心绞痛的鉴别心绞痛参考幻灯片

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心绞痛特点
• SAVES U：
– Sudden onset; – Anterior chest; – Vague sensation; – Exercise precipitated; – Short duration; – Unanimous attack.
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Grading of Angina Pectoris by CCSC
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心绞痛的鉴别 (2)
• Chest Wall – Costochondritis – Fibrositis – Rib fracture – Sternoclavicular arthritis – Herpes zoster (before the rash)
• Psychiatric
– Anxiety disorders
inversion.
• Chest X-ray
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ECHO
• 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)。
– 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
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冠状动脉造影
• 本例冠状动脉造影：
• New onset angina: At least CCSC III severity, <2 months of initial presentation.
• Increasing angina: Distinctly more frequent, longer in duration, lower in Threshold. (ie. Increased by at least one CCSC class in 2 months, to at least CCSC III severity)
• 进一步检查 • 冠心病的易患因素
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心绞痛的鉴别 (1)
• Non-ischemic CV – Aortic dissection – Pericarditis
• Pulmonary – Pulmonary embolus – Pneumothorax – Pneumonia – Pleuritis
much less prognostic significance.
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Noninvasive Testing: Ultrafast Computed Tomography
• Ultrafast (electron beam) computed tomography (EBCT) for the detection and quantification of coronary calcification:
• Hyperventilation • Panic disorder • Primary anxiety
– Affective disorders
• (e.g., depression)
– Somatiform disorders – Thought disorders
• (e.g., fixed delusions)
• Class I: 日常体力活动不引起心绞痛.
• Class II: 日常体力活动显受限.
• Class IV: 任何体力活动都引起症状，可以有休 息时心绞痛。
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UAP 的主要临床表现
• Rest angina: Occurring at rest, usu. >20min, occurring within a week of presentation.
– Sensitivity (detection of calcium): 85-100%. – Specificity: 41-76%. – Positive predictive value: 55-84%. – Negative predictive value: 84-100%.
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Noninvasive Testing: Exercise ECG(1)
– 前降支中段99％狭窄，回旋支近段90％狭窄， 远段50％狭窄。
• Definition of Significant CAD
– 70% diameter stenosis of 1 major epicardial artery segment.
– 50 % diameter stenosis of left main. – Although lesions of less stenosis can cause angina, they have
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，aVL ST 0.5-1mm.
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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
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Noninvasive Testing: ECG/Chest X-ray
• ECG:
– Normal in 50% stable angina. – Abnormal in 50% angina (normal rest ECG). – Equivocal: QIII, QS in V1, V2. – Pseudonormalization of ST depression or T
• Absolute contraindications:
– MI in 2 days; – Significant arrhythmias; – Severe AS; – Symptomatic HF; – Acute PE; – Acute myocarditis or pericarditis; – Acute aortic dissection.
• Gastrointestinal
– Esophageal
• Esophagitis,Spasm, Reflux
– Biliary
• Colic
• Cholecystitis
• Choledocholithiasis
• Cholangitis
– Peptic ulcer
– Pancreatitis