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【正文】 ction of atheromatous plaque •other causes: spasm arterial thrombi coronary emboli ostial narrowing due to luetic aortitis congenital abnormalities severe LV hypertrophy 第三十一页，共一百一十五页。 Factors effect myocardial oxygen supply and demand Oxygen supply Oxygen demand Heart rate Myocardial contractility Systolic wall stress oxygen carrying capacity of blood Coronary blood flow Vascular resistance Extravascular pressive forces autoregulation Metabolic regulation Humoral factor Neural regulation Duration of diastole Pressure gradient Endothelial control 第三十二页，共一百一十五页。 Coronary heart disease Type： •slient ischemia: delitescence： (ECG change) •Angina pectoris： angina, caused by myocardial ischemia • myocardial infarction： acute myocardial ischemic necrosis caused by the occlusion of coronary artery •Ischemia cardiomyopathy (Heart failure and arrhythmia)： cardiac enlargement, heart failure, arrhythmia, caused by the myocardial fibrosis as the consequence of chronic mycardial ischemia •Sudden death： sudden cardiac arrest caused by ventricular fibrillation/flutter 第三十三页，共一百一十五页。 Coronary heart disease (CHD) Type： slient ischemia: delitescence Angina pectoris： myocardial infarction： Ischemic cardiomyopathy (Heart failure and arrhythmia) Sudden death 第三十四页，共一百一十五页。 Acute Coronary Syndrome(ACS) Resting ischemia NonST elevation STelevation Unstable angina NonQ wave AMI Q wave AMI *positive serum cardiac markers * * * * occasionally variant angina 第三十五页，共一百一十五页。 Stable angina pectoris (SAP) 第三十六页，共一百一十五页。 definition: acute and transient myocardial ischemia and anoxaemia usually caused by coronary insufficiency during exertion or emotional stress Characteristics: paroxysmal precordial squeezinglike chest pain, behind the mid sternum， radiated to left shoulder and upper arm precipitated by stress or exertion duration:25min typically relieved rapidly by rest or nitrates Stable angina pectoris 第三十七页，共一百一十五页。 Coronary stenosis (others:aortic valve disease, HOCM, MB) + Myocardial oxygen demand〔 HR X SBP〕increased myocardial hypoxia acumulation of metabolic product, stimulate C15 nerve to cause the sensation of chest pain Stable angina pectoris mechanism 第三十八页，共一百一十五页。 in angiography Significant coronary lesion with diameter stenosis 70% in 75% pts No significant stenosis in about 510% pts, Ischemia may be related to coronary spasm or microvascular dysfunction. Pathology Stable angina pectoris 第三十九页，共一百一十五页。 pathophysiology and electrophysiology • ATP reduced, accumulation of acid substances • Dysfunction of iron pump (Na+K+, and Na+Ca++) • Early depolarization (ST deviation) function and hemodynamic situation • LV contractility and speed, systolic BP, stroke volume, cardiac output decreased • LVED pressure and volume Stunning of myocardium Stable angina pectoris 第四十页，共一百一十五页。 symptom： chest pain or oppression •location behind or slightly to the left of the mid sternum no definite borderline radiated to the left shoulder and upper arm Atypical location: lower jaw, the back of neck Clinical manifestation Stable angina pectoris 第四十一页，共一百一十五页。 chest pain •characteristics： tightness, squeezing, burning, pressing, choking, bursting,rarely sharp, not spasmodic  force the patient stop the activity till the symptom relieved •precipitation exertion or emotional agitation。 •duration： 3－ 5 mins •pain relief: within several mins after rest or using nitroglycerin Clinical manifestation Stable angina pectoris 第四十二页，共一百一十五页。 Physical examination increased HR, elevated BP anxiety sweating occasionally gallop rhythm， transient systolic murmur Clinical manifestation Stable angina pectoris 第四十三页，共一百一十五页。 Laboratory ： •at rest •During chest pain: STT change found in 95% pts •Holter: detect of slient ischemia •Stress test: indication： suspection of CHD, pre and post CABG and PCI, pts with OMI contraindication： AMI, UAP,myocarditis, Hypertension, heart failure,aortic stenosis, HOCM, sever arrhythmia, aortic aneurysm End of the test： ST or ≥， AP attacks， BP220mmHg， BP drop， ventricular arrhythmia Criteria for positive: ST segment depression ， last 2 mins Stable angina pectoris 第四十四页，共一百一十五页。 Stress test rest Exerscise Stable angina pectoris 第四十五页，共一百一十五页。 : 3. Radionuclide imaging assessment: TL201， Tc99msestamibi myocardial perfusion scintigraphy of heart angiography： final diagnose : IVUS、 intracoronary Doppler flow 、 intracoronary pressure Laboratory Stable angina pectoris 第四十六页，共一百一十五页。 Coronary Angiography 第四十七页，共一百一十五页。 pain： aortic dissection, HOCM, aortic stenosis ： PE, pneumothorax, pleuritis : gastroesophageal diseases, Hiatal hernia, cholecystitis, peptic ulceration, pancreatitis ： Tietze Syndrome (Costochondritis), intercostal neuralgia, Herpes zoster : anxiety, depression, panic attacks Stable angina pectoris Diagnosis Chest pain, risk factors, ECG evidence of ischemia during chest pain, angiography Differentiation 第四十八页，共一百一十五页。 Functional classification of SAP(CCS ) CCS I： no chest pain at ordinary activity.  Angina at strenuous or rapid or prolonged exertion CCS II： Slight limitation of ordinary activity. Walking or climbing stairs rapidly, after meals, in cold, in wind. Walking more than 2 blocks,climbing more than stairs of 3rd floor. CCS III： Marked limitation of ordinary activity. Walking 1 to 2 blocks, climbing stairs of 3rd floor CCS IV： Inability to carry on any activity without disfo