冠心病英文版.ppt

Atherosclerosis&Coronary heart diseases Zhengzhou University,First affiliated Hospital Dept.of Cardiology Haiyu Li,M.D.Cardiovascular Diseases Atherosclerosis leading cause of death and disability Common location:Coronary circulation:Proximal left anterior descending coronary artery(LAD)Proximal portion of renal arteries Extracranial circulation to the brain Carotid bifurcation Atherosclerosis Coronary heart disease atherosclerosis Coronary stenosis coronary spasm Myocardial ischemia,anoxaemia Coronary heart disease,CHD Ischemic heart disease Atherosclerosis Stable angina pectoris(SAP)Acute coronary syndrome Unstable angina(UAP)and non-STEMI (UA/NSTEMI)ST elevation myocardial infarction(STEMI)Three fundamental biological processes of atherosclerosis 1.Accumulation of intimal cells:smooth muscle cells Macrophages T-lymphocytes 2.Proliferated connective tissue matrix:collagen elastic fibers proteoglycans 3.Accumulation of lipid:cholesterol esters free cholesterol Pathology and pathophysiology Fatty steak Fibrous plaque Complicated lesion AtherosclerosisAtherosclerosis Initiation of Atherosclerosis Fatty steak formation Initiation of Atherosclerosis Fatty steak formation Lipoprotein oxidation Nonenzymatic glycation Leukocyte recruitment Foam cell formation Atheroma evolution:fibrous plaque Atheroma evolution and complications Vascular remodeling:compensatory enlargement Atheroma evolution:Involvement of arterial smooth-muscle cells Blood coagulation microvessels Atheroma evolution and complications 炎症 细胞 少量平滑肌 细胞 激活的巨噬细胞 血栓 Complicated lesion:thrombosis Atheroma evolution and complications Atheroma evolution and complications Vulnerable plaque:Thin fibrous cap Relatively large lipid core High content of macrophages Inflammatory mediators Intravascular ultrasound Classicification of atherosclerotic lesion using IVUS Clinicl stages and classification Absence of symptom or stage of delitescence ischemia necrosis(target organ)fibrosis Atherosclerosis General manifestation Aortic atherosclerosis Coronary artery atherosclerosis Cerebral atherosclerosis Mesenteric atherosclerosis Peripheral artery atherosclerosis Atherosclerosis clinical manifestation laboratory examination Lack of sensitive and specific methods for early diagnosis Dyslipidemia：X-ray：DSA show severity of stenosis Doppler ultrasound:blood flow radionuclide：detection of ischemia Echocardiogram：CHD ECG and stress test:CHD New techniques:intravascular ultrasound,angioscope CT,MRI Atherosclerosis Risk factors and prevention 1.Lifestyle modification 2.Lipid disorders(Dyslipidemia):cholesterol screening in all 20yrs Elevated:cholesterol(Tc and LDL-c),TG,ApoB/ApoA,Lp(a),Low:HDL-c LDL lowering by HMG-CoA reductase(statins):cardiovascular events 30%，risk of MI 62%3.Hypertension：4.DM,Metabolic syndrome or insulin resistance syndrome:BP,BMI,TG,serum insulin HDL-c Diabetes mellitus(DM):RR 1.9 for male,3.3 for female more diffuse lesion.CAD equivalent 75-80%cause of death in adult DM are vascular diseases:CAD,cerebrovascular disease,or peripheral vascular disease Risk factors and prevention 7 years incidence of death/non-fatal MI(East West Study)*These patients had no history of myocardial infarction Haffner SM,et al.N Engl J Med.1998;339:229234.0 5 10 15 20 25 30 35 40 45 50 Events of MI in 7 years No history of MI OMI No history of MI*OMI non-diabetics diabetics n=1373 n=1059 P 0.001 P 40yrs adults，4/5 fatal myocardial infarction occured in patiens 65 yrs 8.Male gender/postmenopausal state：male:female=2：1,man develop CHD 10-15 yrs earlier than woman 9.alcohol 10.Others:diet,homocysteine,hemostatic factors inflammation/infection Risk factors and prevention Drug therapy：anti-platelet：aspirin,clopidogrel,GPIIb/IIIa inhitibor,Dipyridamole,cilostazol Lipid-lowering Risk factors and prevention 1.HMG-CoA reductase inhibitors（statins）Atorvastatin,Fluvastatin,Lovastatin,Pravastatin,Simvastatin,Cerivastatin,Rosuvastatin：*elevation of aminopherase,rhabdomyolysis 2.Bile acid-binding Resins cholestyramine，colestipol 3.Nicotinic Acid：4.Fibric acid derivatives（fibrates）Gemifibrozil,clofibrate,Fenofibrate 5.Cholesterol absorption inhibitors:ezetimibe 6.Probucol Lipid-lowering drugs Prevention of CAD A:aspirin,ACEI B:blood pressure,-blocker,C:cigarette smoking,Cholesterol D:diet,diabetes E:exercise,education Third Report of the National Cholesterol Education Program(NCEP)Expert Panel on Detection,Evaluation,and Treatment of High Blood Cholesterol in Adults ATP III(adult treatment panel III)Circulation 2002 17/24:3144-3373 Atherosclerosis Coronary heart disease(CHD)Coronary heart disease(CHD)most common cause:obstruction of atheromatous plaque other causes:spasm arterial thrombi coronary emboli ostial narrowing due to luetic aortitis congenital abnormalities severe LV hypertrophy Factors effect myocardial oxygen supply and demand Oxygen supply Oxygen demand Heart rate Myocardial contractility Systolic wall stress oxygen carrying capacity of blood Coronary blood flow Vascular resi