资源简介

(共42张PPT)
Cardiovascular system
心血管系统疾病
Section 2
缺血性心脏病 IHD
Ischemic Heart Disease
冠心病 CHD
Coronary artery Heart Disease
心脏病家族史
近亲中是否有人65岁前患心脏病
男性
年龄大于55岁
吸烟
胆固醇 200毫克/分升
血压 140/90mmHg
超重 30磅
体育锻炼 3次/周
有无糖尿病，糖尿病症状或糖尿病家族史
紧张性格或难于控制情绪
估测你的冠心病危险因素
1 低
2-5 中
6-9 高
10 非常
缺血性心脏病（冠心病 CHD）
Ischemic Heart Disease，IHD
95-99％由冠状动脉硬化引起
心肌氧需求和血供失衡
心绞痛 Angina pectoris
心肌梗死 Myocardial infarction
慢性缺血性心脏病
心源性猝死 Sudden cardiac death
发病机理
粥样斑块导致狭窄
重度狭窄Critical Stenosis -- 75%
动态改变
急性斑块改变 Acute plaque changes
血栓形成 Coronary artery thrombosis
痉挛 Coronary artery vasospasm
心绞痛 Angina Pectoris, AP
短暂、可逆的心肌缺氧导致胸痛
稳定型 Typical or stable AP
不稳定 Unstable AP, crescendo AP
变异型 Prinzemetal or variant AP
心肌梗死 Myocardial Infarction, MI
大部分急性MI由冠脉血栓引起
冠脉广泛狭窄引起低灌注
This 49-year-old married white male school teacher was a 2 pack/day smoker with a history of diabetes mellitus, hyperlipidemia and obesity, and a family history of coronary artery disease.
He was awakened from his sleep at 03:00 with crushing substernal chest pain which radiated to his left arm and was accompanied by shortness of breath. When paramedics （护理人员）arrived, they found the patient cool, clammy（湿冷）, bradycardic and hypotensive. Intravenous fluids and atropine were given and he was transported to a suburban hospital.
Case
On arrival in the emergency department at the hospital, the patient was in considerable distress. He was still bradycardic. He had no jugular venous（颈静脉） distention.
At 04:01 his white blood cell count was 7,900/cu mm, creatine phosphokinase (CPK) 89 IU/L and troponin-I <0.4 ng/ml（肌钙蛋白）. Chest x-ray showed borderline cardiomegaly without signs of pulmonary edema.
Case (con’d)
Case (con’d)
The patient was treated with morphine, atropine and aspirin, but he remained bradycardic and hypotensive. He had decreasing pulse oximeter blood oxygen saturation despite supplemental oxygen and he became cyanotic.
A transcutaneous pacemaker（起搏器） was placed. A dopamine drip was started, resulting in an increase in the patient's blood pressure. He was started on heparin and emergency cardiac catheterization showed non-critical disease of the left anterior descending and left circumflex arteries but a dominant right coronary artery which was totally occluded proximally.
Percutaneous transluminal coronary angioplasty (PTCA) was attempted but failed to re-open the right coronary artery. An intra-aortic balloon pump was placed and the patient was transferred via helicopter to the university hospital.
At the university hospital, his total CPK rose to 4422 IU/L (MB isoenzyme 223.8 ng/ml, relative index 5.1). The evolving clinical data made it clear that his prognosis was extremely grim. He was given comfort measures and he died peacefully.
Case (con’d)
AUTOPSY FINDINGS: GROSS
90% lumnal narrowing of the proximal right coronary
90% lumnal narrowing The left circumflex coronary artery
75% lumnal narrowing The left anterior descending coronary artery
Extensive pallor of the myocardium, which was transmural and maximal in the apex, minimal in the upper anterior left ventricle
AUTOPSY FINDINGS: MICRSCOPIC
左室前壁，心尖，室间隔前2/3 左前降支（40%-50%）
左室后壁，室间隔后1/3
右冠状动脉（30%-40%）
左室侧壁
冠状动脉左旋支
MI好发部位
MI 类型
透壁性（transmural MI）
…累及全心室壁
心内膜下（subendocardial MI）
…累及心内膜下1/3
病理变化
4-8 hours：核改变；PMN出现；
Earliest nuclear changes, polys appear; you may see a bit of dark mottling（斑点状影） grossly
8-24 hours：苍白；凝固坏死；收缩带；
First clear gross changes, i.e., pallor; good coagulation necrosis; often good contraction bands; definitely feels soft by 24 hours
24-72 hours：大量PMNs；软
Looks terrible, lots of polys, fibers very dead; infarct feels soft and looks pale and yellowish
3- 7 days：巨噬细胞；肉芽组织
Macrophages, granulation tissue starts at rim; grossly you see the red granulation tissue around the infarct
10 days ：肉芽组织；
Nice granulation tissue; macrophage cleanup team may be removing the dead fibers, or the dead fibers may persist for weeks
7 weeks ：瘢痕
Nice scar.
Normal appearance of myocardial fibers
Acute MI in the first day： contraction band necrosis
MI about 3 to 4 days old
Myocardial infarction of 1 to 2 weeks
MI scars
心律失常 Rhythm disturbances
心衰 Left-sided congestive heart failure
心源性休克 Cardiogenic shock
破裂 Rupture (free wall/septum/papillary muscle)
室壁瘤 Aneurysm formation
附壁血栓 Mural thrombus formation
Embolization
4％-8％
并发症
75％-95％
10％
60％
15％-49％
Effects of air pollution on the incidence of myocardial infarction
Heart 2009;95;1746-1759;

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