心絞痛的鑒別心絞痛

1、病史特點(diǎn),男性，59歲反復(fù)胸痛4個(gè)月，加重1個(gè)月。胸痛呈壓榨性與勞力有關(guān)。有高血壓，吸煙史。有心腦血管病陽(yáng)性家族史。查體：體胖，無(wú)明顯其他陽(yáng)性發(fā)現(xiàn)。ECG：V4－V6，I，aVL ST ?0.5-1mm.,思考,胸痛的鑒別心絞痛的特點(diǎn)心絞痛的分級(jí)心絞痛的分類不同類型心絞痛的病理基礎(chǔ)進(jìn)一步檢查冠心病的易患因素,心絞痛的鑒別 (1),Non-ischemic CVAortic dissectionPericard

2、itisPulmonaryPulmonary embolusPneumothoraxPneumoniaPleuritis,GastrointestinalEsophagealEsophagitis,Spasm, RefluxBiliaryColicCholecystitisCholedocholithiasisCholangitisPeptic ulcerPancreatitis,心絞痛的鑒別 (

3、2),Chest WallCostochondritisFibrositisRib fractureSternoclavicular arthritisHerpes zoster (before the rash),PsychiatricAnxiety disordersHyperventilationPanic disorderPrimary anxietyAffective disorders(e.g., de

4、pression)Somatiform disordersThought disorders(e.g., fixed delusions),心絞痛特點(diǎn),SAVES U：Sudden onset; Anterior chest; Vague sensation; Exercise precipitated; Short duration; Unanimous attack.,Grading of Angina Pecto

5、ris by CCSC,Class I: 日常體力活動(dòng)不引起心絞痛.Class II: 日常體力活動(dòng)輕度受限.Class III: 日常體力活動(dòng)明顯受限.Class IV: 任何體力活動(dòng)都引起癥狀，可以有休息時(shí)心絞痛。,UAP 的主要臨床表現(xiàn),Rest angina: Occurring at rest, usu. >20min, occurring within a week of presentation.New

6、 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,

7、 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

8、inversion.Chest X-ray,ECHO,本例: 左室肥厚，左室舒張功能減低。室間隔增厚：13mm(7-11mm), 左室后壁10mm(7-11mm)。室壁運(yùn)動(dòng)正常，各瓣膜結(jié)構(gòu)及功能正常，無(wú)心包積液。二尖瓣血流頻譜示左室功能減低，E/A=0.5,冠狀動(dòng)脈造影,本例冠狀動(dòng)脈造影：前降支中段99％狹窄，回旋支近段90％狹窄，遠(yuǎn)段50％狹窄。Definition of Significant CAD? 70% d

9、iameter 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: Ultraf

10、ast Computed Tomography,Ultrafast (electron beam) computed tomography (EBCT) for the detection and quantification of coronary calcification:Sensitivity (detection of calcium): 85-100%.Specificity: 41-76%.Positive pred

11、ictive value: 55-84%.Negative predictive value: 84-100%.,Noninvasive Testing: Exercise ECG(1),Absolute contraindications:MI in 2 days; Significant arrhythmias; Severe AS; Symptomatic HF; Acute PE; Acute myocarditi

12、s or pericarditis; Acute aortic dissection.,Noninvasive Testing: Exercise ECG(2),Relative contraindication:Left main coronary stenosis; Moderate AS; Electrolyte abnormalities; SBP > 200mmHg; DBP >110mmHg; Tac

13、hy- or Brady-arrhythmias; High degree AVBHCMP or other forms of OT obstruction;Mental or physical impairment;,Noninvasive Testing: Exercise ECG(3),Risk: MI and death ? 1/2500 tests.A standard percentage (often 85%) o

14、f age-predicated maximum heart rate is targeted.Reported in estimated METs of exercise (One MET is the standard basal oxygen uptake of 3.5ml/kg per min.)ST depression ? 1mm for 60-80ms after the end of QRS, during or a

15、fter exercise.,Noninvasive Testing: Exercise ECG(4)(Absolute indication for stopping):,SBP drop > 10mmHg with ischemia;Moderate to severe angina;Increasing ataxia;Dizziness or near syncope;Sign of poor perfusion;

16、 Technical difficulties; Sustained VT;ST elevation in leads without Q waves.,Noninvasive Testing: Exercise ECG(5)(Relative indication for stopping):,SBP drop > 10mmHg without ischemia;SBP >250 or DBP >115mm

17、Hg;ST depression > 2mm;Marked axis deviation;Multifocal PVCs, triplets PVCs, SVT, heart block or bradyarrhythmias, BBB or IVCBIncreasing chest pain; Serious symptoms.,Noninvasive Testing: Exercise ECG(6),Sensitivi

18、ty: 68%; Specificity: 77%Influence of other factors on test:Digoxin: 25-40% abnormal ST depression.Beta blockers: Gradually withheld 48hrs.Anti-HBP, vasodilators, nitrates, flacainide.LBBB:RBBB: LV hypertrophy: Mo

19、re false-positive.Rest ST depression: Additional ST? significant.,Stress Imaging Studies,Good candidates for stress imaging, as opposed to exercise ECG:CLBBB, Paced rhythm, WPW etc.ST ? > 1mm at rest,Unable to exe

20、rcise,Angina with prior Revascularization.,Pharmacologic Modalities (Vasodilators) Used in Stress Imaging,Dipyridamole(DIP) inhibiting cellular uptake of adenosine (a potent coronary vasodilators). The flow increase by

21、 adenosine is of lesser magnitude through stenostic arteries, creating heterogeneous myocardial perfusion.Side effects of both DIP and ADE are rare, but may cause severe bronchospasm in patients with asthma or COPD.,Pha

22、rmacologic Modalities (Dobutamine) Used in Stress Imaging,In high doses (20 to 40?g /kg /min) increases HR, SBP and myocardial contractility.The flow increase(2-3 times) is less than that elicited by adenosine or dipyri

23、damole.Side effects are frequent, but the test appears to be safe even in the elderly, including nausea, anxiety, headache, tremor, VPC, APC, SVT, nonsust-VT, chest pain and angina(8%).,Invasive Testing - Angiography(I

24、ndications),Chest pain, possible ischemic, coexisting COPD not a candidate forExercise test because of dyspnea;Perfusion imaging with dipyridamole or adenosine because of bronchospasm and theophylline therapy;Stress E

25、CHO because of poor images.,Invasive Testing - Angiography(Indications),Typical or atypical symptoms and a high clinical probability of sever CAD.Most appropriate for a patient with a high-risk treadmill outcome.Sympt

26、oms suggestive but not characteristic, special occupation, eg. Pilots, firefighters etc.A low threshold angiography is appropriate for diabetics.,RISK STRATIFICATION,A. Clinical AssessmentB. ECG/Chest X-RayNoninvasive

27、 TestingCoronary Angiography and Left Ventriculography,Risk Stratification(Clinical Assessment),Prognosis of CAD for Death or Nonfatal MI: LV function: the strongest predictor, EF is the most commonly used;Anatomic

28、extent and severity of coronary tree involvement. The number of diseased vessels.A recent coronary plaque rupture: worsening clinical symptoms with unstable feature;General health and noncoronary comorbidity.,Risk Stra

29、tification(Clinical Assessment),Clinical Parameters Predictive of Severe (left main or three vessel) CADAge, Gender, Typical angina, Previous MI,DM and use of insulin,Risk Stratification(ECG/Chest X-ray),ECGEvide

30、nce of ? 1 previous MI, Persistent ST-T inversion,LBBB, LAB+RBBB, II or III AVB, Af, VT,LV hypertrophy,Chest X-rayCardiomegaly, LV aneurysm, PV congestionCoronary calcification,Risk Stratification(Noninvasive Test

31、ing),Resting LV FunctionImportance of assessmentGlobal LV FunctionSWMAMR, LV Aneurysm, LV Thrombosis,TREATMENT,Pharmacologic TherapySuccessful and Initiating TreatmentEducation of Patients with CSARisk FactorsR

32、evascularization for CSA,Overview of Treatment,Stable angina-Two purposes:To prevent MI and death.To reduce symptoms of angina and occurrence of ischemia.,穩(wěn)定心絞痛的A，B，C，D，E治療,A=Aspirin and Antianginal B=Beta-blocker and

33、 Blood pressureC=Cigarette smoking and CholesterolD=Diet and DiabetesE=Education and Exercise,To Prevent MI and Death（1〕,抗血小板藥物阿斯匹林抑制環(huán)氧化酶和 TXA2合成。抵克力得 （Ticlopidine〕 a thienopyridine derivative抑制血小板聚集副作用：中心粒細(xì)胞減少,

34、 TTPClopidogrel: 如上潘生丁 （Dipyridamole〕口服增加運(yùn)動(dòng)性缺血，不能用做抗血小板藥。,To Prevent MI and Death（2〕,抗血栓治療用于穩(wěn)定型心絞痛的資料極有限。降脂藥物膽固醇降低1％使心血管事件下降2％。抗心絞痛和抗缺血治療ß 受體阻滯劑鈣拮抗劑硝酸甘油和硝酸鹽類,UAP的治療,阿斯匹林肝素ß 阻滯劑硝酸甘油積極治療24小時(shí)無(wú)效時(shí)需冠狀動(dòng)脈

35、造影,PTCA和CABG,CABG：左主干病變。三支病變。二支病變，但其中一支病變?cè)谇敖抵Ы?。一或二支，無(wú)前降支病變，但有SCD或持續(xù)VT史。PTCA：二或三支病變，包括前降支近端，但病變適合導(dǎo)管治療，LV功能正常，無(wú)需用藥的DM。,Conditions Provoking or Exacerbating Ischemia (Increased Oxygen Demand),Non-CardiacHyperthermia

36、HyperthyroidismSympathomimetic toxicity (e.g., cocaine use)HypertensionAnxietyArteriovenous fistulae,CardiacHCMAortic stenosisDilated CMTachycardiaVentricularSuperventricular,Conditions Provoking or Exacerbatin

37、g Ischemia (Decreased Oxygen Supply),Non-CardiacAnemiaHypoxemiaPneumoniaAsthmaCOPDPul-hypertensionInterstitial Pul-fibrosisOSASSickle cell diseaseSympathomimetictoxicity (e.g., cocaine use),HyperviscosityPoly