慢性稳定性心绞痛的治疗(英文).ppt
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1、GUIDELINES FOR THE MANAGEMENT OF CHRONIC STABLE ANGINA,American College of Cardiology, Puerto Rico Chapter, February 6, 2007,GAP,The Goals of Therapy in CAD,To improve quality of life (symptoms) To reduce mortality To reduce morbidity To reduce progression of disease and induce regression.,Treatment
2、 of Chronic Stable Angina,Medical,Revascularization,PCI,ACBG,MEDICAL THERAPY,ANTIPLATELETS BETA BLOCKERS NITRATES CALCIUM ANTAGONIST ACEI STATINS NEW THERAPIES,ANTIPLATELET AGENTS,ASA Physicians Health Study Swedish Angina Pectoris Trial TICLOPIDINE CLOPIDOGREL CAPRI CURE,Receptor GP IIb-IIIa: The F
3、inal Common Pathway to Platelet Aggregation,White HD. Am J Cardiol 1997; 80:2B-10B. Schafer A. J Clin Invest 1986; 78:73-79. DeJong MJ, et al. Critical Care Nursing Clin of N Am 1999; 11:355-371. Moser M, et al. J Cardiovasc Pharmacol 2003;41:586-592. Phillips DR, Scarborough RM. Am J Cardiol 1997;8
4、0(4A):11B-20B.,GP IIb-IIIa inhibitors displace fibrinogen in existing thrombi to disaggregate thrombus and prevent further platelet cross-linking and thrombosis,GP IIb-IIIa inhibitors prevent platelet activation by blocking GP IIb-IIa (outside-in signaling),High-dose heparin stimulates PAF which act
5、ivates platelets,PHYSICIANS HEALTH STUDY,A randomized, double-blind, placebo controlled trial designed to test the effects of low-dose aspirin and beta-carotene in the primary prevention of CVD and cancer among 22,071 US male physicians, aged 40 to 84 at baseline in 1982. Baseline blood specimens we
6、re collected and frozen for later analyses from 14,916 participants. Using a 2x2 factorial design: 325 mg of aspirin (Bufferin, supplied by Bristol-Myers Products on alternate days) 50 mg of beta-carotene (Lurotin, supplied by BASF AG on alternate days),PHYSICIANS HEALTH STUDY, Total cancer Prostate
7、 cancer Cardiovascular disease Eye disease Cataract Macular degeneration,Primary Endpoints,PHYSICIANS HEALTH STUDY,The trials Data and Safety Monitoring Board stopped the aspirin arm of the PHS several years ahead of schedule because it was clear that aspirin had a significant effect on the risk of
8、a first myocardial infarction. As reported in the July 20, 1989 New England Journal of Medicine, aspirin reduced the risk of first myocardial infarction by 44% (P less than 0.00001). There were too few strokes or deaths upon which to base sound clinical judgment regarding aspirin and stroke or morta
9、lity,Pharmacotherapy for Chronic Stable Angina (class I),1. Aspirin in the absence of contraindications A 2. Beta-blockers as initial therapy in the absence of contraindications in patients with prior myocardial infarction or without prior myocardial infarction A,B 3. ACE inhibitor in all patients w
10、ith CAD who also have diabetes and/or LV systolic dysfunction A 4. LDL-lowering therapy in patients with documented or suspected CAD and LDL cholesterol 130 mg/dl, with a target LDL of 100 mg/dl A 5. Sublingual nitroglycerin or nitroglycerin spray for the immediate relief of angina B 6. Calcium anta
11、gonists or long-acting nitrates as initial therapy for reduction of symptoms when beta blockers are contraindicated B 7. Calcium antagonists or long-acting nitrates in combination with beta blockers when initial treatment with beta blockers is not successful B 8. Calcium antagonists and long-acting
12、nitrates as a substitute for beta blockers if initial treatment with beta blockers leads to unacceptable side effects,Pharmacotherapy for Chronic Stable Angina (class IIa),1. Clopidogrel when aspirin is absolutely contraindicated 2. Long-acting non-dihydropyridine calcium antagonists instead of beta
13、 blockers as initial therapy B 3. In patients with documented or suspected CAD and LDL cholesterol 100129 mg/dl, several therapeutic options are available: B a. Lifestyle and/or drug therapies to lower LDL to 100 mg/dl b. Weight reduction and increased physical activity in persons with the metabolic
14、 syndrome c. Institution of treatment of other lipid or non-lipid risk factors; consider use of nicotinic acid or fibric acid for elevated triglycerides or low HDL cholesterol 4. ACE inhibitor in patients with CAD or other vascular disease,Pharmacotherapy for Chronic Stable Angina,IIb (weak supporti
15、ve evidence) Low-intensity anticoagulation with warfarin in addition to aspirin B III (not indicated) 1. Dipyridamole B 2. Chelation therapy B,CURE,Approach to the treatment of chest pain,OXYGEN DEMAND,Double product = (Heart Rate) (systolic blood pressure),BETA BLOCKERS,Effects of -blockade on isch
16、emic heart,Printed from: Drugs for the Heart 2007 Elsevier,Cardiac effects of -adrenergic blocking drugs at the levels of the SA node, AV node, conduction system, and myocardium,Printed from: Drugs for the Heart 2007 Elsevier,Contraindications to -blockade,Printed from: Drugs for the Heart 2007 Else
17、vier,BETA BLOCKERS STUDIES,TIBET (Total Ischemic Burden European Trial) APSIS (The Angina Prognosis Study In Stockholm) ASIST (Atenolol Silent Ischemia Trial) TIBBS (Total Ischemic Burden Bisoprolol Study) IMAGE (International Multicenter Angina Exercise Study),BB for clinical use,ACC/AHA 2002 Guide
18、line Update for the Management of Patients With Chronic Stable Angina,Comparison of hemodynamic effects of -blockers and of CCBs,Printed from: Drugs for the Heart 2007 Elsevier,CARDIAC VS. VASCULAR,Printed from: Drugs for the Heart 2007 Elsevier,Mechanisms of anti-ischemic effects of calcium channel
19、 blockers,Printed from: Drugs for the Heart 2007 Elsevier,Verapamil and diltiazem have a broad spectrum of therapeutic effects.,Printed from: Drugs for the Heart 2007 Elsevier,Contraindications to verapamil or diltiazem,Printed from: Drugs for the Heart 2007 Elsevier,Contraindications to dihydropyri
20、dines,Printed from: Drugs for the Heart 2007 Elsevier,Properties of CCB in clinical use,Schematic diagram of effects of nitrate on the circulation,Printed from: Drugs for the Heart 2007 Elsevier,Effects of nitrates in generating NO and stimulating guanylate cyclase to cause vasodilation,Printed from
21、: Drugs for the Heart 2007 Elsevier,Current proposals for therapy of nitrate tolerance.,Printed from: Drugs for the Heart 2007 Elsevier,A serious nitrate drug interaction,Printed from: Drugs for the Heart 2007 Elsevier,Nitrates in Angina,Effect of simvastatin on cardiovascular events among patients
22、with and without coronary heart disease (CHD) in the Heart Protection Study,Dual role of ACE inhibitors, both preventing and treating cardiovascular disease,Printed from: Drugs for the Heart 2007 Elsevier,Post-infarction remodeling,Printed from: Drugs for the Heart 2007 Elsevier,ACC/AHA Guidelines f
23、or Treatment of Risk Factors (class I),1. Treatment of hypertension according to Joint National Conference VI guidelines A 2. Smoking cessation therapy B 3. Management of diabetes C 4. Comprehensive cardiac rehabilitation program (including exercise) B 5. LDL-lowering therapy in patients with docume
24、nted or suspected CAD and LDL cholesterol 130 mg/dl, with a target LDL of 100 mg/dl A 6. Weight reduction in obese patients in the presence of hypertension, hyperlipidemia, or diabetes mellitus C,ACC/AHA Guidelines for Treatment of Risk Factors (class IIa),1. In patients with documented or suspected
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- 慢性 稳定性 心绞痛 治疗 英文
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