動(dòng)脈粥樣硬化、高血壓課件

心血管系統(tǒng)疾病

動(dòng)脈粥樣硬化

（Atherosclerosis,AS）

病理學(xué)系周潔P120CaseReport朱某，男，57歲。半年前，提水時(shí)突感胸骨后疼痛，同時(shí)伴左肩、左上臂疼痛，并有氣急、肢體冷、面色蒼白，出冷汗，經(jīng)休息后緩解。以后，每當(dāng)勞累后，上述癥狀時(shí)有發(fā)生并有加重。在醫(yī)院檢查時(shí)發(fā)現(xiàn)，血總膽固醇、脂蛋白↑。數(shù)周前上樓后，胸骨后劇痛，出現(xiàn)呼吸困難、咳粉紅泡沫痰，今晨解大便時(shí)，突然昏倒，經(jīng)搶救無效死亡。尸檢(autopsy)左冠狀A(yù)前降支動(dòng)脈粥樣硬化,血栓形成，管腔閉塞。前壁心肌梗死Coronaryatherosclerosis

withthrombosisandinfarction血脂過多沉積于動(dòng)脈內(nèi)膜并形成壞死粥糜樣物質(zhì)的動(dòng)脈硬化性疾病血脂異常及血管壁成分改變有關(guān)的動(dòng)脈性疾病What’s

atherosclerosis?Howtounderstandatherosclerosis?Cause:lipiddeposition脂質(zhì)代謝障礙/內(nèi)皮損傷Feature:gruelplaques壞死粥糜樣物Site:large&middlevessels大中A,彈力肌型AOutcomes:ischemia管壁增厚變硬,管腔阻塞,器官缺血(心、腦)Definition:

動(dòng)脈硬化

(Arteriosclerosis)(HardeningofArteries)●動(dòng)脈粥樣硬化(Atherosclerosis)大、中A,粥樣硬化斑塊●動(dòng)脈中膜鈣化(MedialCalcificationSclerosis)顳A、四肢A,臨床意義不大●細(xì)動(dòng)脈硬化(Arteriolosclerosis)

Hyalinedegeneration

高血壓病(1)脂斑脂紋（fattyspot&streak)黃色斑點(diǎn)或條紋1.基本病變(basicpathology)fattyspot&plaquefibrousplaque

Basicpathology:atherosclerosis

Basicpathology:atherosclerosis

Basicpathology:atherosclerosis

Basicpathology:atherosclerosis表層—纖維帽,大量膠原玻變,基質(zhì),SMC

深部—大量無定形壞死物,膽固醇結(jié)晶,鈣化底周—肉芽組織，少許FC、淋巴C

中膜—SMC萎縮變薄,彈力纖維破壞

Summary:morphologyofAS動(dòng)脈粥樣硬化—出血(Hemorrhage)動(dòng)脈粥樣硬化—潰瘍(Ulceration)動(dòng)脈粥樣硬化—鈣鹽沉積(Calcification)動(dòng)脈粥樣硬化—?jiǎng)用}瘤(aneurysm)aneurysmSummary:復(fù)合病變(complicatedlesion)①斑塊內(nèi)出血(Hemorrhage):斑塊突大,阻塞②斑塊破裂(Rupture):潰瘍形成(Ulceration)

③血栓形成(Thrombosis):附壁血栓,栓塞,梗死④鈣化(Calcification):A壁硬脆⑤A瘤形成(Aneurysm):

局限性擴(kuò)張或壁內(nèi)大血腔2.主要?jiǎng)用}病變(1)主動(dòng)脈粥樣硬化(AortaAS)部位腹主A,后壁,分支開口，病變

主動(dòng)脈瘤形成→Rupture→大出血→致命(2)冠狀動(dòng)脈粥樣硬化(CoronaryAS)左冠狀A(yù)前降支>右冠狀A(yù)干>左冠狀A(yù)旋支Outcomes

心肌急劇暫時(shí)缺血→心絞痛（Anginapectoris)嚴(yán)重持久缺血→心肌梗死(Myocardialinfarction)慢性供血不足→心肌硬化(Myocardialfibrosis)突然停搏,心室顫動(dòng)→心源性猝死(<1h,6h)(Suddencoronarydeath，SCD)

CerebralInfarction(Stroke)(4)腎動(dòng)脈粥樣硬化(RenalAS)●腎動(dòng)脈開口,主干，葉間動(dòng)脈●腎血管性高血壓●動(dòng)脈粥樣硬化性固縮腎(不規(guī)則瘢痕)

●下肢A,股淺A●間歇跛行●足趾干性壞疽

(5)四肢動(dòng)脈粥樣硬化(LimbsvesselAS)●腸梗死:劇烈腹痛,腹脹,發(fā)熱,便血,腸梗阻,休克(6)腸系膜動(dòng)脈粥樣硬化

(mesentericarteriesAS)Advancein

etiology&pathogenesisofatherosclerosisRiskFactorsNon

modifiablemiddletolateAgeMaleSex,Genetic-Hyperchol.FamilyhistoryPotentially

ModifiableHyperlipidemia–HDL/LDLratio.Hypertension.Smoking.Diabetes.血流剪應(yīng)力反應(yīng)(Shearingstress)

高血壓(Hypertension)

南方醫(yī)科大學(xué)基礎(chǔ)醫(yī)學(xué)院病理學(xué)系周潔

P127CaseReport張某，男，62歲，突然昏迷2小時(shí)入院。10年前發(fā)現(xiàn)高血壓，近來常感心悸，以體力活動(dòng)為甚，近半月覺頭暈、眼花、乏力，四肢麻木，今晨上廁所時(shí)突然跌倒，不省人事，左側(cè)上下肢不能活動(dòng)并有小便失禁。給予吸氧、降壓等治療，療效不顯，昏迷加深，呼吸不規(guī)則，呼吸心跳停止死亡。

AutopsyresultsCerebralInfarction(Stroke)HaemorrhagicNecrosisWhat’shypertension?在安靜休息狀態(tài)下體循環(huán)血壓持續(xù)增高,收縮壓≥140mmHg和/或舒張壓≥90mmHgHypertensioniselevatedlevelsofbloodpressure(HighBloodPressure)Sustainedincreaseinbloodpressure.Systolic>140,Diastolic>90mmHgCausesofhypertension(HT)原發(fā)性(primaryHT)95%特發(fā)性(IdiopathicHT)高血壓病繼發(fā)性(secondaryHT)5%癥狀性(symptomaticHT)

Typesofprimaryhypertension(分型)良性(benign)緩進(jìn)型(Chronic)95-98%惡性(malignant)急進(jìn)型(Accelerated)

2-5%，進(jìn)展迅速,病變嚴(yán)重,1-2y死亡1.良性高血壓

benign(Chronic)hypertension(1)機(jī)能紊亂期(functionalphase)細(xì)小A痙攣(spasm)→血壓波動(dòng)無器質(zhì)性變化(withoutorgandamage)dizziness,headache,andvisualdifficulties

StagesofChronichypertension(2)動(dòng)脈系統(tǒng)病變期(arterieschangephase)細(xì)A(＜1mm)玻璃變→細(xì)A硬化(Arteriolosclerosis)肌型A內(nèi)膜膠原彈力纖維增生,內(nèi)彈力膜分裂→中膜增厚,管腔狹窄BP持續(xù)增高,舒張壓>100mmHg左心室輕度肥大ArteriolosclerosisStagesofChronichypertension(3)內(nèi)臟病變期（visceralchangephase）

a.心(heart)外周阻力↑→左室代償肥大(厚1.5-2.0cm)向心性肥大(concentric):心腔不擴(kuò)張離心性肥大(eccentric):肌原性擴(kuò)張高血壓性心臟病(hypertensiveheartdisease)正常心臟與高血壓心臟(Hypertensiveheartdisease)LeftVentricularHypertrophyLeftVentricularHypertrophyb.腎(kidney)原發(fā)性顆粒性固縮腎(essentialgranularatrophickidney)Grossmorphology彌漫性對(duì)稱性縮小，變硬,表面細(xì)顆粒狀,皮質(zhì)變薄≤2mm（3-5mm)LeatheryGranularityduetominutescarring顆粒性固縮腎和正常腎比較Essentialgranularatrophickidney入球小A玻璃樣變肌型小A纖維化腎小球纖維化玻璃樣變腎小管萎縮腎小球代償性增生、肥大Microscopic:

essentialgranular

atrophickidneyHyalineArteriolosclerosis（3）腦(brain)①高血壓腦?。╤ypertensiveencephalopathy）中樞N功能障礙征候群:顱內(nèi)高壓,頭痛,嘔吐,視力障礙及意識(shí)模糊病變腦水腫，點(diǎn)狀出血②腦軟化(CerebralInfarction)（softeningofthebrain）

微梗死灶(microinfarct）/梗死灶液化性壞死:淡染、疏松網(wǎng)狀周圍膠質(zhì)細(xì)胞↑→膠質(zhì)疤痕CerebralInfarction③腦出血(cerebralhemorrhage)部位基底節(jié),內(nèi)囊,大腦白質(zhì)，腦干原因●細(xì)小A痙攣,腦組織缺血性壞死

●形成微A瘤—破裂出血

●豆紋A大腦中A直角分出,高壓沖擊腦出血(Cerebralhemorrhage)破入腦室→突然昏迷，肢體馳緩，反射消失，二便失禁,死亡內(nèi)囊→偏癱左腦出血→失語橋腦出血→面癱,對(duì)側(cè)上下肢癱血腫占位→顱內(nèi)高壓,腦疝SubarachnoidHaemorrhage:CerebralBloodvesselsSpecialfeatures:Thinwalled*Endarteries*Micro-aneurisms

高血壓危象（hypertensivecrisis）短期內(nèi)血壓急劇升高，舒張壓超過120或130mmHg并伴一系列嚴(yán)重癥狀，危及生命的臨床現(xiàn)象高血壓腦病顱內(nèi)出血蛛網(wǎng)膜下腔出血急性腦梗死急性左心衰竭不穩(wěn)定型心絞痛急性心肌梗死急性腎衰竭Ⅰ級(jí)視網(wǎng)膜動(dòng)脈變細(xì)Ⅱ級(jí)視網(wǎng)膜動(dòng)脈狹窄，動(dòng)脈交叉壓迫；Ⅲ級(jí)

眼底出血或棉絮狀滲出；Ⅳ級(jí)出血或滲出物伴有視神經(jīng)乳頭水腫(4)眼(eyes)NormalRetinaHypertensiveRetinopathyFundoscopy2.惡性高血壓

Malignant(Accelerated)hypertension中青年(Middle&youngages)BP↑↑,舒張壓＞130mmHg快速進(jìn)展(Rapidlyprogressive)較早出現(xiàn)腎衰(Earlyrenalfailure)高血壓腦病(Hypertensiveencephalopathy)

死于尿毒癥(Uraemia)、腦出血、心衰Pathology:Acceleratedhypertension增生性小動(dòng)脈硬化hyperplasticarteriolosclerosis同心性排列,蔥皮樣壞死性細(xì)動(dòng)脈炎necrotizingarteriolitis纖維素樣壞死,小出血微血栓,微梗死Intravascularthrombosis

&infarctionHyperplasticArteriolosclerosisOnionSkinThickeningOfarterioles.NarrowLumenNecrotizingarteriolitisFibrinoid

NecrosisThrombosis3.病因與發(fā)病機(jī)理

(etiology&pathogenesis)RegulationofBP:BP=CardiacOutputxPeripheralResistanceEndocrineFactorsRenin,Angiotensin,ADH,Aldosterone.NeuralFactorsSympathetic&ParasympatheticBloodVolumeSodium,MineralocorticoidsCardiacFactorsHeartrate&Contractility.Hypertension:etiology&pathogenesis(1)遺傳因素(geneticfactor)血管緊張素（AGT）基因缺陷→AGT↑遺傳性排鈉障礙,多基因(2)飲食因素(dietaryfactor)

HeavySodium(Na)Intake

WHO<5g/d(3)社會(huì)心理因素(soci