心绞痛的鉴别-心绞痛

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病史特点
男性，59岁
反复胸痛4个月，加重1个月。
胸痛呈压榨性与劳力有关。
有高血压，吸烟史。
有心脑血管病阳性家族史。
查体：体胖，无明显其他阳性发现。
ECG：V4－V6，I，aVL ST 0.5-1mm.
思考
胸痛的鉴别
心绞痛的特点
心绞痛的分级
心绞痛的分类
不同类型心绞痛的病理基础
进一步检查
冠心病的易患因素

心绞痛的鉴别 (1)
Non-ischemic CV
Aortic dissection
Pericarditis
Pulmonary
Pulmonary embolus
Pneumothorax
Pneumonia
Pleuritis
Gastrointestinal
Esophageal
Esophagitis, Spasm, Reflux
Biliary
Colic
Cholecystitis
Choledocholithiasis
Cholangitis
Peptic ulcer
Pancreatitis
心绞痛的鉴别 (2)
Chest Wall
Costochondritis
Fibrositis
Rib fracture
Sternoclavicular arthritis
Herpes zoster (before the rash)
Psychiatric
Anxiety disorders
Hyperventilation
Panic disorder
Primary anxiety
Affective disorders
(e.g., depression)
Somatiform disorders
Thought disorders
(e.g., fixed delusions)

心绞痛特点
SAVES U：
Sudden onset; 
Anterior chest; 
Vague sensation; 
Exercise precipitated; 
Short duration; 
Unanimous attack.

Grading of Angina Pectoris by CCSC
Class I: 日常体力活动不引起心绞痛.

Class II: 日常体力活动轻度受限.

Class III: 日常体力活动明显受限.

Class IV: 任何体力活动都引起症状，可以有休息时心绞痛。
UAP 的主要临床表现
Rest angina: Occurring at rest, usu. >20min, occurring within a week of presentation.
New onset angina: At least CCSC III severity, 200mmHg; DBP >110mmHg; 
Tachy- or Brady-arrhythmias; 
High degree AVB
HCMP or other forms of OT obstruction;
Mental or physical impairment; 
Noninvasive Testing: Exercise ECG(3)
Risk: MI and death  1/2500 tests.
A standard percentage (often 85%) of age-predicated maximum heart rate is targeted.
Reported in estimated METs of exercise (One MET is the standard basal oxygen uptake of 3.5ml/kg per min.)
ST depression  1mm for 60-80ms after the end of QRS, during or after exercise.
Noninvasive Testing: Exercise ECG(4)(Absolute indication for stopping):
SBP drop > 10mmHg with ischemia;
Moderate to severe angina;
Increasing ataxia;
Dizziness or near syncope;
Sign of poor perfusion; 
Technical difficulties; 
Sustained VT;
ST elevation in leads without Q waves.
Noninvasive Testing: Exercise ECG(5)(Relative indication for stopping):
SBP drop > 10mmHg without ischemia;
SBP >250 or DBP >115mmHg;
ST depression > 2mm;
Marked axis deviation;
Multifocal PVCs, t**lets PVCs, SVT, heart block or bradyarrhythmias, BBB or IVCB
Increasing chest pain; Serious symptoms.
Noninvasive Testing: Exercise ECG(6)
Sensitivity: 68%; Specificity: 77%
Influence of other factors on test:
Digoxin: 25-40% abnormal ST depression.
Beta blockers: Gradually withheld 48hrs.
Anti-HBP, vasodilators, nitrates, flacainide.
LBBB:
RBBB: 
LV hypertrophy: More false-positive.
Rest ST depression: Additional ST significant.
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