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[冠心病] 冠心病

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发表于 2018-12-23 00:01:30 | 显示全部楼层 |阅读模式

插图描绘冠状动脉的动脉粥样硬化。

冠状动脉疾病(CAD),也称为缺血性心脏病(IHD),[13]是最常见的心血管疾病。[14]类型包括稳定型心绞痛,不稳定型心绞痛,心肌梗死和心源性猝死[15]。常见的症状是痛或不适,可能会进入肩部,手臂,背部,颈部或下颌。[4]偶尔它可能会像胃灼热一样。通常症状出现在运动或情绪压力下,持续时间不到几分钟,并随着休息而改善。[4]也可能出现呼吸短促,有时无症状。[4]在许多情况下,第一个迹象是心脏病发作。[5]其他并发症包括心力衰竭或心跳异常。[5]

风险因素包括高血压,吸烟,糖尿病,缺乏运动,肥胖,高血脂,饮食不良,抑郁和过量饮酒。[6] [7] [16]潜在的机制包括由于心脏动脉的动脉粥样硬化而减少血流和氧气到心肌。[6]许多测试可能有助于诊断,包括:心电图,心脏压力测试,冠状动脉计算机断层扫描血管造影和冠状动脉造影等。[8]

降低CAD风险的方法包括健康饮食,定期锻炼,保持健康体重,不吸烟。[9]有时使用糖尿病,高胆固醇或高血压的药物。[9]筛查风险低且没有症状的人的证据有限。[17]治疗涉及与预防相同的措施。[10] [18]可能会推荐其他药物,如抗血小板药(包括阿司匹林),β受体阻滞剂或硝酸甘油。[10]经皮冠状动脉介入治疗(PCI)或冠状动脉搭桥手术(CABG)等手术可用于严重疾病[10] [19]。在那些CAD稳定的患者中,除了其他治疗方法外,PCI或CABG是否可以改善预期寿命或降低心脏病发作风险尚不清楚。[20]

2015年,加元影响了1.1亿人,导致890万人死亡。[11] [12]它占所有死亡人数的15.6%,使其成为全球死亡的最常见原因。[12] 1980年至2010年期间,特定年龄的CAD死亡风险下降,特别是在发达国家。[21] 1990年至2010年期间,特定年龄的CAD病例数也有所减少。[22]在2010年的美国,65岁以上人群中约有20%患有冠心病,而45岁至64岁患者中有7%患有冠心病,而18至45岁患者则为1.3%; [23]男性患者的发病率高于女性特定年龄。[23]

视频:↓  冠心病,动脉阻塞和动脉粥样硬化


目录
1 症状和体征
2 风险因素
2.1 血脂
2.2 遗传学
2.3 其他
3 病理生理学
4 诊断
4.1 稳定型心绞痛
4.2 急性冠脉综合征
4.3 风险评估
5 预防
5.1 饮食
5.2 二级预防
6 治疗
6.1 药物治疗
6.2 手术
7 流行病学
8 社会与文化
8.1 命名
8.2 支持小组
8.3 行业对研究的影响
9 研究
10 参考

体征和症状
经常活动,进食后或在其他可预测的时间发生的胸痛被称为稳定性心绞痛并且与心脏动脉狭窄有关。

强度,性格或频率变化的心绞痛被称为不稳定。不稳定型心绞痛可能发生在心肌梗死之前。对于因疼痛原因不明确而去急诊室的成年人,约有30%的人因冠状动脉疾病而感到疼痛。[24]

风险因素
冠状动脉疾病有许多明确的危险因素。这些包括高血压,吸烟,糖尿病,缺乏运动,肥胖,高血脂,饮食不良,抑郁,家族史和过量饮酒。[6] [7] [16]大约一半的病例与遗传有关。[25]吸烟和肥胖分别与约36%和20%的病例有关。[26]每天只吸一支烟,大约会增加CAD的风险。[27]缺乏锻炼与7-12%的病例有关。[26] [28]接触除草剂橙剂可能会增加风险。[29]类风湿性关节炎,系统性红斑狼疮,牛皮癣和银屑病关节炎等风湿性疾病也是独立的危险因素。[30] [31] [32] [33]

工作压力似乎起了次要作用,约占案件的3%。[26]在一项研究中,没有工作压力的女性血管直径增加,导致动脉粥样硬化进展减少。[34]相比之下,工作压力较高的女性血管直径减小,疾病进展明显增加。[34]具有A型行为模式,一组人格特征,包括时间紧迫性,竞争力,敌意和不耐烦,[35]与冠心病风险增加有关。[36]

血脂
高血胆固醇(特别是血清LDL浓度)。 HDL(高密度脂蛋白)对冠状动脉疾病的发展具有保护作用。[37]
高血甘油三酯可能起作用。[38]
高水平的脂蛋白(a),[39] [40] [41]当LDL胆固醇与称为载脂蛋白(a)的蛋白质结合时形成的化合物。
膳食胆固醇似乎对血液胆固醇没有显着影响,因此可能不需要有关其消费的建议。[42]饱和脂肪仍是一个问题。[42]

遗传学
据估计,冠状动脉疾病的遗传率在40%至60%之间。[43] 全基因组关联研究已经确定了大约60个冠状动脉疾病的遗传易感位点。[44]

其他
40岁以下妇女的子宫内膜异位症。[45]
抑郁和敌意似乎是风险。[46]
儿童不良经历(心理,身体或性虐待;对母亲的暴力行为;或与滥用药物,精神病,自杀或被监禁的家庭成员一起生活)的类别数量与成人疾病的存在呈现分级相关性,包括 冠状动脉(缺血性心脏病)。[47]
止血因子:高水平的纤维蛋白原和凝血因子VII与CAD风险增加有关[48]。
低血红蛋白。[49]
在亚洲人群中,b纤维蛋白原基因G-455A多态性与CAD的风险相关[50]。

病理生理学


冠状动脉的显微照片,最常见的冠状动脉疾病(动脉粥样硬化)和明显的管腔狭窄。 Masson's三色。


插图描绘冠状动脉疾病
对心脏的血流量的限制导致心脏肌细胞的缺血(继发于缺氧的细胞饥饿)。心脏的肌肉细胞可能因缺氧而死亡,这被称为心肌梗塞(通常称为心脏病发作)。它会导致心肌的损伤,死亡和最终疤痕,而不会使心肌细胞再生。慢性高级别的冠状动脉狭窄可以诱发短暂性缺血,导致室性心律失常的诱发,这可能终止于称为心室颤动的危险心律,这常常导致死亡。[51]

通常,当冠状动脉内的光滑弹性衬里(向心肌供血的动脉)的一部分发生动脉粥样硬化时,就会发生冠状动脉疾病。随着动脉粥样硬化,动脉的内层变硬,变硬,并积聚钙,脂肪脂和异常炎症细胞的沉积物 - 形成斑块。血管肌层中的磷酸钙(羟基磷灰石)沉积物似乎在加强动脉和诱导冠状动脉硬化的早期阶段中起重要作用。这可以在所谓的慢性肾病和血液透析中发生的所谓的钙化转移机制中看出(Rainer Liedtke 2008)。虽然这些人患有肾功能不全,但近50%的人因冠状动脉疾病而死亡。斑块可以被认为是突出到动脉通道中的大“丘疹”,导致部分阻塞血流。患有冠状动脉疾病的人可能只有一到两个斑块,或者可能在整个冠状动脉中分布有数十个斑块。当冠状动脉完全阻塞超过3个月时,更严重的形式是慢性完全闭塞(CTO)。[52]

心脏综合征X是在进行血管造影(冠状动脉造影)时心脏较大的冠状动脉没有出现阻塞迹象的人的胸痛(心绞痛)和胸部不适。[53]心脏综合征X的确切原因尚不清楚。解释包括微血管功能障碍或心外膜动脉粥样硬化。[54] [55]由于理解不充分的原因,女性比男性更有可能拥有它;然而,女性独有的激素和其他风险因素可能起作用。[56]

诊断


一名男子的冠状动脉造影


一名妇女的冠状动脉造影
对于有症状的人,应力超声心动图可用于诊断阻塞性冠状动脉疾病。[57]对于没有出现症状且发生冠心病的风险较低的个体,不推荐使用超声心动图,应力心脏成像和/或高级非侵入性成像。[57] [58]

“心脏综合症X”的诊断 - 如上所述,在女性中更常见的罕见冠状动脉疾病是诊断排除。因此,通常使用与怀疑患有冠状动脉疾病的任何人相同的测试:

基线心电图(ECG)
运动心电图 - 压力测试
运动放射性同位素试验(核应激试验,心肌闪烁扫描)
超声心动图(包括压力超声心动图)
冠状动脉造影
血管内超声
磁共振成像(MRI)
特定症状的冠状动脉疾病的诊断在很大程度上取决于症状的性质。第一项调查是心电图(ECG / EKG),用于“稳定”心绞痛和急性冠状动脉综合征。可以进行胸部X光检查和血液检查。

稳定的心绞痛
主要文章:心绞痛
在“稳定”心绞痛,胸痛伴有可预测的运动水平的典型特征,各种形式的心脏压力测试可用于诱导两种症状并通过心电图(使用ECG)检测变化,超声心动图(使用超声心动图)心脏)或闪烁扫描(使用心肌摄取放射性核素)。如果部分心脏似乎血液供应不足,冠状动脉造影可用于识别冠状动脉狭窄和血管成形术或旁路手术的适用性。[59]

稳定型冠状动脉疾病(SCAD)通常也称为稳定性缺血性心脏病(SIHD)。[60] 2015年专着解释说“无论命名如何,稳定性心绞痛是SIHD或SCAD的主要表现。”[60] SIHD / SCAD有美国和欧洲的临床实践指南。[61] [62]

急性冠状动脉综合征
主要文章:急性冠脉综合征

急性冠状动脉综合征的诊断通常在急诊室进行,其中可以顺序执行ECG以识别“进化的变化”(指示对心肌的持续损伤)。如果ECG显示“ST段”的升高,则诊断是明确的,在严重的典型胸痛的情况下,ST段显示急性心肌梗塞(MI);这被称为STEMI(ST段抬高心肌梗死),无论是哪种可用,都可以通过紧急冠状动脉造影和经皮冠状动脉介入治疗(有或没有支架置入的血管成形术)或溶栓(“血栓破坏”药物治疗)作为紧急治疗。在没有ST段抬高的情况下,通过心脏标记物检测心脏损伤(识别心肌损伤的血液测试)。如果有损伤(梗塞)的证据,则胸痛归因于“非ST段抬高MI”(NSTEMI)。如果没有损伤迹象,则使用术语“不稳定型心绞痛”。这个过程通常需要住院和密切观察冠心病监护室是否存在可能的并发症(如心律失常 - 心率不规律)。根据风险评估,压力测试或血管造影可用于识别和治疗患有NSTEMI或不稳定型心绞痛的患者的冠状动脉疾病。

风险评估

有各种风险评估系统可用于确定冠状动脉疾病的风险,并强调上述不同的变量。一个值得注意的例子是弗雷明汉心脏研究中使用的Framingham Score。它主要基于年龄,性别,糖尿病,总胆固醇,高密度脂蛋白胆固醇,吸烟和收缩压。

预防
如果避免确定的风险因素,高达90%的心血管疾病可以预防。[63] [64]预防包括适当的体育锻炼,减少肥胖,治疗高血压,饮食健康,降低胆固醇水平和戒烟。药物和运动大致同样有效。[65]高水平的身体活动可使冠状动脉疾病的风险降低约25%。[66]

大多数指南建议结合这些预防策略。 2015年Cochrane评价发现一些证据表明这种方法可能有助于血压,体重指数和腰围。然而,没有足够的证据表明对死亡率或实际心血管事件有影响。[67]

在糖尿病中,几乎没有证据表明非常严格的血糖控制可以改善心脏病风险,尽管改善糖控制似乎可以减少其他问题,如肾衰竭和失明。世界卫生组织(WHO)建议“低至中度饮酒”以降低冠状动脉疾病的风险,而高摄入会增加风险。[68]

饮食
主要文章:饮食和心脏病
高水果和蔬菜的饮食可以降低患心血管疾病和死亡的风险。[69]素食者患心脏病的风险较低,[70] [71]可能是因为他们更多地食用水果和蔬菜。[72]证据还表明,地中海饮食[73]和高纤维饮食降低了风险。[74]

消耗反式脂肪(通常存在于人造黄油等氢化产品中)已被证明是导致动脉粥样硬化的前兆[75]并增加冠状动脉疾病的风险。[76]

证据不支持omega-3脂肪酸补充剂在预防心血管疾病(包括心肌梗塞和心源性猝死)方面的有益作用。[77] [78]有初步证据表明,摄入甲基萘醌(维生素K2)而不是叶绿醌(维生素K1)可以降低死亡率的风险。[79]

二级预防
二级预防可以防止已经确定的疾病的进一步后遗症。已被证明对此目标有效的生活方式变化包括:

控制体重
戒烟
避免反式脂肪的消耗(部分氢化油)
减少心理社会压力[80]
行使;有氧运动,如散步,慢跑或游泳,可以降低冠状动脉疾病死亡的风险。[81]有氧运动可以帮助降低血压和血液胆固醇(LDL)的数量。它还会增加HDL胆固醇,这被认为是“好胆固醇”。[82] [83]分开运动的好处问题;目前尚不清楚医生是否应该花时间辅导患者进行锻炼。美国预防服务工作组发现“证据不足”,建议医生为患者提供运动建议,但“它没有检查体力活动有效性的证据,以减少慢性疾病,发病率和死亡率”,它只检查了有效性。辅导。[84]美国心脏协会基于非系统评价,建议医生为患者提供运动建议。[85]

治疗
冠状动脉疾病有多种治疗选择:[86]

改变生活方式
药物治疗 - 药物(如降胆固醇药物,β-受体阻滞剂,硝酸甘油,钙通道阻滞剂等);
作为血管成形术和冠状动脉支架的冠状动脉介入治疗;
冠状动脉旁路移植术(CABG)

药物
他汀类药物可降低胆固醇,降低患冠心病的风险[87]
硝酸甘油[88]
钙通道阻滞剂和/或β受体阻滞剂[89]
抗血小板药物如阿司匹林[89] [90]
建议血压通常降至140/90 mmHg以下。[91]然而,舒张压不应低于60 mmHg。[含糊]β受体阻滞剂是推荐用于此用途的第一线。[91]

阿司匹林
在没有心脏病史的患者中,阿司匹林可降低心肌梗死的风险,但不会改变总体死亡风险。[92]因此,仅建议患有冠心病风险增加的成年人[93]将风险增加定义为“年龄大于90岁的男性,绝经后妇女和患有冠状动脉疾病危险因素的年轻人(例如,高血压,糖尿病或吸烟)患心脏病的风险增加,并且可能希望考虑“阿司匹林治疗”。更具体地说,高危人群是“5年风险≥3%的人”。

抗血小板治疗
在STEMI患者中,氯吡格雷加阿司匹林(双重抗血小板治疗)比单用阿司匹林更能减少心血管事件。在其他风险较高但没有发生急性事件的情况下,证据不足。[94]具体而言,它的使用不会改变这一群体的死亡风险。[95]在那些支架超过12个月的氯吡格雷加阿司匹林的患者中,不会影响死亡风险。[96]

手术
急性冠状动脉综合征的血运重建具有死亡率的益处。[97]对于稳定的缺血性心脏病,经皮血运重建似乎没有单独使用药物治疗的益处。[98]对于患有多种动脉疾病的患者,冠状动脉旁路移植术似乎优于经皮冠状动脉介入治疗。[99] [100]较新的“主动脉”或非接触式非体外循环冠状动脉血运重建技术显示,与经皮冠状动脉介入治疗相比,术后卒中发生率降低[101]。混合冠状动脉血运重建术也被证明是一种安全可行的方法,虽然费用较高,但可提供优于传统CABG的一些优势。[102]

流行病学

2012年每百万人因缺血性心脏病死亡


2004年每10万居民缺血性心脏病的残疾调整生命年。[103]


截至2010年,CAD是全球死亡的主要原因,导致700多万人死亡。[104]这一数字从1990年全世界的CAD死亡人数增加到520万。[104]它可能影响任何年龄的个体,但在年龄逐渐变大的情况下变得更加普遍,每生命十年大约增加三倍。[105]男性比女性更容易受到影响。[105]

据估计,世界上60%的心血管疾病负担将发生在南亚次大陆,尽管仅占世界人口的20%。这可能是遗传易感性和环境因素相结合的次要因素。印度心脏协会等组织正在与世界心脏联合会合作,以提高对这一问题的认识。[106]

冠状动脉疾病是男性和女性死亡的主要原因,并且每年在美国造成约600,000人死亡。[107]根据美国目前的趋势,一半健康的40岁男性将来会发展为CAD,三分之一的健康40岁女性将会发展。[108]这是美国20岁以上男性和女性死亡的最常见原因。[109]

社会与文化
名称
有时用于这种情况的其他术语是“动脉硬化”和“动脉狭窄”。[110]在拉丁语中,它被称为morbus ischaemicus cordis(MIC)。

支持小组
Infarct Combat Project(ICP)是一家成立于1998年的国际非营利组织,致力于通过教育和研究来减少缺血性心脏病。[111] [112]

行业对研究的影响
在2016年对[未引用的]档案的研究,糖业协会,美国制糖业的行业协会,赞助了1965年在新英格兰医学杂志上发表的一篇有影响力的文献综述,该评论淡化了早期的研究结果。饮食中重糖的作用在CAD的发展中强调脂肪的作用;该评论影响了数十年的研究经费和健康饮食指导。[113] [114] [115] [116] [117]

研究
进一步的信息:动脉粥样硬化和动脉粥样硬化
研究工作集中在新的血管生成治疗方式和各种(成人)干细胞疗法。 17号染色​​体上的一个区域仅限于多发心肌梗死病例的家庭。[118]其他全基因组研究已经在9号染色体上发现了一个确定的风险变异(9p21.3)。[119]然而,这些和其他基因座存在于基因间片段中,需要进一步研究以了解表型如何受到影响。[120]

一个更有争议的联系是肺炎衣原体感染和动脉粥样硬化之间的关系。[121]虽然这种细胞内生物体已在动脉粥样硬化斑块中得到证实,但关于它是否可被视为致病因素的证据尚无定论。[122]在已证实的动脉粥样硬化患者中使用抗生素治疗并未证明心脏病发作或其他冠状动脉血管疾病的风险降低。[123]

自20世纪90年代以来,寻找冠状动脉疾病患者的新治疗方案,特别是对于所谓的“无选择”冠状动脉患者,主要关注血管生成[124]和(成人)干细胞疗法的使用。 进行了许多临床试验,要么应用蛋白质(血管生成生长因子)治疗,如FGF-1或VEGF,要么使用不同种类的成体干细胞群进行细胞治疗。 研究仍在继续 - 特别是对于FGF-1 [125] [126]和内皮祖细胞的利用的第一个有希望的结果。

髓过氧化物酶已被提议作为生物标志物。[127]

饮食改变可以减少冠状动脉疾病。 例如,数据支持从基于植物的饮食和积极的降脂改善心脏病中获益。[128]

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