【正文】 – Beta阻斷劑保護(hù)心肌， 612小時(shí)內(nèi)使用降低死亡率 – 鎮(zhèn)靜止痛，抗焦慮藥或嗎啡 ? 冠狀血管再通術(shù)， PTCA或 CABG ? Initial therapy for acute MI is directed towards restoration of perfusion in order to salvage as much of the jeopardized myocardium as possible. This may be acplished through medical or mechanical means, such as angioplasty or coronary artery bypass grafting （ CABG） . ? Further treatment is based on (1) restoration of the balance between the oxygen supply and demand to prevent further ischemia, (2) pain relief, and (3) prevention and treatment of the plications that may arise. 輔助治療 ? 抗血小板：阿斯匹林，氯吡格雷，血小板糖蛋白 Ⅱ b/Ⅲ a受體拮抗劑 ? 抗氧化劑：維生素 E、 C， beta胡蘿卜素，硒等 ? 肝素增強(qiáng) tPA的作用 ? 硝酸酯減輕前負(fù)荷，緩和癥狀 ? ACEI減輕后負(fù)荷，改善心室功能，降低死亡率。 some also decrease heart rate, decrease contractility) ? 3. Betaadrenergic antagonists (decrease heart rate, decrease contractility, decrease afterload due to decrease in cardiac output, may inhibit platelet aggregation) 硝酸酯及亞硝酸酯 是緩解心絞痛的主要藥物 ? 增加氧供，改善側(cè)支循環(huán) – 降低心室內(nèi)壓，改善心內(nèi)膜下心肌供血（此處常是缺血最嚴(yán)重的部位），舒張冠脈痙攣 ? 減少氧耗 – 舒張外周靜脈和動(dòng)脈血管，降低心臟前后負(fù)荷，縮小心室容積 ? 一般短效，可產(chǎn)生反射性心動(dòng)過(guò)速 Beta阻斷劑 ? 阻斷交感對(duì)心臟的興奮作用，減慢心率，抑制心肌收縮，降低氧耗量 ? 對(duì)勞作型心絞痛效好，對(duì)變異性無(wú)效？ 可用于先兆心肌梗死和急性心肌梗死 鈣拮抗劑 ? 舒張動(dòng)靜脈血管，減輕后負(fù)荷和前負(fù)荷 ? 冠脈解痙效果好，最適用于變異性心絞痛 ? 要用長(zhǎng)效藥物，短效者可使血壓波動(dòng)過(guò)大 ，興奮交感 ? Use betablockers as firstline antianginal therapy, unless contraindicated. ? Betablockers decrease myocardial oxygen demand by decreasing myocardial contractility, arterial (blood) pressure, and heart rate. Left ventricular perfusion is enhanced by the increased duration of diastole. ? Of all of the medications used in treating angina pectoris, only betablockers have conclusively been shown to reduce both clinical symptoms and cardiac events . ? However, emerging data suggest that angiotensinconverting enzyme (ACE) inhibitors and statins also reduce clinical symptoms and cardiac events . ? bination therapy ? Betablockers and nitrates are frequently used together in patients with chronic stable angina, because their bined use appears to be more effective than monotherapy with either agent . The concurrent use of betablockers attenuates the tendency of nitrates to increase sympathetic tone and cause reflex tachycardia. The potential increase in left ventricular volume, enddiastolic pressure, and wall tension, and the potential decrease in heart rate with betablockers, are counteracted by the concurrent use of nitroglycerin. 對(duì)心肌梗死的治療 ? 冠脈血栓 心肌梗死。s extraction of oxygen is nearly maximal in the resting state. Therefore, in the absence of anemia or systemic hypoxia, an increase in coronary blood flow is essentially the only mechanism available to pensate for increases in myocardial oxygen demand. 影響心肌耗氧量的影響 ? 心肌收縮力 ? 心室壁張力（與心室內(nèi)壓和心室半徑乘積成正比） ? 心率和射血時(shí)間 通常用簡(jiǎn)便的方法來(lái)估算心肌耗氧量 ? 二重乘積（心率收縮壓， HR SBP） ? 三重乘積（心率收縮壓射血時(shí)間 (QT) ，HR SBP ET）。 其特點(diǎn)為發(fā)作與心肌需氧量增加無(wú)明顯關(guān)系 ， 時(shí)間較長(zhǎng) ， 程度較重 ， 且不易為硝酸甘油緩解 。 初發(fā)勞累性心絞痛：勞累性心絞痛病程在一個(gè)月以內(nèi) 。 通常將心絞痛分為穩(wěn)定型心絞痛 、 不穩(wěn)定型心絞痛和變異型心絞痛三型 ， 現(xiàn)根據(jù) WHO意見(jiàn)將心絞痛分為勞累性和自發(fā)性兩類： ① 勞累性心絞痛：由體力活動(dòng) 、 情緒激動(dòng) 、 寒冷或其他增加心肌需氧量的活動(dòng)誘發(fā) 。 ⑶ 急性心肌梗死 （ acute myocardial infarction， AMI） ：心肌嚴(yán)重缺血缺氧持續(xù)時(shí)間過(guò)長(zhǎng) ， 導(dǎo)致心肌代謝和功能障礙 ， 心肌細(xì)胞壞死 。 若管腔被血栓迅速阻塞 ， 可產(chǎn)生急性心肌梗死 。 病因?qū)W Etiology ? The exact pathogenesis of CAD is not clear, and no single theory adequately explains the atherosclerotic process. Two main explanations have been proposed: the lipid hypothesis and the chronic endothelial injury hypothesis. These explanations are probably interrelated and are certainly not mutually exclusive. Risk Factors ? Positive family history, particularly with onset before age 50 in samesex parent ? Male gender ? Age ? Abnormalities in blood lipids/lipid metabolism, ? High Waist/Hip Ratio (Rexrode et al, 1998) ? Elevated blood homocysteine ? Elevated fibrinogen (Bielak et al, 2023) ? High ultrasensitive Creactive