修改后的冠心病ppt课件.pptVIP

* 因此与稳定性心绞痛相比，SCAD是一个更为广泛的概念。指南指出其病生理机制为：①斑块相关的心外膜动脉阻塞；②正常或有斑块动脉局限或弥漫的痉挛；③微血管功能障碍；④既往急性心肌缺血和（或）冬眠导致的左心室功能不全。这些临床表现稳定的情况与ACS并没有截然的界限，有证据表明SCAD患者超敏肌钙蛋白升高，尽管未达到心肌梗死诊断的阈值，与无肌钙蛋白升高的SCAD患者相比其预后更差。这就决定了对于SCAD患者需要进行评估，根据患者的危险分层决定治疗策略，降低其进展为ACS的风险。 * 分级指标-TIMI(0-无血流、I-不完全充盈、 II-显影、III-正常)冠状动脉CTA作为无创评价手段得到越来越多的应用，其敏感性高，可达95%～99%，而特异性较低，为64%～83%。由于其敏感性高而特异性相对较低，因此建议用于SCAD中低可能性（冠心病可能性，pre-test probability，PTP 15%～50%）患者的排除诊断（Ⅱa类推荐，C级证据）。同时，对于中低可能性患者，如负荷试验的结果不能提供肯定性的结论或者患者有负荷试验的禁忌证，为了避免进行侵入性检查，如估计可获得清晰的影像，也可选择冠状动脉CTA（Ⅱa类推荐，C级证据）。该指南不建议冠状动脉CTA用于经皮冠状动脉介入治疗（PCI）术后复查或者无任何冠状动脉疾病征象无症状个体的筛查（Ⅲ类推荐，C级证据）。 * 控制危险因素，稳定冠脉斑块，改善症状和生活质量，减少心肌缺血，预防冠脉疾病事件，延长预期寿命 * Arch Intern Med. 2012 Feb 27;172(4):312-9. doi: 10.1001/archinternmed.2011.1484. Initial coronary stent implantation with medical therapy vs medical therapy alone for stable coronary artery disease: meta-analysis of randomized controlled trials. Stergiopoulos K, Brown DL. Source Division of Cardiovascular Medicine, Department of Medicine, State University of New York-Stony Brook School of Medicine, Health Sciences Center T16-080, Stony Brook, NY 11794. david.brown@sbumed.org. Abstract BACKGROUND:Prior meta-analyses have yielded conflicting results regarding the outcomes of treatment of stable coronary artery disease (CAD) with initial percutaneous coronary intervention (PCI) vs medical therapy. However, most of the studies in prior systematic reviews used balloon angioplasty as well as medical therapies that do not reflect current interventional or medical practices. We therefore performed a meta-analysis of all randomized clinical trials comparing initial coronary stent implantation with medical therapy to determine the effect on death, nonfatal myocardial infarction (MI), unplanned revascularization, and persistent angina. METHODS:Prospective randomized trials were identified by searches of the MEDLINE database from 1970 to September 2011. Trials in which stents were used in less than 50% of PCI procedures were excluded. Data were ext