内科学概论心脏血管内科.pptVIP

SitesofAnti-thromboticDrugActionTissuefactorPlasmaclottingcascadeProthrombinThrombinFibrinogenFibrinThrombusPlateletaggregationConformational

activationofGPIIb/IIIaCollagenThromboxaneA2ADPATATFactorXaCoagulationcascadePlateletcascadePlaquerupturethrombusLCCFibrinThrombinPlateletFibrinolysisAntiplateletAnti-thrombinTHROMBUSPLATELETAntiplatelettherapy-aspirin-clopidogrel-GPIIb/IIIainhibitors-persantin-ticlopidineThrombinAntithrombintherapy-heparinFibrinPlasminogenActivators-t-PAR-PASKTNK-tPALCCABUrokinaseStreptokinase急性心肌梗塞

Thrombolysis一般原則胸痛12小時內STsegmentelevation75yearsold沒有禁忌3小時內好處最大好處壞處LCC急性心肌梗塞

Thrombolysis12小時內注射的好處增加冠狀動脈血流減少結疤的形成減少心室擴大梗塞區域可以重新排列其構造減少心臟衰竭減少死亡率好處壞處LCCThrombolysistPAEarlyreperfusion價錢貴腦溢血機會較高需併用Heparin使用於大片心肌壞死並且腦溢血機會較低者靜脈注射15mg30分鐘內以0.75mg/kgmg的量滴注50mg60分鐘內以0.5mg/kg的量滴注35mgLCCThrombolysis

Streptokinase適用於發作時間較久受損範圍較小患者價錢較便宜腦溢血機會較低易過敏2年內最好不要再使用第二次不必併用Heparin100萬單位1小時內滴注完畢LCC0102急性心肌梗塞

Thrombolysis1Initiatefibrinolysisifindicated2Goals:minfromentrytoER3LCCFIBRINOLYSIS

ABSOLUTECONTRAINDICATIONPreviousHEMORRHAGICSTROKEatanytimeOtherSTROKESorCEREBROVASCULAREVENTSwithinoneyearKnownINTRACRANIALNEOPLASMAActiveINTERNALBLEEDING(doesnotincludemenses)SuspectedAORTICDISSECTIONLCCUnstableandStablePlaqueThin

fibrouscapInflammatory

cellsFew

SMCsEroded

endotheliumActivated

macrophagesThick

fibrouscapLackof

inflammatory

cellsFoamcellsIntact

endotheliumMore

SMCsUnstableStableRiskFactorsforPlaqueRuptureImpaired

FibrinolysisFibrinogenDiabetes

MellitusCholesterolSmokingCapFatigueAtheromatousCore

(size/consistency)CapInflammationSystemicFactorsLocalFactorsHomocysteinePlaque

RuptureCapThickness/ConsistencyPlaqueRupture01誘發因素02Plaque03rupture04運動05抽煙06寒冷天氣07發脾氣08心跳快09血壓高10週邊血管阻力大11LCC12心臟血管阻塞膽固醇沉積于血管壁形成粥狀硬塊(Pl