第19章治疗冠心病药物agentstotreatchdcoronaryheartdisease.pptVIP

第19章 治疗冠心病药物Agents to treat CHD coronary heart disease Background: IHD is the leading single cause of death in the US and is responsible for 1 of every 4.8 deaths. About half of the patients with IHD initially present with chronic stable angina. IHD manifests as an imbalance in myocardial oxygen supply and demand that results in myocardial hypoxemia. IHD is usually due to atherosclerotic disease of the coronary arteries coronary heart disease [CHD] and coronary artery disease [CAD] 。 病因学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 same-sex 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, 2000 High ultra-sensitive C-reactive protein High levels of iron stores Salonen et al, 1992 Low levels of selenium Suadicani et al, 1992 Sedentary lifestyle/poor physical fitness Cigarette smoking Alcohol abuse Diets high in animal fat and calories and low in fruits, vegetables, and fiber Diets low in polyunsaturated fatty acids Diets high in trans fats Willett et al, 1993 Poor stress management High blood levels of insulin Decreased oxidative radical antioxidant capacity ORAC Fazendas et al, 2000 Diabetes mellitus Hypertension Hypothyroidism Marital stress Orth-Gomer, 2002 1．动脉粥样硬化与冠心病 动脉粥样硬化是冠心病的病理基础。 胆固醇等脂质沉着在大中动脉血管壁，形成粥样斑块，尤其在动脉分叉处。在心外膜下中等动脉分支的内膜下胆固醇沉着，管腔内新月形隆起，表面为纤维帽，含增殖平滑肌、胶原、脂质及泡沫细胞，内膜下形成坏死区，含胆固醇结晶、胆固醇酯，钙盐等。 冠脉狭窄为偏狭窄，开始为新月形，狭窄 50%为轻度，对供血影响不大，无明显症状；狭窄50%-70%为重度，供血大减，可出现心绞痛。若管腔被血栓迅速阻塞，可产生急性心肌梗死。 冠脉痉挛亦导致缺血性心脏病，可造成心绞痛（如变异型心绞痛），甚至心肌梗死。 2．冠心病的临床分型及表现 冠心病共分为五型，分述如下