急性冠脉综合征(英文版PPT课件).ppt

,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/2,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/2,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/2,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/2,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/2,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/3,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/3,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/3,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/3,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/3,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/3,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/3,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/3,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/3,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/3,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2020/12/3,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,急性冠脉综合征（英文版PPT课件）,急性冠脉综合征（英文版PPT课件）急性冠脉综合征（英文版PPT课件）AbbreviationsACC:American College of Cardiology,ACE:angiotensin-converting enzyme,ACS:acute coronary syndrome,ACUITY:Acute Catheterization and Urgent Intervention Triage,Strategy,ADP:adenosine diphosphate,AHA:American Heart Association,ARB:angiotensin receptor blocker,ASPECT:Antithrombotics in Secondary Prevention of,Events in Coronary Thrombosis,CK:creatine kinase,22020/12/3,Abbreviations,ACC:American College of Cardiology,ACE:angiotensin-converting enzyme,ACS:acute coronary syndrome,ACUITY:Acute Catheterization and Urgent Intervention Triage,Strategy,ADP:adenosine diphosphate,AHA:American Heart Association,ARB:angiotensin receptor blocker,ASPECT:Antithrombotics in Secondary Prevention of,Events in Coronary Thrombosis,CK:creatine kinase,2020/12/3,2,Abbreviations,CABG:coronary artery bypass graft,CHD:coronary heart disease,CVD:cardiovascular disease,DHA:docosahexaenoic acid,ECG:electrocardiogram,EF:ejection fraction,EPA:eicosapentaenoic acid,EPHESUS:Eplerenone Post-Acute Myocardial Infarction,Heart Failure Efficacy and Survival Study,ExTRACT:Enoxaparin versus Unfractionated Heparin with,Fibrinolysis for ST-elevation Myocardial Infarction,2020/12/3,3,Abbreviations,HIT:Heparin induced thrombocytopenia,ICH:intracranial hemorrhage,INR:international normalized ratio,IV:intravenous,LDL:low-density lipoprotein,LMWH:low-molecular-weight heparin,LV:left ventricular,LVEF:left ventricular ejection fraction,MADIT:Multicenter Automatic Defibrillator Implantation Trial,MB:myocardial band,MI:myocardial infarction,2020/12/3,4,Abbreviations,NCEP:National Cholesterol Education Program,NICE-SUGAR:Intensive Versus Conventional Glucose Control,in Critically Ill Patients Trial,NRMI:National Registry of Myocardial Infarction,NSAID:nonsteroidal antiinflammatory drug,NSTE:nonST-segment elevation,OASIS:Organization for the Assessment of Strategies for,Ischemic Syndromes,OAT:Occluded Artery Trial,PCI:percutaneous coronary intervention,TIMI:Thrombolysis in Myocardial Infarction,UFH:unfractionated heparin,WARIS:Warfarin Re-Infarction Study,2020/12/3,5,Recommendations&Evidence,Strength of recommendations,A:good,B:moderate,C:poor,Quality of evidence,1:more than 1 properly randomized,controlled trial,2:at least 1 well-designed clinical trial with randomization;from cohort or case-controlled analytic studies;or dramatic results from uncontrolled experiments or subgroup analyses,3:opinions of respected authorities,based on clinical experience,descriptive studies,or reports of expert communities,2020/12/3,6,Key Concepts,Acute coronary syndromes(ACS)typically caused by atherosclerotic plaque rupture&subsequent clot formation,Risk-stratify patients with suspected ACS based on ECG,symptoms&lab tests,Early reperfusion with PCI or fibrinolytic recommended for patients with ST-segment elevation myocardial infarction(STEMI),2020/12/3,7,Key Concepts,High-risk NSTE(non ST-segment elevation)ACS patients should have early coronary angiography&revascularization,ACS patients should also receive early therapy with intranasal oxygen,aspirin,clopidogrel,nitroglycerin,-blocker&an anticoagulant,MI patients should receive indefinite therapy with ASA,-blocker,&ACE inhibitor or ARB,Selected patients should receive statin,clopidogrel or anticoagulation,2020/12/3,8,Epidemiology,1.5 million American experience an ACS every year,220,000 of those will die of an MI,Chest discomfort:2,nd,most frequent reason for ED visits,CHD:leading cause of premature disability in the US,2007 cost of CHD:$151.6 billion,Anderson JL,Adams CD,Antman EM,et al.ACC/AHA 2007,Guidelines for the management of patients with unstable angina/non,ST-elevation myocardial infarction:A report of the ACC/AHA Task Force on Practice Guidelines:Circulation 2007;116:803877.,American Heart Association.Heart Disease and Stroke Statistics2007,Update.Dallas,TX:American Heart Association,2007.,2020/12/3,9,Epidemiology,In hospital death rates,STE ACS:4.6%,NSTE ACS:2.2%,Lower mortality rates for patients treated with reperfusion therapy(fibrinolytics or PCI),Mortality rates higher in women&elderly patients,American Heart Association.Heart Disease and Stroke Statistics2007,Update.Dallas,TX:American Heart Association,2007.,2020/12/3,10,HTN,age,male gender,tobacco use,DM,obesity,dyslipidemias,Atherosclerosis starts early in life,Inflammation plays key role,Several factors contribute to evolution of endothelial dysfunction&formation of fatty streaks arteries that lead to atherosclerotic plaques,Etiology,2020/12/3,11,Pathophysiology,ACSs result from myocardial ischemia due to imbalance between myocardial O,2,demand&supply,usually due to occluded coronary artery thrombus,STEMI,NSTEMI,&unstable angina fall under this heading,unstable angina does not produce detectable biochemical marker levels,2020/12/3,12,Comparison of ACSs,Unstable Angina,NSTEMI,STEMI,Symptoms present,+,+,+,ECG changes,None,ST segment depression,T wave inversion,or no changes,ST segment elevation,Biochemical marker,No changes,Increased troponins&CK MB,Increased troponins,&CK MB,DiPiro JT,Talbert RL,Yee GC,Matzke GR,Wells BG,Posey LM:Pharmacotherapy:A Pathophysiologic Approach,7th Edition:,2020/12/3,13,CAD Causes,Type,Comments,Atherosclerosis,Most common cause.Risk factors:hypertension,hypercholesterolemia,diabetes mellitus,smoking,family history of atherosclerosis.,Spasm,Coronary artery vasospasm can occur in any population but is most prevalent in Japanese.Vasoconstriction appears to be mediated by histamine,serotonin,catecholamines,and endothelium-derived factors.Because spasm can occur at any time,the chest pain is often not exertion-related.,Emboli,Rare cause of coronary artery disease.Can occur from vegetations in patients with endocarditis.,Congenital,Congenital coronary artery abnormalities are present in 1 to 2%of the population.However,only a small fraction of these abnormalities cause symptomatic ischemia.,DiPiro JT,Talbert RL,Yee GC,Matzke GR,Wells BG,Posey LM:Pharmacotherapy:A Pathophysiologic Approach,7th Edition:,2020/12/3,14,Plaque Rupture&Clot Formation,90%of ACSs caused by rupture or erosion of an atherosclerotic plaque,Plaques likely to rupture,those that occlude,20 minutes,Pain may radiate,left arm,jaw,back,Nausea,vomiting,diaphoresis,shortness of breath,Women,diabetics,&elderly patients may have atypical or no symptoms,2020/12/3,20,Electrocardiogram,12-lead ECG should be done within 10 min of ED arrival,Key findings indicating myocardial damage,ST-segment elevation,ST-segment depression,T-wave inversion,2020/12/3,21,Biochemical Markers,Evaluate troponin&CK MB to confirm MI,released in response to myocardial necrosis,3 measurements taken over the 1,st,12 to 24 hrs,MI diagnosis:,1 one troponin value greater than MI decision limit set by lab,or,2 CK MB values greater than MI decision limit set by lab,2020/12/3,22,NSTEMI,STEMI,2020/12/3,23,STEMI,2020/12/3,24,2020/12/3,25,2020/12/3,26,Risk Stratification,Treat STEMI patients as fast as possible,NST ACS patients stratified based on clinical presentation,lab findings,Risk categories,high,medium,low,TIMI:,T,hrombolysis,I,n,M,yocardial,I,nfarction,Treatment based on TIMI score,2020/12/3,27,TIMI Risk Score for NonST-Segment Elevation Acute Coronary Syndromes,Past Medical History,Clinical Presentation,Age,65 years,ST-segment depression(,0.5 mm),3 Risk factors for CAD,2 episodes of chest discomfort in the past 24 hrs,Hypercholesterolemia,Positive biochemical marker for infarction,a,HTN,TM,Smoking,Family history of premature CHD,50%stenosis of coronary artery),Use of aspirin within the past 7 days,Using the TIMI Risk Score,One point is assigned for each of the seven medical history and clinical presentation findings.The score(point)total is calculated,and the patient is assigned a risk for experiencing the composite end point of death,myocardial infarction or urgent need for revascularization as follows:,High Risk,Medium Risk,Low Risk,TIMI risk score 57 points,TIMI risk score 34 points,TIMI risk score 02 points,a,Troponin I,troponin T,or creatinine kinase MB greater than the MI detection limit.,DiPiro JT,Talbert RL,Yee GC,Matzke GR,Wells BG,Posey LM:Pharmacotherapy:A Pathophysiologic Approach,7th Edition:,2020/12/3,28,Treatment Goals,Restore blood flow to prevent infarct expansion&MI,Prevent death,complications,Prevent coronary artery reocclusion,Relieve ischemic chest discomfort,Maintain normoglycemia,2020/12/3,29,Performance Measure,Description,1.Aspirin upon arrival,STEMI and NSTE MI patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival,2.Aspirin prescribed at hospital discharge,STEMI and NSTE MI patients without aspirin contraindications who are prescribed aspirin at hospital discharge,3.,Blocker upon hospital arrival,Blocker STEMI and NSTE MI patients without blocker contraindications who received a blocker within 24 hours after hospital arrival,4.,Blocker prescribed at hospital discharge,STEMI and NSTE MI patients without,blocker contraindications who are prescribed a blocker at hospital discharge,5.LDL cholesterol assessment,STEMI and NSTE MI patients with documentation of LDL cholesterol level in the hospital record or documentation that LDL cholesterol testing was done during the hospital stay or is planned for after hospital discharge,6.Lipid-lowering therapy at hospital discharge,STEMI and NSTE MI patients with elevated LDL cholesterol(100 mg/dL)who are prescribed lipid-lowering medicine at hospital discharge,DiPiro JT,Talbert RL,Yee GC,Matzke GR,Wells BG,Posey LM:Pharmacotherapy:A Pathophysiologic Approach,7th Edition:,2006 American College of Cardiology/American Heart Association STE and NSTE MI Performance Measures,2020/12/3,30,Performance Measure,Description,7.ACE inhibitor or ARB for LVSD at discharge,STEMI and NSTE MI patients with LVSD and without ACE inhibitor and ARB contraindications who are prescribed an ACE inhibitor or ARB at hospital discharge,8.Time to fibrinolytic therapy,Median time from arrival to administration of fibrinolytic therapy in patients with STE or LBBB on the ECG performed closest to hospital arrival time,STEMI or LBBB patients receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less,9.Time to PCI,Median time from arrival to PCI in patients with STE or LBBB on the ECG performed closest to hospital arrival time,STEMI or LBBB patients receiving PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less,10.Reperfusion therapy,STEMI patients with STE on the ECG performed closest to the arrival who receive fibrinolytic therapy or primary PCI,11.Adult smoking cessation advice counseling,STEMI and NSTE MI patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay,2006 American College of Cardiology/American Heart Association STE and NSTE MI Performance Measures,DiPiro JT,Talbert RL,Yee GC,Matzke GR,Wells BG,Posey LM:Pharmacotherapy:A Pathophysiologic Approach,7th Edition:,2020/12/3,31,Nonpharmacologic Therapy,STEMI patients should receive either fibrinolysis or primary PCI within 3 hrs of symptom onset,PCI:preferred treatment in capable centers,High risk NST ACS patients may undergo PCI or CABG,“early invasive strategy”,2020/12/3,32,Primary PCI,A meta-analysis comparing fibrinolysis with PCI indicated lower mortality rate in PCI patients,PCI opens arteries better than fibrinolytics,reduces risk of major bleeding,intracranial hemorrhage(ICH),better side effect profile,“Door-to-balloon time”,time of hospital presentation to time occluded artery is opened should be,90 min,2020/12/3,33,Additional Testing,Echocardiogram to determine LV function,LV function:best predictor of mortality after MI,LVEF 40%=higher risk of death,Implantable cardioverter defibrillator(ICD)may be placed in patients with ventricular tachycardias,May perform stress testing in moderate or low risk patients to diagnose CAD,Draw fasting lipid panel,2020/12/3,34,Early Pharmacotherapy for ACS,Intranasal oxygen(if O,2,saturation 1 mm of STE on EKG(Class 1),not indicated in NSTE ACS,CI in patients with high bleeding risk,Fibrinolytic therapy controversial in patients 75 yr,2020/12/3,41,Contraindications to Fibrinolysis,Absolute contraindications,:,active internal bleeding(not including menses),previous intracranial hemorrhage at any time,ischemic stroke within 3 months,intracranial neoplasm,structural vascular lesion(e.g.,arteriovenous malformation),suspected aortic dissection,significant closed head or facial trauma within 3 months,2020/12/3,42,Contraindications to Fibrinolysis,Relative contraindications,:,uncontrolled HTN(BP 180/110 mm Hg),ischemic stroke 3 months,dementia,intracranial pathology,current anticoagulant use,ble