【正文】 090% Acute coronary occlusion 01% 1025% 90% mortality 12% 38% 615%,FPA：fibrinopeptide A TAT：thrombinantithrombin complexes,UAP and nonSTEMI,第五十九頁，共一百一十五頁。,stenting,Stable angina pectoris,第五十六頁，共一百一十五頁。,c.Calcium antagonists： Increase oxygen supply: dilate resistance vessels, release spasm, improve microvascular function Decrease oxygen demand: negative inotropic effect, decrease BP Antiplatelet effect,d. Drugs improving metabolism： trimethazine（vasorel），selectively inhibit 3KAT（3酮酰輔酶(fǔ m233。,Drug therapy,a.nitrates lower oxygen demand: decrease arteriolar and venous tone, reduce preload and afterload increase coronary supply: Coronary dilatation Nitroglycerin Isosorbide dinitrate isosorbide 5mononitrate (longacting nitrates),Stable angina pectoris,第五十二頁，共一百一十五頁。,1.Cardiogenic pain：aortic dissection, HOCM, aortic stenosis 2.Respiratory：PE, pneumothorax, pleuritis 3.Gastrointestinal: gastroesophageal diseases, Hiatal hernia, cholecystitis, peptic ulceration, pancreatitis 4.Neuromuscular/skeletal ：Tietze Syndrome (Costochondritis), intercostal neuralgia, Herpes zoster 5.Psychologic: anxiety, depression, panic attacks,Stable angina pectoris,Diagnosis,Chest pain, risk factors, ECG evidence of ischemia during chest pain, angiography,Differentiation,第四十八頁，共一百一十五頁。,Laboratory,Stable angina pectoris,第四十四頁，共一百一十五頁。,symptom：chest pain or oppression location behind or slightly to the left of the mid sternum no definite borderline radiated to the left shoulder and upper arm Atypical location: lower jaw, the back of neck,Clinical manifestation,Stable angina pectoris,第四十一頁，共一百一十五頁。,definition: acute and transient myocardial ischemia and anoxaemia usually caused by coronary insufficiency during exertion or emotional stress Characteristics: paroxysmal precordial squeezinglike chest pain, behind the mid sternum， radiated to left shoulder and upper arm precipitated by stress or exertion duration:25min typically relieved rapidly by rest or nitrates,Stable angina pectoris,第三十七頁，共一百一十五頁。,Coronary heart disease,Type： slient ischemia: delitescence： (ECG change) Angina pectoris： angina, caused by myocardial ischemia myocardial infarction：acute myocardial ischemic necrosis caused by the occlusion of coronary artery Ischemia cardiomyopathy (Heart failure and arrhythmia)： cardiac enlargement, heart failure, arrhythmia, caused by the myocardial fibrosis as the consequence of chronic mycardial ischemia Sudden death： sudden cardiac arrest caused by ventricular fibrillation/flutter,第三十三頁，共一百一十五頁。,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，共一百一十五頁。,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，共一百一十五頁。,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，共一百一十五頁。,Classicification of atherosclerotic lesion using IVUS,第十八頁，共一百一十五頁。,Atheroma evolution: Involvement of arterial smoothmuscle cells Blood coagulation microvessels,Atheroma evolution and complications,第十四頁，共一百一十五頁。,Pathology and pathophysiology Fatty steak Fibrous plaque Complicated lesion,Atherosclerosis,第十頁，共一百一十五頁。,Atherosclerosis Stable angina pectoris(SAP) Acute coronary syndrome Unstable angina(UAP) and nonSTEMI (UA/NSTEMI) ST elevation myocardial infarction(STEMI),第六頁，共一百一十五頁。,Cardiovascular Diseases,第二頁，共一百一十五頁。 Coronary heart diseases,Zhengzhou University, First affiliated Hospital Dept. of Cardiology Haiyu Li, M.D.,第一頁，共一百一十五頁。,Coronary heart disease,atherosclerosis,Coronary stenosis,coronary spasm,Myocardial ischemia, anoxaemia,Coronary heart disease, CHD Ischemic heart disease,第五頁，共一百一十五頁。,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，共一百一十五頁。,Atheroma evolution: fibrous plaque,Atheroma evolution and complications,Vascular remodeling: compensatory enlargement,第十三頁，共一百一十五頁。,Intravascular ultrasound,第十七頁，共一百一十五頁。,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，共一百一十五頁。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，共一百一十五頁。,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，共一百一十五頁。,Factors effect myocardial oxygen supply and demand,Oxygen supply,Oxygen demand,Heart rate,Myocardial contractility,S