教学讲稿方全－心绞痛

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1、病史特点男性，59岁反复胸痛4个月，加重1个月。胸痛呈压榨性与劳力有关。有高血压，吸烟史。有心脑血管病阳性家族史。查体：体胖，无明显其他阳性发现。ECG：V4－V6，I，aVLST0.5-1mm.思考胸痛的鉴别心绞痛的特点心绞痛的分级心绞痛的分类不同类型心绞痛的病理基础进一步检查冠心病的易患因素心绞痛的鉴别(1)Non-ischemicCVAorticdissectionPericarditisPulmonaryPulmonaryembolusPneumothoraxPneumoniaPleuritisGastrointestinalEsophagea

2、lEsophagitis,Spasm,RefluxBiliaryColicCholecystitisCholedocholithiasisCholangitisPepticulcerPancreatitis心绞痛的鉴别(2)ChestWallCostochondritisFibrositisRibfractureSternoclaviculararthritisHerpeszoster(beforetherash)PsychiatricAnxietydisordersHyperventilationPanicdisorderPrimaryanxietyA

3、ffectivedisorders(e.g.,depression)SomatiformdisordersThoughtdisorders(e.g.,fixeddelusions)心绞痛特点SAVESU：Suddenonset;Anteriorchest;Vaguesensation;Exerciseprecipitated;Shortduration;Unanimousattack.GradingofAnginaPectorisbyCCSCClassI:日常体力活动不引起心绞痛.ClassII:日常体力活动轻度受限.ClassIII:日常体力活动明显受

4、限.ClassIV:任何体力活动都引起症状，可以有休息时心绞痛。UAP的主要临床表现Restangina:Occurringatrest,usu.>20min,occurringwithinaweekofpresentation.Newonsetangina:AtleastCCSCIIIseverity,<2monthsofinitialpresentation.Increasingangina:Distinctlymorefrequent,longerinduration,lowerinThreshold.(ie.Increasedbyatleasto

5、neCCSCclassin2months,toatleastCCSCIIIseverity)NoninvasiveTesting:ECG/ChestX-rayECG:Normalin50%stableangina.Abnormalin50%angina(normalrestECG).Equivocal:QIII,QSinV1,V2.PseudonormalizationofSTdepressionorTinversion.ChestX-rayECHO本例:左室肥厚，左室舒张功能减低。室间隔增厚：13mm(7-11mm),左室后壁10mm(7-11mm)

6、。室壁运动正常，各瓣膜结构及功能正常，无心包积液。二尖瓣血流频谱示左室功能减低，E/A=0.5冠状动脉造影本例冠状动脉造影：前降支中段99％狭窄，回旋支近段90％狭窄，远段50％狭窄。DefinitionofSignificantCAD70%diameterstenosisof1majorepicardialarterysegment.50%diameterstenosisofleftmain.Althoughlesionsoflessstenosiscancauseangina,theyhavemuchlessprognosticsignific

7、ance.NoninvasiveTesting:UltrafastComputedTomographyUltrafast(electronbeam)computedtomography(EBCT)forthedetectionandquantificationofcoronarycalcification:Sensitivity(detectionofcalcium):85-100%.Specificity:41-76%.Positivepredictivevalue:55-84%.Negativepredictivevalue:84-100%.Noni

8、nvasiveTesting:ExerciseECG(1)Absolutecon