心绞痛的鉴别心绞痛.pptVIP

病史特点 男性，59岁 反复胸痛4个月，加重1个月。 胸痛呈压榨性与劳力有关。 有高血压，吸烟史。 有心脑血管病阳性家族史。 查体：体胖，无明显其他阳性发现。 ECG：V4－V6，I，aVL ST ?0.5-1mm. 思考 胸痛的鉴别 心绞痛的特点 心绞痛的分级 心绞痛的分类 不同类型心绞痛的病理基础 进一步检查 冠心病的易患因素 心绞痛的鉴别 (1) Non-ischemic CV Aortic dissection Pericarditis Pulmonary Pulmonary embolus Pneumothorax Pneumonia Pleuritis Gastrointestinal Esophageal Esophagitis, Spasm, Reflux Biliary Colic Cholecystitis Choledocholithiasis Cholangitis Peptic ulcer Pancreatitis 心绞痛的鉴别 (2) Chest Wall Costochondritis Fibrositis Rib fracture Sternoclavicular arthritis Herpes zoster (before the rash) Psychiatric Anxiety disorders Hyperventilation Panic disorder Primary anxiety Affective disorders (e.g., depression) Somatiform disorders Thought disorders (e.g., fixed delusions) 心绞痛特点 SAVES U： Sudden onset; Anterior chest; Vague sensation; Exercise precipitated; Short duration; Unanimous attack. Grading of Angina Pectoris by CCSC Class I: 日常体力活动不引起心绞痛. Class II: 日常体力活动轻度受限. Class III: 日常体力活动明显受限. Class IV: 任何体力活动都引起症状，可以有休息时心绞痛。 UAP 的主要临床表现 Rest angina: Occurring at rest, usu. 20min, occurring within a week of presentation. New onset angina: At least CCSC III severity, 2 months of initial presentation. Increasing angina: Distinctly more frequent, longer in duration, lower in Threshold. (ie. Increased by at least one CCSC class in 2 months, to at least CCSC III severity) Noninvasive Testing: ECG/Chest X-ray ECG: Normal in ? 50% stable angina. Abnormal in 50% angina (normal rest ECG). Equivocal: QIII, QS in V1, V2. Pseudonormalization of ST depression or T inversion. Chest X-ray ECHO 本例: 左室肥厚，左室舒张功能减低。 室间隔增厚：13mm(7-11mm), 左室后壁10mm(7-11mm)。 室壁运动正常，各瓣膜结构及功能正常，无心包积液。 二尖瓣血流频谱示左室功能减低，E/A=0.5 冠状动脉造影 本例冠状动脉造影： 前降支中段99％狭窄，回旋支近段90％狭窄，远段50％狭窄。 Definition of Significant CAD ? 70% diameter stenosis of ? 1 major epicardial artery segment. ? 50 % diameter stenosis of left main. Although lesions of less stenosis can cause angina, they have much less prognostic significance. Noninvasive Testing: Ultrafast Computed Tomograph