogen activator inhibitor（PAI） C reactive protein Coagulation factor Estrogens Alcohol Type A personality and stress,Angina Pectoris,Definition：,A clinical syndrome due to myocardial ischemia characterized by episodes of precordial discomfort or pressure, typically precipitated by exertion and relieved by rest or sublingual nitroglycerin.,Coronary arterial stenosis Coronary arterial spasm Myocardial oxygen consumption ,Mechanism and Pathophysiology,心绞痛发生机制,心肌缺血缺氧,酸性或肽类物质,刺激心脏植物神经传入纤维,15胸交感神经节及相应脊髓段,大脑,疼 痛,牵涉痛发生机制,胸骨后、两前臂内侧及小指（左侧多见）疼痛,反映在1-5胸交感神经节相应脊髓段脊神经,Clinical Presentation:,Episodes of chest pain： Location Character Trigger Duration Relieve,Symptom:,In general, no abnormal sign HR 、BP S3、S4 gallop Apical systolic murmur,Clinical Presentation:,Signs:,Electrocardiogram,ECG at rest ECG at episodes of chest pain Exercise ECG Ambulatory ECG monitoring (Holter),ECG at Episodes of chest pain,Coronary Angiography,1、 心绞痛无法确诊者。 2、对内科治疗中心绞痛仍较重者，明确动脉病变情况以考虑介入治疗或旁路移植手术。 3 、冠脉痉挛行麦角新碱试验。,Other Diagnostic Testing,心脏X线检查 放射性核素检查 二维超声心动图 血管镜,Clinical Type of Angina,劳累性心绞痛 stable angina pectoris initial onset angina pectoris accelerated angina pectoris 自发性心绞痛 angina decubitus Prinzmetals variant angina pectoris acute coronary insufficiency postinfarction angina pectoris 混合型心绞痛,Stable angina pectoris Unstable angina pectoris,Typing by stability or quiescence of an atherosclerotic plaque:,Clinical Type of Angina,Classification of Angina,Class：ordinary physical activity does not cause angina Class ： slight limitation of ordinary physical activity Class ：marked limitation of ordinary physical activity Class ：inability to carry on any activity without discomfort,Canadian Class:,Differential Diagnosis,心脏神经官能症 急性心肌梗塞 其它疾病引起的心绞痛 消化道疾病 呼吸系统引起的胸痛 心包疾病,Therapy of Angina,Medical therapy Percutaneous transluminal coronary angioplasty (PTCA) Coronary artery bypass grafting （CABG）,Platelet inhibitors： Aspirin、ticlipidine、clopidogrel Nitrates -blockers Calcium channel blockers Lipid-lowering agents 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) (statin) fibrate,Therapy of Angina,Pharmacologic therapy:,阿司匹林 抑制环氧酶，阻止花生四烯酸转化为前列腺素G2、前列腺素H2，使血小板合成血栓素A2(TXA2)减少，抑制血小板的聚集和释放。剂量：0.050.3/天，长期服用。 噻氯匹啶(Ticlopidine,抵克力得) 机制不清，可能与ADP介导的血小板聚集有关。剂量：0.250.5/天，长期服用。 氯吡格雷(Chlopidogrel) 与抵克力得类似，但起效快、作用更强，没有降低白细胞之副作用。剂量：75mg/天，长期服用。,Pharmacologic therapy,硝酸酯类 机理：扩张冠脉。 扩张周围血管，特别是静脉，减少回流及缩小心脏。同时降低血压，从而降低心肌耗氧量。 制剂及用法： 硝酸甘油片（0.6mg/片）、消心痛（10mg/片）、5单硝酸异山梨醇酯（20mg、50mg、60mg/片），含化或口服（13次/日）。尚有气雾剂、贴剂及注射剂。 副作用：头痛、颜面潮红、血压下降。,Pharmacologic therapy,阻滞剂 机理：降低心率及心肌收缩力，而减低心肌耗氧量。因可诱发冠脉痉挛，仅适用于劳累型心绞痛。 剂型及用法：普奈洛尔（心得安，Propranolol),10mg/片，1040mg.tid.。 心脏1受体选择性阻滞剂： 美托洛尔（Betaloc,倍它乐克），25、50mg/片，2550mg，tid.。 阿替洛尔（Atenolol,氨酰心安），25mg/片，25mg,bid.。 副作用：心动过缓、诱发或加重心衰、支气管痉挛、血压下降。,Pharmacologic therapy,钙拮抗剂:主要用于自发型心绞痛（变异型） 机理：抑制Ca+进入细胞内，也抑制心肌细胞兴奋收缩耦联中Ca+的利用。 作用：扩张冠脉、抑制心肌收缩力、扩张周围血管（动脉）、降低血液粘度、抗血小板聚集、改善心肌微循环。 剂型及用法： 地尔硫卓（Diltiazem,合心爽、合贝爽），30、90mg/片，30mg,tid.，90mg,qd.，亦有注射剂。 韦拉帕米及硝苯吡啶很少使用。 副作用：抑制房室传导、诱发及加重心衰。,Pharmacologic t