内科学概论心脏血管内科.ppt

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1、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 n收縮壓收縮壓n n舒張壓舒張壓LCC高血壓分類n n原發性高血壓原發性高血壓 Primary Hypertensionn n續發性高血壓續發性高血壓 Secondary HypertensionLCCn n遺傳基因的影響遺傳基因的影響n n鈉鹽的過度攝取鈉鹽的過度攝取n nRenin-Angiotensin systemn n交感神經系統交感神經系統n n細胞膜的異常細胞膜的異常n n血管的增生肥厚血管的增生肥厚n n內皮細胞功能異常內皮細胞功能異常n 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JNC7

2、Normal 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-Meas

3、urementn 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 n正確測量血壓正確測量血壓正確測量血壓

4、正確測量血壓n n外觀外觀外觀外觀:脂肪分布脂肪分布脂肪分布脂肪分布 皮膚皮膚皮膚皮膚 肌肉肌肉肌肉肌肉 及神智狀況及神智狀況及神智狀況及神智狀況n n眼底檢查眼底檢查眼底檢查眼底檢查n n頸部頸部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頚動脈及甲狀腺觸診聽診頚動脈及甲狀腺觸診聽診n n心臟心臟心臟心臟大小節律及心音異常大小節律及心音異常大小節律及心音異常大小節律及心音異常n n肺肺肺肺有無囉音有無囉音有無囉音有無囉音n n腹部腹部腹部腹部腫瘤腫瘤腫瘤腫瘤?動脈雜音動脈雜音動脈雜音動脈雜音 股動脈搏動股動脈搏動股動脈搏動股動脈搏動n n四肢四肢四肢四肢動脈博動動脈博動動脈博動動脈博

5、動 水腫水腫水腫水腫n n神經檢查神經檢查神經檢查神經檢查 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心肌梗塞 Sudden deathn n50%到達醫院前發生 ventricular f

6、ibrillation sudden deathsudden deathn n發生時機胸痛後4小時n n早期送醫n n電擊器的使用可以救命LCC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

7、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LCCTroponin 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

8、valuesLCCNon-ST segment elevation AMI Criteria are not adequate to define AMIST segment elevation AMIlNew ST elevation in 2 or more leads(In V1-V3)l0.1 in other leadsLCCST segment elevationPathologic Q waveLCCIn the absence of QRS confounders(BBB,LVH,WPW)lAny Q wave in leads V1-V3lQ waves must be 30

9、 msec durationlQ waves in other leads must have Qs in 2 contiguous leads(eg,II and III)lQs must be 1mm in depthLCCInfarct manifests itself as decreased wall motion by echo or hypoperfusion by radionuclide SPECTIschemia,stunning,and hibernation will produce similar changesLCCCardiac troponin after cl

10、assical AMICK-MB after AMICardiac troponin aftermicroinfarctionDays after onset of AMIDays after onset of AMILCCn nChest painChest painn nTroponin I/T,CK-MBTroponin I/T,CK-MBn nECG changesECG changesn nEchocardiographyEchocardiographyn nNuclear cardiologyNuclear cardiologyn nCardiac catheterizationC

11、ardiac catheterizationLCCuHypokinesiauakinesiauHyperkinesiauLV aneurysmuLV size EFuMRuLV thrombusLCCHypoperfusionLV systolic functionLV diastolic functionLCCFilling defectContrast造影劑造影劑LCCarrhythmiaLoss of muscleSudden deathVentricular remodelingVentricular dilationHeart failuredeathLCCLCC Thrombin/

12、Fibrin Thrombin/FibrinPlateletPre-PCIPre-PCIASAASAStatinStatinACEIACEIClopidogrelClopidogrelPost-PCIPost-PCIASAASAStatinStatinACEIACEIClopidogrelClopidogrelGP IIb/IIIA Embolic protectionAnti-inflammatoryCoated stentPlaquerupturethrombusLCCintervensionthrombolysisLCCOptimal Strategy UA/NSTEMITIMI III

13、B2002ConservativeInvasiveVANQWISHMATEFRISC IITACTICS-TIMI 18VINORITA-3TRUCSn nInitiate PTCA if available and suitablen nGoals:PTCA within 90 30 minLCC氣氣球球擴擴張張術術StentingStentingLCC網狀支架置放術Interventional CardiologyInterventional CardiologypostStentingTissue factorPlasma clottingcascadeProthrombinThromb

14、inFibrinogenFibrinThrombusPlatelet aggregationConformational activation of GPIIb/IIIaCollagenThromboxane A2ADPATATFactorXaCoagulationcascadePlateletcascadePlaquerupturethrombusLCCFibrinThrombinPlateletFibrinolysisAntiplateletAnti-thrombinTHROMBUSPLATELETPLATELETAntiplatelet therapy-aspirin-clopidogr

15、el-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 n一般原則一般原則uu胸痛胸痛胸痛胸痛uu1212小時內小時內小時內小時內uuST segment ST segment elevationelevationuu 75 years old180/110 mmHg

16、)(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)(Wi

17、thin 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 ruptureACSThrombolysisThromb

18、olysisLCCTHROMBUSPLATELETPLATELETAntiplatelet therapy-aspirin-clopidogrel-GP IIb/IIIa inhibitors-persantin-ticlopidineThrombinThrombinAntithrombin therapy-heparinFibrinFibrinPlasminogenActivators-t-PAR-PASKTNK-tPALCCGP IIb/IIIa Inhibitors1.Platelet Adhesion2.Platelet ActivationPlateletGP Ib Plaque r

19、uptureActivated Platelet GP IIb/IIIa 3.Platelet AggregationASA,Clopidogrel/TiclopidineTxA2FibrinogenPlatelets Role in ThrombosisPlatelets Role in ThrombosisActs by selective inhibition of ADP binding to its platelet receptor and prevents subsequent platelet aggregationADPADPFibrinogen Fibrinogen Bin

20、ding Site SiteClopidogrelClopidogrelFibrinogen Binding ReducedFibrinogenPlateletPlateletLCCPlatelet aggregationInhibition of aggregationby GP IIb/IIIa inhibitorsLCCThrombinSerotoninEpinephrineCollagenADPADPActivationTXATXA2 2ActivatedPlateletCOXCOXDegranulationAspirin Gp Gp IIb/IIIa fibrinogenfibrin

21、ogenreceptorreceptorTo neighboringTo neighboringplateletplateletClopidogrelTiclopidinePlatelet agonistsADPATPserotonincalciummagnesiumAdhesive proteinsthrombospondinfibrinogenp-selectinvWFCoagulation factorsfactor Vfactor XIPAI-1Inflammatory factorsplatelet factor 4CD 154(CD 40 ligand)PDGFIV Gp IIb/

22、IIIaInhibitorsTHROMBUSPLATELETPLATELETAntiplatelet therapy-aspirin-clopidogrel-GP IIb/IIIa inhibitors-persantin-ticlopidineThrombinThrombinAntithrombin therapy-heparinFibrinFibrinPlasminogenActivators-t-PAR-PASKTNK-tPALCCUnfractionated heparinLow molecular weight heparinEnoxaparinDalteparinNadropari

23、nDirect Thrombin inhibitorsHirudinBivalirudinwarfarinLCCTissue factorPlasma clottingcascadeProthrombinThrombinFibrinogenFibrinThrombusPlatelet aggregationConformational activation of GPIIb/IIIaCollagenThromboxane A2ADPATATAspirinTiclopidineClopidogrelGPIIb/IIIainhibitorsFactorXaBivalirudinHirudinArg

24、atrobanLMWHHeparinThrombo-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 160-325mgLCC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 n低血壓低血壓低血壓低血壓u病人平躺病人平躺病人平躺病人平躺u補充生理食鹽水液補充生理食鹽水液補充生理食鹽水液補充生理食鹽水液n n呼吸抑制呼吸抑制呼吸抑制呼吸抑制uNaloxoneNaloxone 0.4

25、mg 0.4mg IVIVu每三分鐘注射一次每三分鐘注射一次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可重複三劑量可重複三劑量LCCVery high15%intermediate38%Very high815%DeathMIAspirin heparinGP IIb/IIIaUrgent cathClopidogrel prior PCIAspirin LMWH GP IIb/IIIaClopidogrelCoronary angioAspirin LMWHIschemia-guided RxLCCACC/AHA UA/NSTEMI Guidelines ACC/AHA UA/

26、NSTEMI Guidelines ACC/AHA UA/NSTEMI Guidelines ACC/AHA UA/NSTEMI Guidelines Recommendations for Long-term Medical TherapyRecommendations for Long-term Medical TherapyRecommendations for Long-term Medical TherapyRecommendations for Long-term Medical TherapyClass IClass I1.1.AspirinAspirin 75 to 325 m

27、g/day 75 to 325 mg/day2.2.Clopidogrel Clopidogrel 75 mg daily(in the absence of contraindications)75 mg daily(in the absence of contraindications)when aspirin is not tolerated because of hypersensitivity or when aspirin is not tolerated because of hypersensitivity or gastrointestinal intolerance gas

28、trointestinal intolerance 3.3.The combination of The combination of aspirin and clopidogrelaspirin and clopidogrel for 9 months after for 9 months after UA/NSTEMIUA/NSTEMI4.4.-Blockers-Blockers in the absence of contraindications in the absence of contraindications 5.5.Lipid-lowering agents and diet

29、Lipid-lowering agents and diet in post-ACS and in post-ACS and postrevascularization patients with LDL-C 130 mg/dL postrevascularization patients with LDL-C 130 mg/dL 6.6.Lipid-lowering agents if LDL-C level after diet is 100 mg/dLLipid-lowering agents if LDL-C level after diet is 100 mg/dL7.7.ACE i

30、nhibitorsACE inhibitors for patients with CHF,LV dysfunction(EF 0.40),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 n n高血壓高血壓n n高血脂肪高血脂肪n n糖尿病糖尿病n n冠狀動脈心臟冠狀動脈心臟病病n n腦中風腦中風n n死亡率較高死亡率較高n n膽結石n n惡化關節炎n n呼吸系統易生問題n n子宮 乳房 前列腺 大腸等易生癌症 LCCn n飲食治療飲食治療 低熱量低熱量 低脂

31、肪低脂肪n 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LCCn 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 n降低降低血壓血壓n n血糖血糖控制較佳控制較佳 n n減輕減輕體重體重及及肥胖肥胖n n較容易較容易戒菸戒菸n n骨骼骨骼 肌肉肌肉 關節關節 較較 不易退化不易退化n n較少發生較少發生大腸癌大腸癌n n減輕減輕憂鬱憂鬱及及焦慮焦慮 對人

32、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 n預防預防心臟病心臟病發作發作n n減少減少死亡率死亡率 LCCACC/AHA UA/NSTEMI*Guideline ACC/AHA UA/NSTEMI*Guideline Update:Risk Factor ModificationUpdate:Risk Factor ModificationClass IClass I Smoking cessation Smoking cessation Achieving optimal weight Achieving optimal weight Daily exerciseDaily exe

33、rcise AHA diet AHA diet BP control to 130/85 mm HgBP control to 130 HMG-CoA reductase inhibitor for LDL-C 130 mg/dLmg/dL Lipid-lowering agent if LDL-C after diet is 100 Lipid-lowering agent if LDL-C after diet is 100 mg/dLmg/dL A fibrate or niacin if HDL-C 40 mg/dLA fibrate or niacin if HDL-C 40 mg/dLn n高血壓高血壓n n糖尿病糖尿病n n高血高血 脂脂n n抽煙抽煙n n肥胖肥胖n n缺乏適當運動缺乏適當運動LCCLCC預防才是最好的才是最好的治療LCC再再見見