血管痙攣和冠脈微血管疾病

1、煩惱有何懼怕，既然躲不掉，就調(diào)好心態(tài)與它共存。心向陽光，何懼風(fēng)霜。茫茫人海你我相遇就是緣分，歡迎下載！2021/4/2622021/4/263u Coronary perfusion can be transiently or persistently impaired by coronary vasoconstriction resulting in myocardial ischemia. u Vasoconstriction may occur in large coronary arteries and in the microcirculation.2021/4/264 u Coro

2、nary vasomotion modulates residual coronary flow reserve, resulting in a variable effort tolerance when stenosing plaques have a preserved muscular media which can vary the residual lumen2021/4/265Coronary Artery Spasmu Coronary spasm can cause persistent coronary occlusion when associated with loca

3、l thrombosis, resulting in acute infarctionu Soon after acute MI, intracoronary acetilcoline cause coronary spasm in about 60% of Japanese patients, but only in 20% of ItaliansPristipino et al, Circulation 2000; 101:1102-11082021/4/266Vasoconstriction of Epicardial Coronary Arteriesu Variant angina

4、is typically characterized by angina at rest, particularly at night or in the morning, in the presence of a normal effect tolerance, but often causes infarction and fatal arrhythmias2021/4/267Suspicion of Variant AnginauPredominantly spontaneous attacks with preserved effort tolerance, often in clus

5、ters of 2-3uPredominantly spontaneous attacks with preserved effort tolerance, often in clusters of 2-3uLasting 1-10 mins, relieved by GTNuPredominantly spontaneous attacks with preserved effort tolerance, often in clusters of 2-3uLasting 1-10 mins, relieved by GTNuOften at night or early morning wi

6、th waxing and waning over periods of weeks and monthsuPredominantly spontaneous attacks with preserved effort tolerance, often in clusters of 2-3uLasting 1-10 mins, relieved by GTNuOften at night or early morning with waxing and waning over periods of weeks and monthsuSometimes associated with synco

7、pe uNegative exercise test after GTN2021/4/268Prevalence of Variant AnginauPisa, London, Rome = 1.0% of admissions uDiagnosed only after weeks, months or yearsuRome (1991-96): 64 cases aged 19-75 years 60% had normal angiograms 40% major events 40% had stenosis 6% major events2021/4/269Pathogenetics

8、 Mechanisms of SpasmuA local coronary hyper-response Hackett 1986Hence: a smooth muscle post-receptorial alteration Maseri 1990uProvocation by stimuli acting on different receptors:wErgonovine Higgins 1976wMetacholine Endo 1976wDopamine Crea 1986wHystamine Ginsburg 1981- Kaski 1986wAcetylcholine Yas

9、ue 1986wSerotonin Mc Fadden 19912021/4/2610Treatment of Variant AnginauReduce aspecifically smooth muscle constrictor response by nitrates and calcium-antagonists Sometimes very high doses requiredFrenneaux et al. Am J Cardiol 1988;62:832Lefroy et al. Coronary artery disease 1992;3:745uPace-maker, i

10、mplantable defibrillator2021/4/2611This syndrome includes 60-70% of women (about 60% post-menopausal and 40% pre-menopausal) but also 30-40% of men.It is characterized by angina pectoris and normal coronary angiography. Its incidence may vary from 10% to 50% of patients submitted to coronary arterio

11、graphy.The diagnosis of myocardial ischemia is difficult for a number of reasons.9、 人的價(jià)值，在招收誘惑的一瞬間被決定。2022-3-232022-3-23Wednesday, March 23, 202210、低頭要有勇氣，抬頭要有低氣。2022-3-232022-3-232022-3-233/23/2022 9:15:45 PM11、人總是珍惜為得到。2022-3-232022-3-232022-3-23Mar-2223-Mar-2212、人亂于心，不寬余請(qǐng)。2022-3-232022-3-232022-3

12、-23Wednesday, March 23, 202213、生氣是拿別人做錯(cuò)的事來懲罰自己。2022-3-232022-3-232022-3-232022-3-233/23/202214、抱最大的希望，作最大的努力。2022年3月23日星期三2022-3-232022-3-232022-3-2315、一個(gè)人炫耀什么，說明他內(nèi)心缺少什么。2022年3月2022-3-232022-3-232022-3-233/23/202216、業(yè)余生活要有意義，不要越軌。2022-3-232022-3-23March 23, 202217、一個(gè)人即使已登上頂峰，也仍要自強(qiáng)不息。2022-3-232022-3-

13、232022-3-232022-3-232021/4/2613uIn spite of the absence of increased risk of infarction and cardiac death, these patients may be crippled by pain. Syndrome X: PROBLEMuThe inconsistent response to nitrates and anti-anginal drugs and to non conventional anti-ischemic therapy, indicates the need for re

14、search on multiple, potential causes of coronary vascular dysfunction, in order to develop rational forms of therapy.2021/4/2614Suspicion of Microvascular AnginauLong-lasting (10-30), poorly responsive to GTNuTransient ECG changes or positive myocardial scintigraphy Cardiac origin of painuNo evidenc

15、e of left ventricular dysfunctionuWorsening of exercise test following GTN Lanza et al, Circulation 19942021/4/2615Mechanisms of Microvascular AnginaNo flow limiting stenosisPrearterioles 0.1 mmConduitDistributionEpicardial 0.5 mmEndoEpiArterioles 0.1 mmMetabolic flow controlMaseri A et al, JACC 199

16、1; 17: 499-506Maseri A et al, AJC 1992; 70: 1602-16052021/4/2616Myocardial Phosphorus-31 NMR Spectroscopy in women with angina and normal coronary arteries Buchthal SD et al, NEJM 2000; 342Ischemia-reperfusion damage after pacingin patients with cardiac syndrome X Buffon A et al, Am J Physiol Heart

17、Circ Physiol 2000; 279Subendocardial perfusion reserve index in patients with syndrome X is reduced Panting JR et al, NEJM 2002Evidence of Myocardial Ischemia2021/4/2617NPY Clarke et al, Lancet 1977Endothelin Larkin et al, Am J Cardiol 1989Altered adrenergic function Lanza et al, Circulation 1997Ser

18、otonin Mc Fadden et al, NEJM 1991Acetylcholine Neumann et al, Am J Cardiol 1990Na+/H+ exchanger upregulation Karen et al, Eur Heart J 1997 Potential Causes of Microvascular Dysfunction2021/4/2618Enhanced Pain PerceptionGeneralized8Turiel et al. Am J Cardiol 1987; 608Cannon et al. JACC 1990; 16Cardia

19、c8Shapiro et al. Br Med J 1988; 2968Pasceri et al. JACC 1998; 312021/4/2619Coronary Microvascular Constriction in CADuMaseri A, NEJM 91; 325: 1579-80 uPupita G et al, NEJM 1990; 323:514-20uUren N et al, NEJM 1994; 331:222-72021/4/2620uClinical history can provide clues of the causes of recurring angina in patients with angiographically normal coronary arteries:wMicrovascular dysfunctionwVasospastic angina ( “A variant of the variant”, Cheng et al)uMicrovascular