内科学概论心脏血管内科课件.ppt

,內科學概論,高雄醫學大學,Lin CC,心臟血管內科,内科学概论心脏血管内科,1,內科學概論高雄醫學大學Lin CC心内科学概论心脏血管内科1,血壓的形成,收縮壓舒張壓,LCC,内科学概论心脏血管内科,2,血壓的形成收縮壓LCC内科学概论心脏血管内科2,高血壓分類,原發性高血壓 Primary Hypertension續發性高血壓 Secondary Hypertension,LCC,内科学概论心脏血管内科,3,高血壓分類原發性高血壓 LCC内科学概论心脏血管内科,遺傳基因的影響鈉鹽的過度攝取Renin-Angiotensin system交感神經系統細胞膜的異常血管的增生肥厚內皮細胞功能異常胰島素抗性,原發性高血壓致病機轉,LCC,内科学概论心脏血管内科,4,遺傳基因的影響原發性高血壓致病機轉LCC内科学概论心脏,續發性高血壓,内科学概论心脏血管内科,5,續發性高血壓内科学概论心脏血管内科5,高血壓的分類JNC7,Normal 120 80Prehypertetnsion 120-139 or 80-89 Stage 1 hypertension 140-159 or 90-99Stage 2 hypertension 160 or100,内科学概论心脏血管内科,6,高血壓的分類JNC7Normal,Initial Measurements,内科学概论心脏血管内科,7,Initial Measurements内科学概论心脏血管内,血壓的測定,基礎血壓隨時血壓休息血壓,LCC,内科学概论心脏血管内科,8,血壓的測定基礎血壓LCC内科学概论心脏血管内科8,Clinical pressureAmbulatory pressureHome pressure,血壓的測定,LCC,内科学概论心脏血管内科,9,Clinical pressure血壓的測定LCC内科学概论,Blood Pressure Measurement,内科学概论心脏血管内科,10,Blood Pressure Measurement内科学概,Ambulatory Measurement,内科学概论心脏血管内科,11,Ambulatory Measurement内科学概论心脏血,Advantages of Self-Measurement,内科学概论心脏血管内科,12,Advantages of Self-Measurement,高血壓臨床表現,頭重 頭痛耳鳴 眼花 失眠頭頸部酸痛兩肩酸痛大部分沒有症狀,40歲 20%罹患高血壓,隱形殺手,LCC,内科学概论心脏血管内科,13,高血壓臨床表現頭重 頭痛40歲 20%罹患高血壓隱形殺,高血壓自然病程,高血壓前期遺傳-環境因素,惡性高血壓,心臟,大血管,腎,眼,腦,合併症,高血壓,高血壓早期,年齡0-3020-4030-50,LCC,内科学概论心脏血管内科,14,高血壓自然病程高血壓前期惡性心臟大血管腎眼腦合併症高血壓高,正確測量血壓外觀: 脂肪分布 皮膚 肌肉 及神智狀況眼底檢查頸部頚動脈及甲狀腺觸診聽診心臟大小節律及心音異常肺有無囉音腹部腫瘤? 動脈雜音 股動脈搏動四肢動脈博動 水腫神經檢查,高血壓臨床檢查重點,LCC,内科学概论心脏血管内科,15,正確測量血壓高血壓臨床檢查重點LCC内科学概论心脏血管内科,Laboratory tests,内科学概论心脏血管内科,16,Laboratory tests内科学概论心脏血管内科16,Optimal Tests,内科学概论心脏血管内科,17,Optimal Tests内科学概论心脏血管内科17,What is the target of BP with therapy?,General: 140/90 mmHgDiabetes: 130/80 mmHgCHF or renal disease: 130/85 mmHg,LCC,内科学概论心脏血管内科,18,What is the target of BP Gener,Cardiovascular Risk In Patients with Hypertension,内科学概论心脏血管内科,19,Cardiovascular Risk 内科学概论,Clinical Risk factors for Stratification,内科学概论心脏血管内科,20,Clinical Risk factors for Stra,高血壓的治療,危險因素的根除外科手術藥物治療非藥物治療,LCC,内科学概论心脏血管内科,21,高血壓的治療危險因素的根除LCC内科学概论心脏血管内科21,Treatment,Not at good blood pressure,内科学概论心脏血管内科,22,TreatmentNot at good blood pre,Treatment,Start at low dose and titrate upwardLow dose combinations may be appropriate,Not at good blood pressure,内科学概论心脏血管内科,23,TreatmentStart at low dose and,Antihypertensive drugs,内科学概论心脏血管内科,24,Antihypertensive drugs内科学概论心脏血,Treatment,内科学概论心脏血管内科,25,Treatment内科学概论心脏血管内科25,Treatment,内科学概论心脏血管内科,26,Treatment内科学概论心脏血管内科26,Treatment,内科学概论心脏血管内科,27,Treatment内科学概论心脏血管内科27,Treatment,内科学概论心脏血管内科,28,Treatment内科学概论心脏血管内科28,Treatment,内科学概论心脏血管内科,29,Treatment内科学概论心脏血管内科29,Lifestyle Modifications,内科学概论心脏血管内科,30,Lifestyle Modifications内科学概论心脏,Treatment,内科学概论心脏血管内科,31,Treatment内科学概论心脏血管内科31,Treatment,内科学概论心脏血管内科,32,Treatment内科学概论心脏血管内科32,Follow Up,内科学概论心脏血管内科,33,Follow Up内科学概论心脏血管内科33,動脈粥狀硬化的故事,内科学概论心脏血管内科,34,動脈粥狀硬化的故事内科学概论心脏血管内科34,冠狀動脈,Left anteriorDescending artery,Left circumflex artery,Right coronaryartery,Left main coronaryartery,LCC,The coronary arteries deliveroxygen-rich blood to the muscletissues of the heart. If they become blocked, heart tissue will die, resulting in a heart attack,Coronaryarteries,内科学概论心脏血管内科,35,冠狀動脈Left anteriorLeft circumfl,冠狀動脈,氧供應,氧需求,平衡,冠狀動脈灌注壓力小血管阻力動靜脈氧氣差,心室容積心室壓力心室張力心跳心臟收縮情況,LCC,内科学概论心脏血管内科,36,冠狀動脈氧供應氧需求平衡冠狀動脈灌注壓力心室容積LCC内科学,冠狀動脈的故事,Atherosclerosis timeline,Endothelial dysfunction,Foam fatty intermediate fibrous complicatedCells streak lesion atheroma plaque lesion/rupture,From first decade,From third decade,From fourth decade,Growth mainly by lipid accumulation,SmoothMuscle andcollagen,Thrombosishematoma,LCC,内科学概论心脏血管内科,37,冠狀動脈的故事Atherosclerosis timelin,血管內腔變小,粥狀硬塊,LCC,内科学概论心脏血管内科,38,血管內腔變小粥狀硬塊LCC内科学概论心脏血管内科38,Plaque inArterial wall,Blood clot,Left anteriorDescendingartery,RightCoronaryartery,内科学概论心脏血管内科,39,Plaque inBlood clotLeft anteri,AtherothrombosisThrombus and Plaque,内科学概论心脏血管内科,40,AtherothrombosisThrombus and,Unstable and Stable Plaque,Thin fibrous cap,Inflammatory cells,FewSMCs,Erodedendothelium,Activatedmacrophages,Thickfibrous cap,Lack ofinflammatory cells,Foam cells,Intactendothelium,MoreSMCs,Unstable,Stable,内科学概论心脏血管内科,41,Unstable and Stable PlaqueThin,Risk Factors for Plaque Rupture,Impaired Fibrinolysis,Fibrinogen,DiabetesMellitus,Cholesterol,Smoking,Cap Fatigue,Atheromatous Core(size/consistency),Cap Inflammation,Systemic Factors,Local Factors,Homocysteine,PlaqueRupture,Cap Thickness/ Consistency,内科学概论心脏血管内科,42,Risk Factors for Plaque Ruptur,Plaque Rupture誘發因素,Plaque rupture,運動抽煙寒冷天氣發脾氣心跳快血壓高週邊血管阻力大,LCC,内科学概论心脏血管内科,43,Plaque Rupture誘發因素Plaque 運動LC,心臟血管阻塞,膽固醇沉積于血管壁 形成粥狀硬塊 (Plaque, Atheroma)粥狀硬塊破裂 ( Rupture of Plaque )血小板 纖維蛋白等凝聚于破裂的粥狀硬塊上 修補破裂的粥狀硬塊 而形成血栓粥狀硬塊加上血栓 阻塞血管,LCC,内科学概论心脏血管内科,44,心臟血管阻塞膽固醇沉積于血管壁 形成粥狀硬塊 (Plaqu,Hemostatic clot Formation,Thrombin,AGGREGATION,Fibrin,HemostaticClot,Clotting,Platelet Aggregation,0 min,10 min,5 min,SECONDARY,PRIMARY,COAGULATION,内科学概论心脏血管内科,45,Hemostatic clot FormationThrom,Thrombus formation,Platelet activationadhesion, aggregation,Coagulation-pathwayactivation and thrombinformation,Fibrinogen conversion to fibrin with cross-linkingOf bands,LCC,platelet,fibrin,内科学概论心脏血管内科,46,Thrombus formationPlatelet act,冠狀動脈疾病,穩定性心絞痛,不穩定性心絞痛,ST elevationMI,NON-ST elevationMI,LCC,内科学概论心脏血管内科,47,冠狀動脈疾病穩定性不穩定性心絞痛ST elevationNO,内科学概论心脏血管内科,48,内科学概论心脏血管内科48,Plaque/atheromaobstruction of the coronary artery lumen,Chest pain,Ischemic Heart Disease,穩定性心絞痛,LCC,内科学概论心脏血管内科,49,Plaque/atheromaChest painIsche,休息時胸痛通常持續超過20分鐘近二星期內新出現的胸痛加重型胸痛較頻繁發作時間延長較容易發生,不穩定性心絞痛Unstable Angina Pectoris,LCC,内科学概论心脏血管内科,50,休息時胸痛通常持續超過20分鐘不穩定性心絞痛Unstabl,Ischemic Heart Disease胸痛,流冷汗嘔吐噁心,呼吸困難 窒息感 欲昏倒,30分鐘對舌下nitroglycerine反應不好,急性心肌梗塞,LCC,内科学概论心脏血管内科,51,Ischemic Heart Disease胸痛流冷汗呼吸,猝心絞痛 心肌梗塞Sudden death,心肌梗塞 Sudden death50%到達醫院前發生 ventricular fibrillation sudden death發生時機胸痛後4小時早期送醫電擊器的使用可以救命,CPR,LCC,内科学概论心脏血管内科,52,猝心絞痛 心肌梗塞Sudden death 心肌梗塞,冠狀動脈疾病,心肌梗塞不穩定型心絞痛PTCA,24%的男性和42%的女性會在發生心肌梗塞後的一年內死亡不穩定型心絞痛的病人在三個月內的死亡率將近10 %進行PTCA的病人中 有40 %可能在六個月內需要再進行手術,LCC,内科学概论心脏血管内科,53,冠狀動脈疾病心肌梗塞24%的男性和42%的女性會在發生心肌梗,New Definition of MI-biochemist,Troponin or CK-MB elevations are defined as 3xabove the normal (99% of normal)Total CK, SGOT, and LDH are not recommended(low specificity)Employ the full clinical picture to diagnose MI, not merely lab values,LCC,内科学概论心脏血管内科,54,New Definition of MI-biochemi,New Definition of MI-ECG,Non-ST segment elevation AMI Criteria are not adequate to define AMIST segment elevation AMINew ST elevation in 2 or more leads (0.2 In V1-V3)0.1 in other leads,LCC,内科学概论心脏血管内科,55,New Definition of MI-ECGNon-ST,急性心肌梗塞 Acute MYOCARDIAL INFARCTION,ST segment elevation,Pathologic Q wave,LCC,内科学概论心脏血管内科,56,急性心肌梗塞 Acute MYOCARDIAL INFAR,New Definition of MI-established MI,In the absence of QRS confounders (BBB,LVH, WPW)Any Q wave in leads V1-V3Q waves must be 30 msec durationQ waves in other leads must have Qs in 2 contiguous leads (eg, II and III)Qs must be 1mm in depth,LCC,内科学概论心脏血管内科,57,New Definition of MI-establish,New Definition of MI-image,Infarct manifests itself as decreased wall motion by echo or hypoperfusion by radionuclide SPECTIschemia, stunning, and hibernation will produce similar changes,LCC,内科学概论心脏血管内科,58,New Definition of MI-imageInfa,Use of cardiac markers in ACS,Cardiac troponin after classical AMI,CK-MB after AMI,Cardiac troponin aftermicroinfarction,Days after onset of AMI,LCC,内科学概论心脏血管内科,59,Use of cardiac markers in ACSC,Chest painTroponin I/T, CK-MBECG changesEchocardiographyNuclear cardiologyCardiac catheterization,急性心肌梗塞-診斷,LCC,内科学概论心脏血管内科,60,Chest pain急性心肌梗塞-診斷LCC内科学概论心,急性心肌梗塞 Acute MYOCARDIAL INFARCTION,HypokinesiaakinesiaHyperkinesiaLV aneurysmLV size EFMRLV thrombus,LCC,内科学概论心脏血管内科,61,急性心肌梗塞 Acute MYOCARDIAL INFAR,急性心肌梗塞 Acute MYOCARDIAL INFARCTION,HypoperfusionLV systolic functionLV diastolic function,LCC,内科学概论心脏血管内科,62,急性心肌梗塞 Acute MYOCARDIAL INFAR,急性心肌梗塞-心導管,Filling defect,Contrast造影劑,LCC,内科学概论心脏血管内科,63,急性心肌梗塞-心導管Filling defectContra,Myocardial infarction,arrhythmia,Loss of muscle,Sudden death,Ventricular remodeling,Ventricular dilation,Heart failure,death,LCC,内科学概论心脏血管内科,64,Myocardial infarctionarrhythmi,LCC,Thrombin/Fibrin,Platelet,thrombus,内科学概论心脏血管内科,65,LCC Thrombin/FibrinPlateletthr,Pre-PCIASAStatinACEIClopidogrel,Post-PCIASAStatinACEIClopidogrel,GP IIb/IIIA Embolic protectionAnti-inflammatoryCoated stent,Plaquerupture,thrombus,LCC,内科学概论心脏血管内科,66,Pre-PCIPost-PCIGP IIb/IIIA Pl,Reperfusion,intervension,thrombolysis,LCC,内科学概论心脏血管内科,67,Reperfusionintervensionthrombo,Optimal Strategy UA/NSTEMI,TIMI IIIB,2002,Conservative,Invasive,VANQWISH,MATE,FRISC II,TACTICS-TIMI 18,VINO,RITA-3,TRUCS,内科学概论心脏血管内科,68,Optimal Strategy UA/NSTEMITI,急性心肌梗塞 Primary PTCA,Initiate PTCA if available and suitableGoals: PTCA within 90 30 min,LCC,内科学概论心脏血管内科,69,急性心肌梗塞 Primary PTCAInitiate P,氣球擴張術,内科学概论心脏血管内科,70,氣球擴張術内科学概论心脏血管内科70,Stenting,Stenting,LCC,網狀支架置放術,内科学概论心脏血管内科,71,StentingStentingLCC網狀支架置放術内科学概,Interventional Cardiology,post,Stenting,内科学概论心脏血管内科,72,Interventional CardiologypostS,Sites of Anti-thrombotic Drug Action,Tissue factor,Plasma clottingcascade,Prothrombin,Thrombin,Fibrinogen,Fibrin,Thrombus,Platelet aggregation,Conformational activation of GPIIb/IIIa,Collagen,Thromboxane A2,ADP,AT,AT,FactorXa,Coagulationcascade,Plateletcascade,内科学概论心脏血管内科,73,Sites of Anti-thrombotic Drug,Plaquerupture,thrombus,LCC,Fibrin,Thrombin,Platelet,FibrinolysisAntiplateletAnti-thrombin,内科学概论心脏血管内科,74,PlaquethrombusLCCFibrinThrombi,THROMBUS,PLATELET,Antiplatelet therapy-aspirin-clopidogrel-GP IIb/IIIa inhibitors-persantin-ticlopidine,Thrombin,Antithrombin therapy-heparin,Fibrin,PlasminogenActivators-t-PAR-PASKTNK-tPA,LCC,内科学概论心脏血管内科,75,THROMBUSPLATELETAntiplatelet t,StreptokinaseUrokinase,内科学概论心脏血管内科,76,Streptokinase内科学概论心脏血管内科76,急性心肌梗塞 Thrombolysis,一般原則胸痛12小時內ST segment elevation 75 years old沒有禁忌3小時內 好處最大,好處,壞處,LCC,内科学概论心脏血管内科,77,急性心肌梗塞 Thrombolysis一般原則好壞LCC内,急性心肌梗塞 Thrombolysis,12小時內 注射的好處增加冠狀動脈血流減少結疤的形成減少心室擴大梗塞區域可以重新排列其構造減少心臟衰竭減少死亡率,好處,壞處,LCC,内科学概论心脏血管内科,78,急性心肌梗塞 Thrombolysis12小時內 注射的好,ThrombolysistPA,Early reperfusion價錢貴腦溢血機會較高需併用Heparin使用於大片心肌壞死並且腦溢血機會較低者,靜脈注射15mg30分鐘內以0.75mg/kg mg的量滴注50mg60分鐘內以0.5mg/kg的量滴注35 mg,LCC,内科学概论心脏血管内科,79,ThrombolysistPAEarly reperfus,適用於發作時間較久 受損範圍較小患者價錢較便宜腦溢血機會較低易過敏 2年內最好不要再使用第二次不必併用Heparin100萬單位1小時內 滴注完畢,ThrombolysisStreptokinase,LCC,内科学概论心脏血管内科,80,適用於發作時間較久 受損範圍較小患者Thrombolysis,Initiate fibrinolysis if indicatedGoals: 30 min from entry to ER,急性心肌梗塞 Thrombolysis,LCC,内科学概论心脏血管内科,81,Initiate fibrinolysis if indic,FIBRINOLYSISABSOLUTE CONTRAINDICATION,Previous HEMORRHAGIC STROKE at any timeOther STROKES or CEREBROVASCULAR EVENTS within one yearKnown INTRACRANIAL NEOPLASMAActive INTERNAL BLEEDING ( does not include menses )Suspected AORTIC DISSECTION,LCC,内科学概论心脏血管内科,82,FIBRINOLYSISABSOLUTE CONTRAIN,FIBRINOLYSIS RELATIVE CONTRAINDICATION,Severe UNCONTROLLED HYPERTENSION (BP180/110 mmHg)History of PRIOR CVD or known INTRACEREBRAL PATHOLOGY Current use of ANTICOAGULANTS ( INR2-3 ) Known BLEEDING DIATHESISRECENT TRAUMA (Within 2-4 WKS) Including head injuryNONCOMPRESSIBLE VASCULAR PUNCTURES,LCC,内科学概论心脏血管内科,83,FIBRINOLYSIS RELATIVE CONTR,No benefitharmful,20%40% Decreased mortality,Non-ST segment elevation ACS,ST segment elevation ACS,Plaque rupture,ACS,Thrombolysis,LCC,内科学概论心脏血管内科,84,No benefit20%40% Decreased No,内科学概论心脏血管内科,85,内科学概论心脏血管内科85,THROMBUS,PLATELET,Antiplatelet therapy-aspirin-clopidogrel-GP IIb/IIIa inhibitors-persantin-ticlopidine,Thrombin,Antithrombin therapy-heparin,Fibrin,PlasminogenActivators-t-PAR-PASKTNK-tPA,LCC,内科学概论心脏血管内科,86,THROMBUSPLATELETAntiplatelet t,Adhesion,Platelets Role in thrombosis,Aggregation,1,Activation,2,3,内科学概论心脏血管内科,87,AdhesionPlatelets Role in thro,GP IIb/IIIa Inhibitors,1. Platelet Adhesion,2. Platelet Activation,Platelet,GP Ib,Plaque rupture,3. Platelet Aggregation,ASA, Clopidogrel/Ticlopidine,TxA2,Platelets Role in Thrombosis,内科学概论心脏血管内科,88,GP IIb/IIIa Inhibitors1. Plat,Acts by selective inhibition of ADP binding to its platelet receptor and prevents subsequent platelet aggregation,ADP,ADP,Fibrinogen Binding Site,Clopidogrel,Clopidogrel,Fibrinogen Binding Reduced,Fibrinogen,Platelet,LCC,Clopidogrelmechanism of action,内科学概论心脏血管内科,89,Acts by selective inhibition o,Platelet aggregation,Inhibition of aggregationby GP IIb/IIIa inhibitors,LCC,内科学概论心脏血管内科,90,Platelet aggregationInhibition,ThrombinSerotoninEpinephrineCollagen,Activation,ActivatedPlatelet,COX,Degranulation,Gp IIb/IIIa fibrinogenreceptor,To neighboringplatelet,ClopidogrelTiclopidine,内科学概论心脏血管内科,91,ThrombinADPActivationTXA2Activ,THROMBUS,PLATELET,Antiplatelet therapy-aspirin-clopidogrel-GP IIb/IIIa inhibitors-persantin-ticlopidine,Thrombin,Antithrombin therapy-heparin,Fibrin,PlasminogenActivators-t-PAR-PASKTNK-tPA,LCC,内科学概论心脏血管内科,92,THROMBUSPLATELETAntiplatelet t,Unfractionated heparinLow molecular weight heparinEnoxaparinDalteparinNadroparinDirect Thrombin inhibitorsHirudinBivalirudinwarfarin,LCC,Antithrombotic Treatment,内科学概论心脏血管内科,93,Unfractionated heparinLCCAntit,Sites of Anti-thrombotic Drug Action,Tissue factor,Plasma clottingcascade,Prothrombin,Thrombin,Fibrinogen,Fibrin,Thrombus,Platelet aggregation,Conformational activation of GPIIb/IIIa,Collagen,Thromboxane A2,ADP,AT,AT,FactorXa,Coagulationcascade,Plateletcascade,内科学概论心脏血管内科,94,Sites of Anti-thrombotic Drug,MONAMorphine 靜脈注射Oxygen 4L/minNitroglycerine 舌下錠或噴劑Aspirin 160-325mg,急性心肌梗塞 胸痛,LCC,内科学概论心脏血管内科,95,MONA急性心肌梗塞 胸痛LCC内科学概论心脏血管内科95,急性心肌梗塞 Morphine,解除胸痛鎮靜 減少焦慮每5-10分鐘 靜脈注射2-4mg,低血壓病人平躺補充生理食鹽水液呼吸抑制Naloxone 0.4mg IV每三分鐘注射一次可重複三劑量,LCC,内科学概论心脏血管内科,96,急性心肌梗塞 Morphine解除胸痛低血壓LCC内科学概,Management non-ST segment elevation ACS,Very high15%,intermediate38%,Very high815%,DeathMI,Aspirin heparinGP IIb/IIIaUrgent cathClopidogrel prior PCI,Aspirin LMWH GP IIb/IIIaClopidogrelCoronary angio,Aspirin LMWHIschemia-guided Rx,LCC,内科学概论心脏血管内科,97,Management non-ST segment elev,ACC/AHA UA/NSTEMI Guidelines Recommendations for Long-term Medical Therapy,Class IAspirin 75 to 325 mg/dayClopidogrel 75 mg daily (in the absence of contraindications) when aspirin is not tolerated because of hypersensitivity or gastrointestinal intolerance The combination of aspirin and clopidogrel for 9 months after UA/NSTEMI-Blockers in the absence of contraindications Lipid-lowering agents and diet in post-ACS and postrevascularization patients with LDL-C 130 mg/dL Lipid-lowering agents if LDL-C level after diet is 100 mg/dLACE inhibitors for patients with CHF, LV dysfunction (EF 0.40), hypertension, or diabetes,内科学概论心脏血管内科,98,ACC/AHA UA/NSTEMI Guidelines,Management of ACS,Focal Rx of ruptured culprit lesion (stents).Systemic Rx to prevent future ischemic events.Risk factor modification + 5 drugs for long-term medical therapy to treat:“Athero+thrombosis”StatinsASAACE inhibitorClopidogrel-blocker,内科学概论心脏血管内科,99,Management of ACSFocal Rx of r,?,LCC,心臟血管疾病的危險因素,内科学概论心脏血管内科,100,?LCC心臟血管疾病的危險因素内科学概论心脏血管内科100,Multiple Risk Factors,LifestyleSmokingDietLack of exercise,Genetic TraitsGenderPlA2,GeneralizedDisordersAgeObesity,SystemicConditionsHypertensionHyperlipidemiaDiabetesHypercoagulable statesHomocysteinemia,Atherothrombotic Manifestations(MI, stroke, vascular death),InflammationElevated CRPCD40 Ligand, IL-