冠心病课件(大医英).pptVIP

Determinants of Plaque Vulnerability Lipid-rich core size Cap thickness Cap inflammation and repair 斑块破裂引起急性严重事件 不稳定 心绞痛 心肌梗死 猝死 稳定性 (劳力性) 心绞痛 不稳定斑块的进展过程 稳定斑块的进展过程 Nissen SE. Am J Cardiol. 2000;86(suppl):12H-17H 不稳定斑块 斑块破裂 血栓形成 稳定斑块 斑块体积增加 管腔狭窄 Physical Examinaton Not that helpful May have evidence of CHF: JVD, rales, edema May have S4 May have murmur of mitral regurgitation from papillary muscle dysfunction Investigation ECG Cardiac Enzyme or Troponin Coronary angiography Acute Coronary Syndromes 评估住院期间和出院后长期缺血风险 评估住院期间死亡风险 (c-index 0.83)* 及出院后6个月死亡风险 (c-index 0.81)** 多个大型数据库中验证其有效性 (c-indices分别为 0.84*和0.75**) 评价死亡/再发心梗的长期风险 网络版可下载 /GRACE *Granger CB, et al. Arch intern Med. 2003;163:2345-2353. **Eagle K, at al. JAMA. 2004;291:2727-2733. management Admitted to hospital Best rest,Oxygen Anti-platelet:asprin, Clopidogrel , GP IIb/IIIa inhibitors Anticoagulant: UFH or LMWH B-blocker Nitrates (intravenous) CCB Statins ACEI Coronary revascularisation Definite ACS Possible ACS (–) ECG; Normal biomarkers Observe; repeat ECG, markers at 4-8 hrs No recurrent pain; (–) follow-up studies Recurrent pain; (+) follow-up studies Stress test; ? LV function if ischemia (–) test: outpt follow-up (+) test Admit, Use Acute Ischemia Pathway ST ? Use MI Guidelines No ST ? ST-T ?’s, chest pain, ? markers Initial Chest Pain Evaluation Symptoms Suggestive of ACS Acute Coronary Syndromes Preparation for Discharge After UA/NSTEMI Antiplatelet Rx ASA 75 - 162 mg/day Clopidogrel 75 mg/day Beta Blocker ACEI / ARB Especially if DM, HF, EF 40%, HTN Statin LDL 100 mg/dL (ideally 70 mg/dL) Secondary Prevention Measures Smoking Cessation BP 140/90 mm HG or 130/80 mm HG for DM or chronic kidney disease HbA1C 7% BMI 18.5-24.9 Physical Exercise 30-60 min at least 5 days/wk No ST Elevation ST Elevation Acute Coronary Syndrome Unstable Angina NQMI Qw MI NSTEMI Myocardial Infarction Davies MJ Heart 83:361, 2000 Ischemic Discomfort Presentation Working Dx ECG Biochem. Marker Final D