最牛的心肌梗死,PBL教学专用案例.ppt

心肌梗死（Myocardial Infarction, MI） 内科学-康品方 学时数：2学时 病例 患者，莫文青，男，51岁，早上7点在活动中突发压榨样疼痛90分钟，无放射痛，伴出汗。 既往史：糖尿病，陈旧性脑梗死。 1. 该患者的诊断依据是什么？ 2.该患者最佳的治疗方案是什么？ 3. III°AVB是植入起搏器的一类指征，该患者是否需要进行起搏器植入术？ 急性ST段抬高型心肌梗死（STEMI） （一）定义：急性心肌缺血性坏死，大多是在冠脉病变的基础上，发生冠脉血供急剧减少或中断，使相应的心肌严重而持久地急性缺血所致。 （二）诱因 1.晨起6时至12时，交感神经活动增加； 2.高脂饱餐后； 3.重体力劳动，情绪激动，用力大便； 4.休克，脱水，出血，严重心律失常..... （三）病因 冠状动脉粥样硬化， 冠状动脉痉挛， 冠状动脉栓塞、炎症， 冠状动脉先天畸形… * * * * * Disruption of an atherosclerotic plaque is a complex pathophysiologic process central to the initiation of the acute coronary syndromes (ACS). A mature plaque is made up of 2 main components: a lipid-rich core and extracellular matrix proteins forming a fibrous cap. The presence of large, eccentric lipid pools and the infiltration of foam cells are features most often associated with plaque rupture or fissure, which usually occurs at the sites of the greatest mechanical stress. Fissures that occur at weak cap sites not under great mechanical stress are thought to be initiated by enzymatic degradation of the cap. Local thrombosis following plaque disruption results from interactions between the lipid core and blood. Numerous factors probably trigger the rupture of a vulnerable plaque. Rupture exposes tissue factor in the lipid core, which precipitates platelet activation, adhesion, and aggregation, resulting in the formation of an occlusive thrombus. If the process leads to complete occlusion of the artery, an acute MI results. Alternatively, if occlusion is incomplete, unstable angina or non–Q-wave MI may develop. Spontaneous or pharmacologic lysis of thrombus, or pharmacologic interruption of platelet aggregation, may lead to resolution of the syndrome. Slide 16 Yeghiazarians Y, Braunstein JB, Askari A, Stone PH. Unstable angina pectoris. N Engl J Med. 2000;342:101-114. P波与QRS波群无关，即两者分离，心房率快于心室率 III度房室传导阻滞 ↓ HDL ↓ ALB ↑ LDH ↓ TP ↑ HBDH ↑ IBIL ↑ ↑ TBIL ↑ CKMB ↑ AST ↑ CK ↑ ALT CTnI 7.79 下壁心肌梗死并发III°AVB * * （四）发病机制 冠状动