【正文】 Atherosclerosis amp。 Coronary heart diseases,Zhengzhou University, First affiliated Hospital Dept. of Cardiology Haiyu Li, M.D.,第一頁(yè)，共一百一十五頁(yè)。,Cardiovascular Diseases,第二頁(yè)，共一百一十五頁(yè)。,Atherosclerosis,第三頁(yè)，共一百一十五頁(yè)。,leading cause of death and disability Common location: Coronary circulation: Proximal left anterior descending coronary artery(LAD) Proximal portion of renal arteries Extracranial circulation to the brain Carotid bifurcation,Atherosclerosis,第四頁(yè)，共一百一十五頁(yè)。,Coronary heart disease,atherosclerosis,Coronary stenosis,coronary spasm,Myocardial ischemia, anoxaemia,Coronary heart disease, CHD Ischemic heart disease,第五頁(yè)，共一百一十五頁(yè)。,Atherosclerosis Stable angina pectoris(SAP) Acute coronary syndrome Unstable angina(UAP) and nonSTEMI (UA/NSTEMI) ST elevation myocardial infarction(STEMI),第六頁(yè)，共一百一十五頁(yè)。,Three fundamental biological processes of atherosclerosis,Accumulation of intimal cells: smooth muscle cells Macrophages Tlymphocytes Proliferated connective tissue matrix : collagen elastic fibers proteoglycans 3. Accumulation of lipid: cholesterol esters free cholesterol,第七頁(yè)，共一百一十五頁(yè)。,Hypothesis of lipoprotein infiltration Aggregation of platelets and thrombosis Clonal theory the responsetoinjury hypothesis,AtherosclerosisHypothesis,第八頁(yè)，共一百一十五頁(yè)。,Responsetoinjury,Atherosclerosis: hypothesis,High blood pressure,bacterium,virus,toxin,oxLDL, immune factor,vasoactive substance endothelium damage and dysfunction (vasoactive substance, adhesion and aggregation of monocytesfoam cell, platelets) Lipidosis, growth factor, proliferation of smooth mucle cells, collagen, lipolytic enzyme,atherosclerosis,第九頁(yè)，共一百一十五頁(yè)。,Pathology and pathophysiology Fatty steak Fibrous plaque Complicated lesion,Atherosclerosis,第十頁(yè)，共一百一十五頁(yè)。,Initiation of Atherosclerosis,Fatty steak formation,第十一頁(yè)，共一百一十五頁(yè)。,Initiation of Atherosclerosis,Fatty steak formation Lipoprotein oxidation Nonenzymatic glycation Leukocyte recruitment Foam cell formation,第十二頁(yè)，共一百一十五頁(yè)。,Atheroma evolution: fibrous plaque,Atheroma evolution and complications,Vascular remodeling: compensatory enlargement,第十三頁(yè)，共一百一十五頁(yè)。,Atheroma evolution: Involvement of arterial smoothmuscle cells Blood coagulation microvessels,Atheroma evolution and complications,第十四頁(yè)，共一百一十五頁(yè)。,Complicated lesion: thrombosis,Atheroma evolution and complications,第十五頁(yè)，共一百一十五頁(yè)。,Atheroma evolution and complications,Vulnerable plaque: Thin fibrous cap Relatively large lipid core High content of macrophages,Inflammatory mediators,第十六頁(yè)，共一百一十五頁(yè)。,Intravascular ultrasound,第十七頁(yè)，共一百一十五頁(yè)。,Classicification of atherosclerotic lesion using IVUS,第十八頁(yè)，共一百一十五頁(yè)。,Clinicl stages and classification Absence of symptom or stage of delitescence ischemia necrosis(target organ ) fibrosis,Atherosclerosis,第十九頁(yè)，共一百一十五頁(yè)。,General manifestation Aortic atherosclerosis Coronary artery atherosclerosis Cerebral atherosclerosis Mesenteric atherosclerosis Peripheral artery atherosclerosis,Atherosclerosis,clinical manifestation,第二十頁(yè)，共一百一十五頁(yè)。,laboratory examination Lack of sensitive and specific methods for early diagnosis Dyslipidemia： Xray：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,第二十一頁(yè)，共一百一十五頁(yè)。,Risk factors and prevention,1.Lifestyle modification 2.Lipid disorders (Dyslipidemia): cholesterol screening in all 20yrs Elevated: cholesterol (Tc and LDLc), TG, ApoB/ApoA,Lp(a), Low: HDLc LDL lowering by HMGCoA reductase(statins): cardiovascular events 30%，risk of MI 62% 3.Hypertension： 4.DM,Metabolic syndrome or insulin resistance syndrome: BP, BMI ,TG, serum insulin HDLc,第二十二頁(yè)，共一百一十五頁(yè)。,Diabetes mellitus(DM): RR 1.9 for male, 3.3 for female more diffuse lesion. CAD equivalent 7580% cause of death in adult DM are vascular diseases: CAD, cerebrovascular disease, or peripheral vascular disease,Risk factors and prevention,第二十三頁(yè)，共一百一十五頁(yè)。,7 years incidence of death/nonfatal MI (East West Study),* These patients had no history of myocardial infarction Haffner SM, et al. N Engl J Med. 1998。339:229–234.,,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,nondiabetics diabetics n = 1373 n = 1059,P 0.001,P 0.001,4%,19%,20%,45%,DM: CAD equivalent,第二十四頁(yè)，共一百一十五頁(yè)。,5. Cigarette smoking：more thrombogenic 6. Family history：genetic factor 7. Aging：40yrs adults ，4/5 fatal myocardial infarction occured in patiens 65 yrs 8. Male gender/ postmenopausal state： male:female = 2：1, man develop CHD 1015 yrs earlier than woman 9. alcohol 10. Others: diet,homocysteine, hemostatic factors inflammation/infection,Risk factors and prevention,第二十五頁(yè)，共一百一十五頁(yè)。,Drug therapy： antiplatelet： aspirin, clopidogrel, GPIIb/IIIa inhitibor, Dipyridamole, cilostazol Lipidlowering,Risk factors and prevention,第二十六頁(yè)，共一百一十五頁(yè)。,HMGCoA reductase inhibitors（statins） Atorvastatin,Fluvastatin,Lovastatin,Pravastatin,Simvastatin,Cerivastatin, Rosuvastatin： *elevation of aminopherase, rhabdomyolysis 2. Bile acidbinding Resins cholestyramine，colestipol 3. Nicotinic Acid： 4. Fibric acid derivatives（fibrates） Gemifibrozil, clofibrate, Fenofibrate 5. Cholesterol absorption inhibitors: ezetimibe 6. Probucol,Lipidlowering drugs,第二十七頁(yè)，共一百一十五頁(yè)。,Prevention of CAD,A: aspirin,ACEI B: blood pressure, βblocker, C: cigarette smoking, Cholesterol D: diet, diabetes E: exercise, education,第二十八頁(yè)，共一百一十五頁(yè)。,Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults ATP III (adult treatment panel III) Circulation 2002 17/24: 31443373,Atherosclerosis,第二十九頁(yè)，共一百一十五頁(yè)。,Coronary heart disease (CHD),第三十頁(yè)，共一百一十五頁(yè)。,Coronary heart disease (CHD),most