【正文】 ol,第七頁，共一百一十五頁。,Atherosclerosis,第三頁，共一百一十五頁。Atherosclerosis amp。,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，共一百一十五頁。,Hypothesis of lipoprotein infiltration Aggregation of platelets and thrombosis Clonal theory the responsetoinjury hypothesis,AtherosclerosisHypothesis,第八頁，共一百一十五頁。,Initiation of Atherosclerosis,Fatty steak formation Lipoprotein oxidation Nonenzymatic glycation Leukocyte recruitment Foam cell formation,第十二頁，共一百一十五頁。,Atheroma evolution and complications,Vulnerable plaque: Thin fibrous cap Relatively large lipid core High content of macrophages,Inflammatory mediators,第十六頁，共一百一十五頁。,General manifestation Aortic atherosclerosis Coronary artery atherosclerosis Cerebral atherosclerosis Mesenteric atherosclerosis Peripheral artery atherosclerosis,Atherosclerosis,clinical manifestation,第二十頁，共一百一十五頁。,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。,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，共一百一十五頁。,Coronary heart disease (CHD),most common cause: obstruction of atheromatous plaque other causes: spasm arterial thrombi coronary emboli ostial narrowing due to luetic aortitis congenital abnormalities severe LV hypertrophy,第三十一頁，共一百一十五頁。,Acute Coronary Syndrome(ACS),Resting ischemia,NonST elevation,STelevation,Unstable angina,NonQ wave AMI,Q wave AMI,*positive serum cardiac markers,*,*,*,*, occasionally variant angina,第三十五頁，共一百一十五頁。,in angiography Significant coronary lesion with diameter stenosis 70% in 75% pts No significant stenosis in about 510% pts, Ischemia may be related to coronary spasm or microvascular dysfunction.,Pathology,Stable angina pectoris,第三十九頁，共一百一十五頁。 duration： 3－5 mins pain relief: within several mins after rest or using nitroglycerin,Clinical manifestation,Stable angina pectoris,第四十二頁，共一百一十五頁。,2.Echocardiography: 3. Radionuclide imaging assessment: TL201，Tc99msestamibi myocardial perfusion scintigraphy 4.Xray of heart 5.coronary angiography：final diagnose 6.others: IVUS、intracoronary Doppler flow 、intracoronary pressure,Laboratory,Stable angina pectoris,第四十六頁，共一百一十五頁。,General consideration： rest，avoid provocative factors , risk factors control 2. Drug therapy: prevent MI and death symptom relief and quality of life improvment 3. Coronary revascularization: percutaneous coronary intervention (PCI) Coronary artery bypass surgery (CABG) SVG, LIMA,Prevention and treatment,Stable angina pectoris,第五十頁，共一百一十五頁。－blockers: reduce myocardial oxygen: reduce HR, myocardial contractility, BP,the LV wall stress Abslute contraindications： sever bradycardia: highdegree AV block, SSS, severe unstable LV failure Relative contraindications: asthma and bronchospastic disease peripheral vascular disease 223。,prevent MI and death therapy a.antiplatelet angents： ASA，75325mg/d clopidogrel。,Resting ischemia,NonST elevation,STelevation,Unstable angina,NonQ wave AMI,Q wave AMI,*positive serum cardiac markers,*,*,*,*, occasionally variant angina,Acute Coronary Syndrome(ACS),第五十八頁，共一百一十五頁。,Braunwald classification of unstable angina,Severity： Class I： Newonset, or accelerated severe angina no rest pain within 2 months Class II： Angina at rest, subacute angina at rest (within the preceding month but not within 48 h) Class III： Angina at rest, acute ( within the preceding 48 h),UAP and nonSTEMI,第六十一頁，共一百一十五頁。,Risk stratification：TIMI Risk Score Age =65yrs More than 3 coronary risk factors Prior angiographic coronary obstruction STsegment deviation ?0.5 mm More than 2 angina events within 24 hours Development of UA/NSTEMI while on aspirin Elevated cardiac markers,Antaman, JAMA 2000。,Treatment,2. Drug therapy: C. other medical therapy a. lipidlowering drugs: statins, early use(in first 24 hrs) LDLc target: 70 mg/dl b. ACEI: longterm secondary prevention,UAP and nonSTEMI,第六十八頁，共一百一十五頁。,SYMPTOMS SUGGESTIVE OF ACS,Noncardiac Diagnosis,Chronic Stable Angina,Possible ACS,Definite ACS,Treatment as indicated by alternative diagnosis,ACC/AHA Chronic Stable Angina Guidelines,No STElevation,STElevation,Nondiagnostic ECG Normal initial serum cardiac biomarkers,ST and/or T wave changes Ongoing pain Positive cardiac biomarkers Hemodynamic abnormalities,Evaluate for reperfusion therapy,ACC/AHA STEMI Guidelines,Observe ≥ 12 h from symptom onset,No recurrent pain。,ST elevation myocardial infarction STEMI,第七十二頁，共一百一十五頁。,1.incidence ：in USA, 71‰ in male between 3584 yrs, 22‰ in female, 1 attack in about 20 second 2. mortality： decreased in 30% recent 10 years still 1/3 of the patients died 50% of the death occured within 1 h after the onset MI most deathes result from ventricular fibrillation,epidemiology,STEMI,第七十五頁，共一百一十五頁。,Possible mechanism of the chronic CAD to ACS,第七十八頁，共一百一十五頁。,Ventricular remodeling concept: the changes in LV size, shape, and thickness involving both the infarcted and noninfarcted segments Determinants: the size of infarction Ventricular loading conditions Infarct related artery patency,STEMI,第八十二頁，共一百一十五頁。,Symptom Chest pain severe, sometimes intolerable, prolonged, usually lasting for 30 mins， less effective of sublingual nitroglycerin, retrosternal in location, sweating,