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2015胸痛鉴别诊断及处理课件

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胸痛鉴别诊断PPT课件 鉴别诊断和处理 胸痛诊断与鉴别诊断PPT课件 诊断与鉴别诊断 鉴别诊断ppt课件 鉴别诊断与处理 诊断与鉴别诊断ppt课件 胸痛鉴别诊断及处理ppt 鉴别诊断及处理
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do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 胸痛诊断、鉴别诊断及处理胸痛诊断、鉴别诊断及处理 宁津县人民医院 詹志芳 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 胸痛是临床工作中最常遇到的问 题,其病因复杂多样,且危险性 存在较大差别,对胸痛患者给予 快速诊断,同时对其危险性给予 准确的评估,并作出及时、正确 的处理,是我们面临的巨大挑战 概 述 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 诊断胸痛的主要目的有两个: Ø 首先是快速识别高危患者包括急性冠 状动脉综合征(ACS) 、主动脉夹层、 肺栓塞、张力性气胸、心包炎致心脏 压塞及食管损伤等 Ø 其次是排除低危患者 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 胸痛诊断、鉴别诊断及处理胸痛诊断、鉴别诊断及处理 胸痛 胸痛总论 急性冠脉 综合征 主动脉 夹层 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 胸壁的神经、肌肉、骨骼和胸腔内的脏 器、组织,以及膈肌、膈下部分脏器在 炎症、缺血、外伤、肿瘤、机械压迫、 理化刺激等因素的作用下,都可以引起 胸痛 主要病因大体上包括以下几个方面: 病 因 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 胸腔内疾病: 心源性胸痛:最常见的是缺血性心脏 病引起的ACS占急性胸痛的大部分其 次是急性纤维素性心包炎 病 因 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 非心源性胸痛: 胸腔内除心脏外的其 他器官结构包括肺脏、气管、大血管、 纵隔、食管、胸膜等,在病理状态下都 可以引起胸痛 病 因 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 主动脉病变: 主动脉夹层 肺部疾病: 如急性肺栓塞、张力性气胸、 肺癌、大叶性肺炎和严重的肺动脉高压等 胸膜疾病: 包括急性胸膜炎、胸膜间皮 瘤、肺癌累及胸膜 食管疾病: 反流性食管炎、食管贲门失 弛缓症、食管下段黏膜撕裂 纵隔病变: 纵隔气肿、纵隔内占位病变 都可出现胸痛 病 因 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 胸壁组织病变: 构成胸壁的皮肤、肌肉、 肋骨、肋软骨,以及分布在胸壁的肋间神经 出现炎症、损伤或感染时, 都可以引起胸 痛。共同的特点,病变局部常有明显的压痛 病 因 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 膈下脏器的病变:胃、十二指肠、肝脏、 胆囊、胰腺等脏器的病变可以表现为胸腹 痛 功能性胸痛:在年轻人和更年期女性患者 出现的胸痛中,功能性胸痛占有相当的比 例,常见的有心脏神经官能症、过度通气 综合征等 病 因 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 发病年龄:青壮年胸痛多考虑结核性胸膜 炎、自发性气胸、心肌炎、心肌病、风湿 性心瓣膜病,40岁以上则须注意心绞痛、 心肌梗死和支气管肺癌 临床表现 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 部位:胸壁疾病所致的胸痛常固定在病变部 位, 且局部有压痛 胸壁皮肤的炎症性病变 带状疱疹 肋软骨炎 临床表现 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 心绞痛或心肌梗死痛疼多位于胸骨后和心前 区并放射至左前臂 主动脉夹层疼痛多位于胸背部,向下放射至 下腹、腰、双侧腹股沟、下肢 胸膜炎引起的胸痛多在胸侧部 食管及纵隔病变所致胸痛多在胸骨后 肝胆疾病及膈下脓肿胸痛多在右下胸,向右肩 背部放射 肺尖部肺癌疼痛多以肩部、腋下为主 临床表现 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 性质:胸痛的性质可多种多样,程度可呈剧 烈、轻微或隐痛 带状疱疹呈刀割样或烧灼样剧痛 食管炎为烧灼痛 肋间神经痛为阵发性灼痛或刺痛 心绞痛呈绞榨样痛并有重压窒息感,心肌梗 死时疼痛更为剧烈并有恐惧、濒死感 临床表现 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 气胸在发病初期有撕裂样疼痛 胸膜炎常呈隐痛、钝痛和刺痛 主动脉夹层为突然发生的胸背部撕裂样剧痛或 锥痛 肺梗死亦可突然发生胸部剧痛或绞痛,常伴呼 吸困难、咯血与发绀 临床表现 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 疼痛持续时间:心绞痛发作时间短暂,持 续1~15min不等而心肌梗死疼痛持续数 小时平滑肌痉挛或血管狭窄缺血所致的 疼痛为阵发性,而炎症、肿瘤或梗死所 致的疼痛多呈持续性 临床表现 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 影响疼痛的因素:心绞痛可在劳累或精神紧 张时诱发,休息或含服硝酸酯类药物于3~5 min内很快缓解,而心肌梗死所致的胸痛则 用上述方法无效 食管疾病多在进食时发作或加重,服用抗酸 剂和促动力药物可减轻或消失 胸膜炎或心包炎的胸痛因咳嗽和用力呼吸而 加剧 临床表现 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 伴随症状:伴有咳嗽、咳痰和(或) 发热,常见 于气管、支气管和肺部疾病 伴有咯血见于肺梗死、支气管肺癌 伴有面色苍白、大汗、血压下降或休克时,多 见于心肌梗死、主动脉夹层、主动脉窦瘤破 裂和大块肺梗死 临床表现 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 伴有吞咽困难多提示食管疾病,如返流性食 管炎等 伴有呼吸困难提示病变累及范围大,如自发 性气胸、大叶性肺炎、肺栓塞等 当胸痛的患者出现明显的焦虑、抑郁、唉声 叹气症状时,应想到心脏神经官能症等功能 性胸痛的可能 临床表现 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 首先要注意生命体征,包括体温、呼吸、脉搏、 血压 怀疑主动脉夹层时应测四肢血压,注意颈部有 无血管异常搏动,主动脉弓部的夹层可以在胸 骨上窝出现异常搏动 颈静脉充盈或怒张可见于心包压塞、肺栓塞等 引起的急性右心衰 必要的体格检查和辅助检查 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 气管有无偏移是项简单有用的体征 注意胸廓有无单侧隆起,有无皮肤异常,有无 触痛 肺部呼吸音,胸膜摩擦音,心界大小、心音强 弱、杂音及心包摩擦音 腹部注意压痛,尤其是剑突下、胆囊区 肺栓塞要检查下肢有无肿胀,是否有下肢深静 脉血栓形成的依据 必要的体格检查和辅助检查 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 心电图、心肌酶、肌钙蛋白是确诊心肌 梗死的重要手段 D2二聚体:急性肺栓塞 血气分析 胸部X线 B 超帮助判断肝脏、胆囊和膈下病变 心脏超声、主动脉螺旋CT, 主动脉夹层 冠状动脉造影是诊断冠心病的金标准 必要的体格检查和辅助检查 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 胸痛患者的处理应注意两个原则: 首先要快速排除最危险、最紧急的疾病: 急性心肌梗死、主动脉夹层、肺栓塞、张 力性气胸等 对不能明确诊断的患者应留院观察病情演 变 , 获取详细的病史和体征,进行有针对性 的辅助检查 处理原则 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 具体处理方法如下: l 首先判断病情的严重程度,生命体征不稳 定者立即开始治疗 l 生命体征稳定者应获取详细的病史和体征 同时进行有针对性的辅助检查,经以上处 理能够明确病因的患者立即开始进行有针 对性的病因治疗 l 对不能明确病因的,留院观察至少24 h ,尽 量减少漏诊高危患者 处理原则 胸痛总论 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 胸痛诊断、鉴别诊断及处理胸痛诊断、鉴别诊断及处理 胸痛 胸痛总论 急性冠脉 综合征 主动脉 夹层 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 急性冠脉综合征 (Acute coronary syndrome, ACS): 在急性心肌梗死病理生理研究取得进展 的基础上,重新认识急性心肌梗死的表 现形式而提出的新概念 概 念 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 本综合征包括: l 不稳定性心绞痛(UA) l 无Q波型急性心肌梗死(NQAMI) l Q波型急性心肌梗死(QAMI) l 心源性猝死(CSD) 概 念 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 概 念 • 心电图可见ST段抬高、压低(非Q波心梗及 不稳定心绞痛)或非特异性的ST-T改变 • 在成年人中,ACS几乎是所有发生的心源性 猝死的原因 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 治疗目标: • 减少梗死病人的心肌坏死 • 预防严重不良心脏事件(死亡、非致死性 心梗、需要急诊血管重建) • 发生室颤(VF)时快速除颤 概 念 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians ACS的发病机制 ACS的病理及病理生理: 共同病理生理基础是斑块破裂 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 斑块破裂 • 脂质斑块表面薄的纤维帽破裂 • 内皮下炎症 • 血流速度、涡流以及血管壁的解剖改变 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 稳定斑块不稳定斑块破裂斑块 ACS斑块的特征 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians The “Vulnerable Plaque” Paradigm (易损斑块的特征) Non-vulnerable plaque (非易损斑块) fibrous tissue that partially blocks blood flow, but is not likely to cause a clot or cardiac event. 纤维组织部分阻塞血流,但不易引起血凝块 及心脏事件 Vulnerable Plaque(易损斑块) with lipid-rich core, thin fibrous cap, inflammation at margins 富含脂质核、纤维帽薄、边缘炎症反应明 显,易于破裂 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians Ross R. N Engl J Med. 1999;340:115-126. 斑块不稳定 和血栓形成 氧化炎症内皮功能受损 动脉粥样硬化的进展 斑块破裂氧化 LDL-CLDL-C 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 不稳定性冠状动脉疾病 Adventitia(外膜) lipid core lipid core (脂质核) 血栓 (thrombus) 血栓形成,并且伸入管腔和斑块内部 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians ACS的主要发病机理 • 动脉粥样硬化斑块--不稳定或破裂 • 血栓形成 炎症炎症 细胞细胞 少量少量平滑肌平滑肌 细胞细胞 激活激活的巨噬细胞的巨噬细胞 血栓 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians ACS的病理生理基础 CK- MB or Troponin Troponin elevated or not Adapted from Michael Davies Adapted from Michael Davies ACS 无持续ST段抬高 ACS 伴持续ST段抬高 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 血小板聚集 纤维蛋白 组织因子 巨噬细胞 血流 斑块破裂导致血栓形成 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 斑块破裂栓塞微血管阻塞 斑块破裂与微血管阻塞 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 血小板聚集 • 斑块破裂或表面侵蚀后,血小板发生粘附、聚 集和激活 • 纤维蛋白和血小板交织形成血栓,激活凝血系 统 • 抗血小板制剂,如阿斯匹林、GPIIb/IIIa 受 体阻滞制在这一时期有效;溶栓治疗不仅无效 ,反而有可能加速血管闭塞的发生 急性冠脉综合症 血小板在ACS过程中的角色 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 滚动的盘 状血小板 滚动的球 状血小板 半球形血小 板 平铺的血小板 牢固但可逆的黏附不可逆黏附 血小板聚集和黏附过程中的变化 急性冠脉综合症 血小板在ACS过程中的角色 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 活化聚集的血小板盘状静止的血小板 血小板聚集和黏附过程中的变化 急性冠脉综合症 血小板在ACS过程中的角色 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians Von Willebrand Von Willebrand 因因 子子 Gp IIb / IIIa Gp IIb / IIIa 复合复合 物物 血小板血小板 纤维蛋白纤维蛋白 原原 纤维蛋白纤维蛋白 原原 血小板启动参与血栓形成的过程 急性冠脉综合症 血小板在ACS过程中的角色 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 心肌坏死 • 血栓所致的间歇闭塞可引起阻塞血管远端心肌 的坏死,形成非Q波心梗,伴肌钙蛋白的轻度 增高 • 冠脉血管持续性闭塞时间较长,则发生Q波心 梗 • 引起Q波梗死血栓富含纤维蛋白及凝血酶,这 时早期行PCI或溶栓治疗可以限制梗死的范围 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians ACS的新旧分型 急性冠状动脉综合征急性冠状动脉综合征 ST ST 段不抬高段不抬高ST ST 段抬高段抬高 不稳定性心绞痛NQMIQMI 心肌梗死 NSTEMI 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians ACS新的临床分型 ACS ST 段持续抬高的 ACS无 ST 段抬高的 ACS cTnT ( cTnI ) ≥0.1μg/L 或CK-MB≥正常上限的2倍 cTnT ( cTnI ) <0.1μg/L 或CK-MB75岁患者IIa级) 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians GISSI-1发现链激酶溶栓组比安慰剂组的21天死 亡率明显降低,该组患者10 年死亡率也明显降 低 ISIS-2研究表明,单独应用阿司匹林抗血小板治 疗,或单独应用链激酶行溶栓治疗可以降低心梗 患者的死亡率。两者联用的效果更好,死亡率降 低42% 溶栓治疗 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 决定心肌存活和远期预后因素 • 早期行再灌注治疗 • 早期、持久的开通梗塞相关血管,并有 正常的血流(TIMI 3级) • 正常的微血管灌注 溶栓治疗 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 溶栓的获益 • 美国最初推荐ST段抬高的患者在发病6小时内 行溶栓治疗,而12小时内行溶栓治疗也可使患 者获益 • 溶栓治疗早期获益是心肌存活,心肌存活是否 取决于快速血管开通和完全恢复灌注的结果( 时间就是心肌) • 溶栓治疗的晚期获益是血管再通改善左室功能 ,降低死亡率。其原因是血管再通后可以减少 心肌瘢痕的形成,减少心室扩张和心肌重构 溶栓治疗 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 溶栓治疗的局限性 溶栓治疗 颅内出血 溶栓治疗可以引起较小的但明确的出血性脑卒中 的增加,在治疗的第一天其危险性最大 T-PA和肝素的使用较之链激酶和阿斯匹林合用危 险性更明显 临床危险因素包括年龄(65岁)、低体重、高血 压(180/110mmHg)和使用t-PA。 SBP 180mmHg或 DBP110mmHg是溶栓的相对禁忌症 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 溶栓的时间限制 • 发病12小时的患者一般不采用溶栓治疗,但 对于发病12小时的大面积心梗并有持续的胸 痛的患者,可以考虑溶栓治疗(IIb级)。 • 对于胸痛持续24小时以上的患者,即使有ST段 抬高,溶栓治疗也是无益处甚至是有害处的 • 对于发病12—24小时之内的患者仅有一些有获 益的趋势 溶栓治疗 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 溶栓治疗的风险获益比 • 大量证据表明,有持续缺血性胸痛表现,有两 个相邻导联的ST段抬高0.1mv,并且发病12小 时内的患者,溶栓治疗有最大获益 • GISSI研究发现无论哪一壁的心梗、有多少个 导联ST段抬高,溶栓治疗都可使患者获益 • 随着年龄的增大,脑卒中的发生率增高,溶栓 治疗的相对获益减低 ,75岁以上患者行溶栓 治疗对其生存率并无明显的改善,但危险性也 无明显的增加 溶栓治疗 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians 溶栓药物的评价 • GUSTO研究发现t-PA可以提供最早、最完全的 再灌注,可以达到早期完全的恢复血供的治疗 目标 • 应用t-PA对于年轻、发现早、有较大面积梗塞 的患者可以有最好的治疗效果,且ICH的发现 率也较低。而对于老年、心梗面积不大、发现 较晚以及发生ICH危险性较大的患者,应用链 激酶能取得更好的疗效。 • 链激酶在发病最初3小时内血栓尚未形成时应 用效果最好 溶栓治疗 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians • 冠脉成形术可以获得更高的TIMI3级血流,并 在90%的患者中获得成功,且较溶栓治疗有更 低的血管再闭塞及心梗后心肌缺血的发生率 • 对心梗患者早期行支架治疗的效果现正在评价 中,这些研究显示了血管成形术及支架治疗的 优势,但是死亡率并没有如预计的那样降低 PCI治疗 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians • 如果可能,应将死亡危险性高的患者,或有严 重左室功能不全伴休克体征、肺充血、心率 100次/分、SBP100mmHg的患者送到可行心导 管术和早期行PCI或CABG的医院。75岁的患者 ,该治疗为首选。如果没有延误,对于可行再灌 注治疗但有溶栓治疗禁忌症的患者可行PCI治 疗(IIa级) PCI治疗 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians ST段压低的心肌梗死 非QMI/UAP的初期治疗措施 一般同时需要抗凝血酶(肝素)和 抗血小板药物(阿司匹林) 高危病人的治疗: 阿司匹林 GP II b/IIIa抑制剂和肝素,低分子 量肝素(与GP IIb/IIIa抑制剂合用 时的疗效和安全性尚有待观察) 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of Family Physicians • 无禁忌症者使用β受体阻滞剂 • 反复心绞痛发作可使用硝酸酯类 • 钙通道阻滞剂适用于β受体阻滞剂 禁忌或难治患者 ST段压低的心肌梗死 急性冠脉综合症 do we simplify complex fractions and complex rational Disorders Building a Community of Support Immunizations American Academy of
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