内科学概论心脏血管内科文档资料.ppt

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1、血壓的形成,收縮壓舒張壓,LCC,高血壓分類,原發性高血壓 Primary Hypertension續發性高血壓 Secondary Hypertension,LCC,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,續發性高血壓,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 or1

2、00,Initial Measurements,血壓的測定,基礎血壓隨時血壓休息血壓,LCC,Clinical pressureAmbulatory pressureHome pressure,血壓的測定,LCC,Blood Pressure Measurement,Ambulatory Measurement,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,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

3、期,年齡0-3020-4030-50,LCC,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,Laboratory tests,Optimal Tests,What is the target of BP with therapy?,General:140/90 mmHgDiabetes:130/80 mmHgCHF or renal disease:130/85 mmHg,LCC,Cardiovascular Risk In Patient

4、s with Hypertension,Clinical Risk factors for Stratification,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,Treatment,Not at good blood pressure,Treatment,Start at low dose and titrate upwardLow dose combinations may be appropriate,Not at good blood pressure,Antihypertensive drugs,Treatment,Treatment,Treatment,Tre

5、atment,Treatment,Lifestyle Modifications,Treatment,Treatment,Follow Up,動脈粥狀硬化的故事,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

6、tissue will die,resulting in a heart attack,Coronaryarteries,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,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 thir

7、d decade,From fourth decade,Growth mainly by lipid accumulation,SmoothMuscle andcollagen,Thrombosishematoma,LCC,血管內腔變小,粥狀硬塊,LCC,Plaque inArterial wall,Blood clot,Left anteriorDescendingartery,RightCoronaryartery,AtherothrombosisThrombus and Plaque,Unstable and Stable Plaque,Thin fibrous cap,Inflamma

8、tory cells,FewSMCs,Erodedendothelium,Activatedmacrophages,Thickfibrous cap,Lack ofinflammatory cells,Foam cells,Intactendothelium,MoreSMCs,Unstable,Stable,Risk Factors for Plaque Rupture,Impaired Fibrinolysis,Fibrinogen,DiabetesMellitus,Cholesterol,Smoking,Cap Fatigue,Atheromatous Core(size/consiste

9、ncy),Cap Inflammation,Systemic Factors,Local Factors,Homocysteine,PlaqueRupture,Cap Thickness/Consistency,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,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,Hemostatic c

10、lot Formation,Thrombin,AGGREGATION,Fibrin,HemostaticClot,Clotting,Platelet Aggregation,0 min,10 min,5 min,SECONDARY,PRIMARY,COAGULATION,Thrombus formation,Platelet activationadhesion,aggregation,Coagulation-pathwayactivation and thrombinformation,Fibrinogen conversion to fibrin with cross-linkingOf

11、bands,LCC,platelet,fibrin,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,Plaque/atheromaobstruction of the coronary artery lumen,Chest pain,Ischemic Heart Disease,穩定性心絞痛,LCC,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,Ischemic Heart Disease胸痛,流冷汗嘔吐噁

12、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,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,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,New Definition of M

13、I-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,New Definition of MI-ECG,Non-ST segment elevation AMI Criteria are not adequate

14、 to define AMIST segment elevation AMINew ST elevation in 2 or more leads(0.2 In V1-V3)0.1 in other leads,LCC,急性心肌梗塞 Acute MYOCARDIAL INFARCTION,ST segment elevation,Pathologic Q wave,LCC,New Definition of MI-established MI,In the absence of QRS confounders(BBB,LVH,WPW)Any Q wave in leads V1-V3Q wav

15、es 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,New Definition of MI-image,Infarct manifests itself as decreased wall motion by echo or hypoperfusion by radionuclide SPECTIschemia,stunning,and hibernation will produce sim

16、ilar changes,LCC,Use of cardiac markers in ACS,Cardiac troponin after classical AMI,CK-MB after AMI,Cardiac troponin aftermicroinfarction,Days after onset of AMI,LCC,Chest painTroponin I/T,CK-MBECG changesEchocardiographyNuclear cardiologyCardiac catheterization,急性心肌梗塞-診斷,LCC,急性心肌梗塞 Acute MYOCARDIAL

17、 INFARCTION,HypokinesiaakinesiaHyperkinesiaLV aneurysmLV size EFMRLV thrombus,LCC,急性心肌梗塞 Acute MYOCARDIAL INFARCTION,HypoperfusionLV systolic functionLV diastolic function,LCC,急性心肌梗塞-心導管,Filling defect,Contrast造影劑,LCC,Myocardial infarction,arrhythmia,Loss of muscle,Sudden death,Ventricular remodelin

18、g,Ventricular dilation,Heart failure,death,LCC,LCC,Thrombin/Fibrin,Platelet,thrombus,Pre-PCIASAStatinACEIClopidogrel,Post-PCIASAStatinACEIClopidogrel,GP IIb/IIIA Embolic protectionAnti-inflammatoryCoated stent,Plaquerupture,thrombus,LCC,Reperfusion,intervension,thrombolysis,LCC,Optimal Strategy UA/N

19、STEMI,TIMI IIIB,2002,Conservative,Invasive,VANQWISH,MATE,FRISC II,TACTICS-TIMI 18,VINO,RITA-3,TRUCS,急性心肌梗塞 Primary PTCA,Initiate PTCA if available and suitableGoals:PTCA within 90 30 min,LCC,氣球擴張術,Stenting,Stenting,LCC,網狀支架置放術,Interventional Cardiology,post,Stenting,Sites of Anti-thrombotic Drug Act

20、ion,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,Plaquerupture,thrombus,LCC,Fibrin,Thrombin,Platelet,FibrinolysisAntiplat

21、eletAnti-thrombin,THROMBUS,PLATELET,Antiplatelet therapy-aspirin-clopidogrel-GP IIb/IIIa inhibitors-persantin-ticlopidine,Thrombin,Antithrombin therapy-heparin,Fibrin,PlasminogenActivators-t-PAR-PASKTNK-tPA,LCC,StreptokinaseUrokinase,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

22、禁忌3小時內 好處最大,好處,壞處,LCC,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,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,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Hepar

23、in100萬單位1小時內 滴注完畢,ThrombolysisStreptokinase,LCC,Initiate fibrinolysis if indicatedGoals:30 min from entry to ER,急性心肌梗塞 Thrombolysis,LCC,FIBRINOLYSISABSOLUTE CONTRAINDICATION,Previous HEMORRHAGIC STROKE at any timeOther STROKES or CEREBROVASCULAR EVENTS within one yearKnown INTRACRANIAL NEOPLASMAActi

24、ve INTERNAL BLEEDING(does not include menses)Suspected AORTIC DISSECTION,LCC,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

25、2-4 WKS)Including head injuryNONCOMPRESSIBLE VASCULAR PUNCTURES,LCC,No benefitharmful,20%40%Decreased mortality,Non-ST segment elevation ACS,ST segment elevation ACS,Plaque rupture,ACS,Thrombolysis,LCC,THROMBUS,PLATELET,Antiplatelet therapy-aspirin-clopidogrel-GP IIb/IIIa inhibitors-persantin-ticlop

26、idine,Thrombin,Antithrombin therapy-heparin,Fibrin,PlasminogenActivators-t-PAR-PASKTNK-tPA,LCC,Adhesion,Platelets Role in thrombosis,Aggregation,1,Activation,2,3,GP IIb/IIIa Inhibitors,1.Platelet Adhesion,2.Platelet Activation,Platelet,GP Ib,Plaque rupture,3.Platelet Aggregation,ASA,Clopidogrel/Ticl

27、opidine,TxA2,Platelets Role in Thrombosis,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,Platel

28、et aggregation,Inhibition of aggregationby GP IIb/IIIa inhibitors,LCC,ThrombinSerotoninEpinephrineCollagen,Activation,ActivatedPlatelet,COX,Degranulation,Gp IIb/IIIa fibrinogenreceptor,To neighboringplatelet,ClopidogrelTiclopidine,THROMBUS,PLATELET,Antiplatelet therapy-aspirin-clopidogrel-GP IIb/III

29、a inhibitors-persantin-ticlopidine,Thrombin,Antithrombin therapy-heparin,Fibrin,PlasminogenActivators-t-PAR-PASKTNK-tPA,LCC,Unfractionated heparinLow molecular weight heparinEnoxaparinDalteparinNadroparinDirect Thrombin inhibitorsHirudinBivalirudinwarfarin,LCC,Antithrombotic Treatment,Sites of Anti-

30、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,MONAMorphine 靜脈注射Oxygen 4L/minNitroglycerine 舌下錠或噴劑As

31、pirin 160-325mg,急性心肌梗塞 胸痛,LCC,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,Management non-ST segment elevation ACS,Very high15%,intermediate38%,Very high815%,DeathMI,Aspirin heparinGP IIb/IIIaUrgent cathClopidogrel prior PCI,Aspirin LMWH GP IIb/

32、IIIaClopidogrelCoronary angio,Aspirin LMWHIschemia-guided Rx,LCC,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 gastroin

33、testinal 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

34、 inhibitors for patients with CHF,LV dysfunction(EF 0.40),hypertension,or diabetes,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 inhi

35、bitorClopidogrel-blocker,?,LCC,心臟血管疾病的危險因素,Multiple Risk Factors,LifestyleSmokingDietLack of exercise,Genetic TraitsGenderPlA2,GeneralizedDisordersAgeObesity,SystemicConditionsHypertensionHyperlipidemiaDiabetesHypercoagulable statesHomocysteinemia,Atherothrombotic Manifestations(MI,stroke,vascular d

36、eath),InflammationElevated CRPCD40 Ligand,IL-6 Prothrombotic factors(F I and II)Fibrinogen,Local FactorsBlood flow patternsShear stressVessel diameterArterial wall structure%arterial stenosis,中性脂肪增加,糖尿病,高血壓,肥胖,抽煙,運動不足,壓力人格,痛風,LDL增加,HDL減少,高膽固醇症,性別,家族病史,遺傳,老化,血管狹窄,Plaque,LCC,怎樣生活不傷心血脂肪,總膽固醇:HDL-C 小于 5

37、:1不飽和脂肪酸 使血液凝塊較不易形成全穀類 水果 蔬菜,食用油 不飽和脂肪酸 沙拉油 葵花油 豆油膽固醇 每天的攝取量不超過 300 mg 蛋 壹星期內不超過 3-4個肉類 魚(深海魚類)雞(去皮),LCC,怎樣生活不傷心抽煙,動脈血管硬化阻塞 心臟血管阻塞 腦血管阻塞 周邊血管阻塞慢性阻塞性肺病 COPD癌症,LCC,怎樣生活不傷心抽煙,禁煙 1年 心臟病發作的危險性 減少 50%以上禁煙 15年 心臟病發作的危險性 同一般正常人,LCC,怎樣生活不傷心肥胖,身體的脂肪過多BODY MASS INDEX:kg/m2正常 18.5-24.9 BMI OVERWEIGHT 25-30 BMI

38、OBESITY 30 BMI,LCC,遺傳 文化背景 社交行為 生理 新陳代謝,怎樣生活不傷心肥胖,高血壓高血脂肪糖尿病冠狀動脈心臟病腦中風死亡率較高,膽結石惡化關節炎呼吸系統易生問題子宮 乳房 前列腺 大腸等易生癌症,LCC,怎樣生活不傷心肥胖,飲食治療 低熱量 低脂肪運動治療 適當運動 30-45分鐘 3-5天/週 熱量消耗 500-1000 kcal/天,減輕體重 6月內 10%行為治療藥物治療外科手術,LCC,適當運動好處多,增加高密度脂蛋白膽固醇(HDL-C)降低血壓血糖控制較佳 減輕體重及肥胖較容易戒菸骨骼 肌肉 關節 較 不易退化,較少發生大腸癌減輕憂鬱及焦慮 對人生感覺較良好及

39、較有信心預防心臟病發作減少死亡率,LCC,ACC/AHA UA/NSTEMI*Guideline Update:Risk Factor Modification,Class ISmoking cessation Achieving optimal weight Daily exerciseAHA diet BP control to 130 mg/dLLipid-lowering agent if LDL-C after diet is 100 mg/dLA fibrate or niacin if HDL-C 40 mg/dL,心臟病六大害,高血壓糖尿病高血 脂抽煙肥胖缺乏適當運動,LCC,LCC,保護心臟,預防才是最好的治療,LCC,再,再,見,見,