冠心病诊疗昨天和今天.ppt

“Vein-to-Brain”ReportingTimes

forCardiacMarkersBedsideTest(mean=15mins)LaboratoryTest(mean=128mins)020406080100120140160180TestTypeVein-toBrainReportingTimes(mins)n=939SD=46.74慢性CAD的治疗昨天：针对心肌缺血及限制血流量的狭窄今天：针对狭窄药物降低心肌耗氧量和/或增加心肌血流量（硝酸酯、β阻滞剂、CCB）抗凝、抗血小板药物（阿司匹林、氯吡格雷、肝素/LMWH）血管重建：PCI/CABG处理非阻塞性病变血运重建能够缓解冠脉硬化引起的症状，但并不能够保护病人日后不发生血栓性事件最佳血运重建方针与长期的危险降低相结合改变生活方式药物治疗SourceGlagovS,WeisenbergE,ZarinsCK,etal.Compensatoryenlargementofhumanatheroscleroticcoronaryarteries.NEnglJMed1987;316:1371-1375.[ALL]Coronaryremodelingisanadaptiveprocessbywhichthearterialwallchangesinshapetomaintainflow,despitetheencroachmentofplaque.ThisprocessmayexplainwhylesssevereluminalnarrowingmaystillbeassociatedwithprogressiveatherosclerosisandCAD.Asplaqueaccumulates,thearterialwallreactsbyremodeling.Asatherosclerosisprogressestowardthemoreseverestagespicturedontheright,thelumenremainsrelativelyconstantbecauseofcompensatoryexpansionofthearterialwall.Eventually,inmoreseverestagesofthedisease,thearteryisunabletoexpandfurtherandthelumenbeginstonarrow.Thesameprocessmayworkinreversewithdiseaseregression.Thatis,plaquecanberemovedfromthearterialwallwithlittlechangeinlumensize.Therefore,luminalmeasurementbyquantitativecoronaryangiography(QCA)maybealesssensitivemarkerfortheprogressionorregressionofdisease,incomparisontodirectevaluationofplaquethicknessthroughtheuseofintravascularultrasound.Upuntilthe1990’s,itwasassumedthatMIsresultedfromthebuildupofplaqueincoronaryarteriesuntilitreducedcirculationtothepointwherethrombosiswouldoccur.ThisanalysisofautopsydatabyFaulkdemonstratedthatthemajorityofMIsresultfromsmallerplaquesthatarelessthan50%stenosed.Thisleadtotheconceptthatmanyofthesmallerplaquesweremoreunstableandmore