内科学概论心脏血管内科.pptx

內科學概論高高雄雄醫醫學學大大學學Lin CC血壓的形成n收縮壓收縮壓n舒張壓舒張壓LCC高血壓分類n原發性高血壓原發性高血壓 Primary Hypertensionn續發性高血壓續發性高血壓 Secondary HypertensionLCCn遺傳基因的影響遺傳基因的影響n鈉鹽的過度攝取鈉鹽的過度攝取nRenin-Angiotensin systemn交感神經系統交感神經系統n細胞膜的異常細胞膜的異常n血管的增生肥厚血管的增生肥厚n內皮細胞功能異常內皮細胞功能異常n胰島素抗性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JNC7Normal 120 80Prehypertetnsion 120-139 or 80-89 Stage 1 hypertension 140-159 or 90-99Stage 2 hypertension 160 or100Initial Measurements血壓的測定n基礎血壓基礎血壓n隨時血壓隨時血壓n休息血壓休息血壓LCCnClinical pressurenAmbulatory pressurenHome pressure血壓的測定LCCBlood Pressure MeasurementAmbulatory MeasurementAdvantages of Self-Measurement高血壓臨床表現n n頭重頭重頭重頭重 頭痛頭痛頭痛頭痛n n耳鳴耳鳴耳鳴耳鳴 n n眼花眼花眼花眼花 n n失眠失眠失眠失眠n n頭頸部酸痛頭頸部酸痛頭頸部酸痛頭頸部酸痛n n兩肩酸痛兩肩酸痛兩肩酸痛兩肩酸痛n n大部分大部分大部分大部分沒有症沒有症沒有症沒有症狀狀狀狀 40歲歲 20%罹患高血壓罹患高血壓隱形殺手隱形殺手LCC高血壓自然病程高血壓前期高血壓前期高血壓前期高血壓前期遺傳遺傳遺傳遺傳-環境因素環境因素環境因素環境因素惡性惡性高血壓高血壓心臟心臟大血管大血管腎腎眼眼腦腦合併症合併症高血壓高血壓高血壓早期高血壓早期年齡年齡0-3020-4030-50LCCn正確測量血壓正確測量血壓n外觀外觀:脂肪分布脂肪分布 皮膚皮膚 肌肉肌肉 及神智狀況及神智狀況n眼底檢查眼底檢查n頸部頸部頚動脈及甲狀腺觸診聽診頚動脈及甲狀腺觸診聽診n心臟心臟大小節律及心音異常大小節律及心音異常n肺肺有無囉音有無囉音n腹部腹部腫瘤腫瘤?動脈雜音動脈雜音 股動脈搏動股動脈搏動n四肢四肢動脈博動動脈博動 水腫水腫n神經檢查神經檢查 高血壓臨床檢查重點LCCLaboratory testsOptimal TestsWhat is the target of BP What is the target of BP with therapy?with therapy?General:140/90 mmHgDiabetes:130/80 mmHgCHF or renal disease:30分鐘分鐘對舌下對舌下nitroglycerine反應不好反應不好急急性性心心肌肌梗梗塞塞LCC猝心絞痛猝心絞痛 心肌梗塞心肌梗塞Sudden deathSudden death 心肌梗塞 Sudden deathn50%到達醫院前發生 ventricular fibrillation sudden deathn發生時機胸痛後4小時n早期送醫n電擊器的使用可以救命LCC冠狀動脈疾病冠狀動脈疾病心肌梗塞心肌梗塞不穩定型心絞痛不穩定型心絞痛PTCAPTCAn n24%24%的男性和的男性和的男性和的男性和42%42%的女性會在發生心肌的女性會在發生心肌的女性會在發生心肌的女性會在發生心肌梗塞後的一年內死亡梗塞後的一年內死亡梗塞後的一年內死亡梗塞後的一年內死亡n n不穩定型心絞痛的病不穩定型心絞痛的病不穩定型心絞痛的病不穩定型心絞痛的病人在三個月內的死亡人在三個月內的死亡人在三個月內的死亡人在三個月內的死亡率將近率將近率將近率將近10%10%n n進行進行進行進行PTCAPTCA的病人中的病人中的病人中的病人中 有有有有40%40%可能在六個可能在六個可能在六個可能在六個月內需要再進行手術月內需要再進行手術月內需要再進行手術月內需要再進行手術LCC New Definition of MI-biochemistTroponin 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 valuesLCCNew Definition of MI-ECGNon-ST segment elevation AMI Criteria are not adequate to define AMIST segment elevation AMIlNew ST elevation in 2 or more leads(0.2 In V1-V3)l0.1 in other leadsLCC急性心肌梗塞急性心肌梗塞 Acute MYOCARDIAL INFARCTIONAcute MYOCARDIAL INFARCTIONST segment elevationPathologic Q waveLCCNew Definition of MI-established MIIn the absence of QRS confounders(BBB,LVH,WPW)lAny Q wave in leads V1-V3lQ waves must be 30 msec durationlQ waves in other leads must have Qs in 2 contiguous leads(eg,II and III)lQs must be 1mm in depthLCCNew Definition of MI-imageInfarct manifests itself as decreased wall motion by echo or hypoperfusion by radionuclide SPECTIschemia,stunning,and hibernation will produce similar changesLCCUse of cardiac markers in ACSUse of cardiac markers in ACSCardiac troponin after classical AMICK-MB after AMICardiac troponin aftermicroinfarctionDays after onset of AMIDays after onset of AMILCCnChest painChest painnTroponin I/T,CK-MBTroponin I/T,CK-MBnECG changesECG changesnEchocardiographyEchocardiographynNuclear cardiologyNuclear cardiologynCardiac catheterizationCardiac catheterization急性心肌梗塞急性心肌梗塞-診斷診斷LCC急性心肌梗塞急性心肌梗塞 Acute MYOCARDIAL INFARCTIONAcute MYOCARDIAL INFARCTIONuHypokinesiauakinesiauHyperkinesiauLV aneurysmuLV size EFuMRuLV thrombusLCC急性心肌梗塞急性心肌梗塞 Acute MYOCARDIAL INFARCTIONAcute MYOCARDIAL INFARCTIONHypoperfusionLV systolic functionLV diastolic functionLCC急性心肌梗塞急性心肌梗塞-心導管心導管Filling defectContrast造影劑造影劑LCCMyocardial infarctionMyocardial infarctionarrhythmiaLoss of muscleSudden deathVentricular remodelingVentricular dilationHeart failuredeathLCCLCC Thrombin/FibrinPlateletthrombusPre-PCIPre-PCIASAASAStatinStatinACEIACEIClopidogrelClopidogrelPost-PCIPost-PCIASAASAStatinStatinACEIACEIClopidogrelClopidogrelGP IIb/IIIA Embolic protectionAnti-inflammatoryCoated stentPlaquerupturethrombusLCCReperfusionReperfusionintervensionthrombolysisLCCOptimal Strategy UA/NSTEMITIMI IIIB2002ConservativeInvasiveVANQWISHMATEFRISC IITACTICS-TIMI 18VINORITA-3TRUCS急性心肌梗塞急性心肌梗塞 Primary PTCAnInitiate PTCA if available and suitablenGoals:PTCA within 90 30 minLCC氣氣球球擴擴張張術術StentingStentingStentingLCC網狀支架置放術Interventional CardiologypostStentingSites of Anti-thrombotic Drug ActionTissue factorPlasma clottingcascadeProthrombinThrombinFibrinogenFibrinThrombusPlatelet aggregationConformational activation of GPIIb/IIIaCollagenThromboxane A2ADPATATFactorXaCoagulationcascadePlateletcascadePlaquerupturethrombusLCCFibrinThrombinPlateletFibrinolysisAntiplateletAnti-thrombinTHROMBUSPLATELETPLATELETAntiplatelet therapy-aspirin-clopidogrel-GP IIb/IIIa inhibitors-persantin-ticlopidineThrombinThrombinAntithrombin therapy-heparinFibrinFibrinPlasminogenActivators-t-PAR-PASKTNK-tPALCCStreptokinaseUrokinase急性心肌梗塞急性心肌梗塞 Thrombolysisn一般原則一般原則u胸痛胸痛u12小時內小時內uST segment elevationu180/110 mmHg)(BP180/110 mmHg)n nHistory of History of PRIOR CVDPRIOR CVD or known or known INTRACEREBRAL PATHOLOGYINTRACEREBRAL PATHOLOGY n nCurrent use of Current use of ANTICOAGULANTSANTICOAGULANTS(INR(INR 2-3)2-3)Known Known BLEEDING DIATHESISBLEEDING DIATHESISn nRECENT TRAUMARECENT TRAUMA(Within 2-4 WKS)(Within 2-4 WKS)Including head injuryIncluding head injuryn nNONCOMPRESSIBLE VASCULAR PUNCTURESNONCOMPRESSIBLE VASCULAR PUNCTURESLCCNo benefitNo benefitharmfulharmful20%40%Decreased 20%40%Decreased mortalitymortalityNon-ST segment elevation ACSST segment elevation ACSPlaque ruptureACSThrombolysisThrombolysisLCCTHROMBUSPLATELETPLATELETAntiplatelet therapy-aspirin-clopidogrel-GP IIb/IIIa inhibitors-persantin-ticlopidineThrombinThrombinAntithrombin therapy-heparinFibrinFibrinPlasminogenActivators-t-PAR-PASKTNK-tPALCCGP IIb/IIIa Inhibitors1.Platelet Adhesion2.Platelet ActivationPlateletGP Ib Plaque ruptureActivated Platelet GP IIb/IIIa 3.Platelet AggregationASA,Clopidogrel/TiclopidineTxA2FibrinogenPlatelets Role in ThrombosisActs by selective inhibition of ADP binding to its platelet receptor and prevents subsequent platelet aggregationADPADPFibrinogen Fibrinogen Binding Site SiteClopidogrelClopidogrelFibrinogen Binding ReducedFibrinogenPlateletPlateletLCCClopidogrelClopidogrelmechanism of actionPlatelet aggregationInhibition of aggregationby GP IIb/IIIa inhibitorsLCCThrombinSerotoninEpinephrineCollagenADPADPActivationTXATXA2 2ActivatedPlateletCOXCOXDegranulationAspirin Gp Gp IIb/IIIa fibrinogenfibrinogenreceptorreceptorTo neighboringTo neighboringplateletplateletClopidogrelTiclopidinePlatelet agonistsADPATPserotonincalciummagnesiumAdhesive proteinsthrombospondinfibrinogenp-selectinvWFCoagulation factorsfactor Vfactor XIPAI-1Inflammatory factorsplatelet factor 4CD 154(CD 40 ligand)PDGFIV Gp IIb/IIIaInhibitorsTHROMBUSPLATELETPLATELETAntiplatelet therapy-aspirin-clopidogrel-GP IIb/IIIa inhibitors-persantin-ticlopidineThrombinThrombinAntithrombin therapy-heparinFibrinFibrinPlasminogenActivators-t-PAR-PASKTNK-tPALCCUnfractionated heparinLow molecular weight heparinEnoxaparinDalteparinNadroparinDirect Thrombin inhibitorsHirudinBivalirudinwarfarinLCCAntithrombotic TreatmentAntithrombotic TreatmentSites of Anti-thrombotic Drug ActionTissue factorPlasma clottingcascadeProthrombinThrombinFibrinogenFibrinThrombusPlatelet aggregationConformational activation of GPIIb/IIIaCollagenThromboxane A2ADPATATAspirinTiclopidineClopidogrelGPIIb/IIIainhibitorsFactorXaBivalirudinHirudinArgatrobanLMWHHeparinThrombo-lyticsCoagulationcascadePlateletcascadeMONAnMorphine 靜脈注射靜脈注射nOxygen 4L/minnNitroglycerine 舌下錠或噴劑舌下錠或噴劑nAspirin 160-325mg急性心肌梗塞急性心肌梗塞 胸痛胸痛LCC急性心肌梗塞急性心肌梗塞 Morphine解除胸痛解除胸痛鎮靜鎮靜 減少焦慮減少焦慮每每5-10分鐘分鐘 靜脈注靜脈注射射2-4mgn低血壓低血壓u病人平躺病人平躺u補充生理食鹽水液補充生理食鹽水液n呼吸抑制呼吸抑制uNaloxone 0.4mg IVu每三分鐘注射一次每三分鐘注射一次可重複三劑量可重複三劑量LCCManagement non-ST segment elevation ACSManagement non-ST segment elevation ACSVery high15%intermediate38%Very high815%DeathMIAspirin heparinGP IIb/IIIaUrgent cathClopidogrel prior PCIAspirin LMWH GP IIb/IIIaClopidogrelCoronary angioAspirin LMWHIschemia-guided RxLCCACC/AHA UA/NSTEMI Guidelines Recommendations for Long-term Medical TherapyClass I1.Aspirin 75 to 325 mg/day2.Clopidogrel 75 mg daily(in the absence of contraindications)when aspirin is not tolerated because of hypersensitivity or gastrointestinal intolerance 3.The combination of aspirin and clopidogrel for 9 months after UA/NSTEMI4.-Blockers in the absence of contraindications 5.Lipid-lowering agents and diet in post-ACS and postrevascularization patients with LDL-C 130 mg/dL 6.Lipid-lowering agents if LDL-C level after diet is 100 mg/dL7.ACE inhibitors for patients with CHF,LV dysfunction(EF 30 BMI LCCn遺傳遺傳 n文化背景文化背景 n社交行為社交行為 n生理生理 n新陳代謝新陳代謝 怎樣生活不傷心怎樣生活不傷心肥胖肥胖n高血壓高血壓n高血脂肪高血脂肪n糖尿病糖尿病n冠狀動脈心臟冠狀動脈心臟病病n腦中風腦中風n死亡率較高死亡率較高n膽結石n惡化關節炎n呼吸系統易生問題n子宮 乳房 前列腺 大腸等易生癌症 LCC怎樣生活不傷心怎樣生活不傷心肥胖肥胖n飲食治療飲食治療 低熱量低熱量 低脂肪低脂肪n運動治療運動治療 適當運動適當運動 30-45分鐘分鐘 3-5天天/週週 熱量消耗熱量消耗 500-1000 kcal/天天n減輕體重減輕體重 6月內月內 10%n行為治療行為治療n藥物治療藥物治療n外科手術外科手術LCC適當運動好處多適當運動好處多n增加增加高密度脂蛋白高密度脂蛋白膽固醇膽固醇(HDL-C)n降低降低血壓血壓n血糖血糖控制較佳控制較佳 n減輕減輕體重體重及及肥胖肥胖n較容易較容易戒菸戒菸n骨骼骨骼 肌肉肌肉 關節關節 較較 不易退化不易退化n較少發生較少發生大腸癌大腸癌n減輕減輕憂鬱憂鬱及及焦慮焦慮 對人生感覺較良好對人生感覺較良好及較有及較有信心信心n預防預防心臟病心臟病發作發作n減少減少死亡率死亡率 LCCACC/AHA UA/NSTEMI*Guideline Update:Risk Factor ModificationClass 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心臟病六大害心臟病六大害n高血壓高血壓n糖尿病糖尿病n高血高血 脂脂n抽煙抽煙n肥胖肥胖n缺乏適當運動缺乏適當運動LCCLCC保護心臟保護心臟預防才是最好的才是最好的治療LCC再再見見