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 心絞痛的鑒別-心絞痛

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病史特點
男性，59歲
反復胸痛4個月，加重1個月。
胸痛呈壓榨性與勞力有關。
有高血壓，吸煙史。
有心腦血管病陽性家族史。
查體：體胖，無明顯其他陽性發現。
ECG：V4－V6，I，aVL ST 0.5-1mm.
思考
胸痛的鑒別
心絞痛的特點
心絞痛的分級
心絞痛的分類
不同類型心絞痛的病理基礎
進一步檢查
冠心病的易患因素

心絞痛的鑒別 (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
心絞痛的鑒別 (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)

心絞痛特點
SAVES U：
Sudden onset; 
Anterior chest; 
Vague sensation; 
Exercise precipitated; 
Short duration; 
Unanimous attack.

Grading of Angina Pectoris by CCSC
Class I: 日常體力活動不引起心絞痛.

Class II: 日常體力活動輕度受限.

Class III: 日常體力活動明顯受限.

Class IV: 任何體力活動都引起癥狀，可以有休息時心絞痛。
UAP 的主要臨床表現
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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