内科学概论心脏血管内科-课件.ppt

1、內科學概論高雄醫學大學高雄醫學大學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LCCn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

2、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

3、然病程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

4、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 deathsudden deathn發生時機胸痛

5、後4小時n早期送醫n電擊器的使用可以救命LCCLCC 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 segme

6、nt 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

7、 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

8、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 aftermicroinfarctionLCCnChest painChest painnTroponin I/T,CK-MBTroponin I/T,CK-MBnECG ch

9、angesECG 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

10、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 failu

11、redeathLCCLCC Thrombin/Fibrin Thrombin/FibrinPlateletthrombusthrombusPre-PCIPre-PCIASAASAStatinStatinACEIACEIClopidogrelClopidogrelPost-PCIPost-PCIASAASAStatinStatinACEIACEIClopidogrelClopidogrelGP IIb/IIIA Embolic protectionAnti-inflammatoryCoated stentPlaquerupturethrombusLCCintervensionthrombolys

12、isLCCOptimal 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氣球擴張術氣球擴張術LCC網狀支架置放術Interventional CardiologyInterventional CardiologypostStentingTissue fa

13、ctorPlasma clottingcascadeProthrombinThrombinFibrinogenFibrinThrombusPlatelet aggregationConformational activation of GPIIb/IIIaCollagenThromboxane A2ADPATATFactorXaCoagulationcascadePlateletcascadePlaquerupturethrombusLCCFibrinThrombinPlateletFibrinolysisAntiplateletAnti-thrombinTHROMBUSPLATELETPLA

14、TELETAntiplatelet 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 elevationu15%intermediate38%Ver

15、y high815%DeathMIAspirin heparinGP IIb/IIIaUrgent cathClopidogrel prior PCIAspirin LMWH GP IIb/IIIaClopidogrelCoronary angioAspirin LMWHIschemia-guided RxLCCACC/AHA UA/NSTEMI Guidelines ACC/AHA UA/NSTEMI Guidelines Recommendations for Long-term Medical TherapyRecommendations for Long-term Medical Th

16、erapyClass 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 contrai

17、ndications 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

18、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 30-4530-45分鐘分鐘 3-53-5天天/週週 熱量消耗熱量消耗 500-1000 kcal/500-1000 kcal/天天n減輕體重減輕體重 6 6月內月內 10%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

19、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/NSTEMIACC/AHA UA/NSTEMI*Guideline Guideline Update:Risk Factor ModificationUpdate: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