急性冠脉综合症

Chapter 1 Acute coronary syndromes1章急性冠状动脉综合征Coronary artery disease is the leading cause of death among adults in the united states.it may be asymptomatic but usually presents with symptoms like angina pectoris,acute myocardial infarction(AMI),or sudden death.冠状动脉性疾病在美国成年人中是导致死亡的主要原因。

它可以无症状，但通常伴随的症状，如心绞痛，急性心肌梗死（急性心肌梗死），或猝死。

Etiology and pathogenesis病因和发病机制Atherosclerotic produces narrowing of the coronary arteries and inadequate blood flow to the myocardium leading to iscnemia .angina pectoris,the chest discomfort associated with myocardial ischemia,is caused by an imbalance between oxygen supply and oxygen demand .the lesion that causes angina is a smoothsurfaced atherosclerotic plaque that allows sufficient flow to the myocardium at rest but insufficient flow during times of increased exertion ,causing symptoms. symptoms subside a rest because oxygen demand has decreased, restoring the supply-demandbalance .unstable angina is thought to occur when a complex irregular atherosclerotic plaque ruptures , causing thrombus formation ,increased platelet activity ,and increased coronary vasomotor tone (vasospasm).unstable angina has a higher chance of progressing to an AMI.AMI is necrosis to a segment of heart muscle resulting from prolonged ischemia .It usually occurs when an acute thrombus or a ruptured atherosclerotic plaque suddenly occludes a coronary artery ,resulting in myocardial ischemia and ultimately tissue death caused byhypoxia .Myocardial infarcts are divided into two types ,depending on the extent of necrosis within the myocardial wall(Figure1-1).动脉粥样硬化产生缩小冠状动脉和心肌血流量，导致局部缺血。

心绞痛，胸部不适与心肌缺血有关，是氧气供求不平衡造成的。

造成心绞痛的病变原因是一个平滑肌表面动脉粥样硬化斑块，在休息状态时可有足够的血液流向心肌，但增加体力时则不足而引起的症状。

症状消退静息状态因为氧气需求下降，恢复供需平衡。

不稳定型心绞痛被认为发生在一个复杂的不规则的动脉粥样硬化斑块破裂，导致血栓形成，增加血小板活性，增加冠状动脉血管舒缩痉挛。

不稳定型心绞痛有较高机会进展到急性心肌梗死.急性心肌梗死坏死部分的心肌因长期缺血。

它通常发生在急性血栓或动脉粥样硬化斑块破裂突然闭塞冠状动脉，造成心肌缺血和最终因缺氧造成组织死亡。

心肌梗死分为两种类型，按照不同程度的坏死的心肌壁（Figure1-1）。

1. ST elevation myocardial infarction (STEMI):typically result from full thickness (transmural) necrosis caused by total prolonged occlusion of a coronary artery.1.ST段抬高心肌梗死（STEMI）：通常因长期闭塞的冠状动脉造成心肌全层坏死。

2. NON-ST elevation myocardial infarction(NSTEMI):usually results from incomplete coronary artery occlusion, causing ischemia of only the innermost layers of the myocardium (subendocardial).2.非ST段抬高心肌梗死（NSTEMI）：通常因不完全闭塞的冠状动脉，造成只有内层的心肌缺血。

Valvular heart disease, congenital heart disease ,coronary artery vasculitis, and coronary dissection are nonatherosclerotic causes of ischemic heart disease .瓣膜性心脏病，先天性心脏病，冠状动脉性血管炎，和非动脉粥样硬化性冠状动脉解剖原因，缺血性心脏病。

Clinical manifestations临床表现History历史A detailed history, including the onset and duration ofsymptoms ,precipitating factors , and previous episodes , should be addressed . risk factors for CAD(box 1-1)should also be evaluated.详细的历史，包括发病症状的持续时间，沉淀的因素，和既往史，应予以处理。

冠心病的危险因素（BOX1 - 1）也应进行评估。

Angina pectoris is a chronic predictable sensation ( pressure ,squeezing ,tightness ,or burning)that occurs during physical exertion or emotional stress and is relieved by rest or nitrates within a few minutes .this discomfort can radiate to the neck, lower jaw, left shoulder ,and left arm .it is often associated with diaphoresis , dyspnea , nausea, vomiting ,or lightheadedness . anginal symptoms typically last more than 15 seconds but less than 15 minutes.心绞痛是一种慢性可预见的感觉（压力，挤压，紧密，或燃烧）在身体劳累或情绪紧张的情况下发生，或在休息或口服硝酸盐在几分钟后缓解。

这样的不适症状可以辐射到颈部，下巴，左肩及左手臂。

它往往伴有出汗，呼吸困难，恶心，呕吐，或头晕。

心绞痛症状通常持续15秒以上但小于15分钟。

Angina is considered unstable when it has one of the following three characteristics.心绞痛是不稳定的，它有以下三个特点。

It is new onset这是新的开始It has an increasing pattern:episodes are more frequent ,last longer or are not relieved by medicaltions它呈一个增长模式：症状会越来越频繁，持续时间会更长或是口服药物不能缓解It is produced by less exertion or while at rest它在轻度运动或静息状态下也可发生。

The symptomns of AMI may not be different from those of severe stable angina or unstable angina except the pain typically lasts longer急性心肌梗死的症状可能与那些严重的稳定型心绞痛或不稳定心绞痛的症状相同但疼痛持续时间会更长。

Physical examination体格检查The physical examination can be normal. Box 1-2 lists signs that should be looked for during examination.身体检查可以是正常的。

BOX1 - 2列出的迹象，可以从检查中得出。

BOX 1-1 Risk factors for CAD框- 1冠心病的危险因素Hypertension高血压Hypercholesterolemia or hypertriglyceridemia高胆固醇血症、高甘油三酯血症High LDL cholesterol升高的低密度脂蛋白Low HDL cholesterol降低的高密度脂蛋白Cigarette smoking吸烟Diabetes mellitus糖尿病Family history of premature CAD<55家族史的早发冠心病< 55Advanced age？年龄Males and postmenopausal women男性和绝经后妇女Differential diagnosis鉴别诊断The complete differential diagnosis is listed below. 完整的鉴别诊断列表如下。