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Name of sudden death in coronary artery disease, atherosclerotic heart disease, symptoms and signs of cardiovascular medicine classification of ischemic heart disease is as follows:
(A) primary cardiac arrest
Is a sudden event, it is envisaged due to instability caused by ECG and no other diagnosis can be made the basis. If not done the recovery or recovery failure, primary cardiac arrest attributed to sudden death. Evidence of previous ischemic heart disease dispensable, in case of death, who see no signs of the speculative nature of the diagnosis.2, spontaneous angina pectoris: the characteristics of spontaneous angina, chest pain and myocardial oxygen demand enough to increase no significant relationship. Compared with angina pectoris, the pain typically lasts longer, more severe, and difficult to nitroglycerin relieved at the end see the enzyme changes. Often appear in some temporary ECG ST segment depression or T wave changes. Spontaneous angina pectoris may occur alone or in combination with angina pectoris. Spontaneous pain in patients with angina attack frequency, duration and degree of pain may have a different spectrum of clinical manifestations, and sometimes patients may have longer duration of chest pain, similar to myocardial infarction but no ECG changes and enzyme characteristics. Some of the spontaneous onset of angina patients during their transient ST-segment elevation, often referred to as variant angina. However, when myocardial infarction has b


een recorded to the ECG chart type, the name can not be applied.
(C) myocardial infarction
1, acute myocardial infarction: clinical diagnosis of acute myocardial infarction often based on history, ECG and serum enzyme changes made.
(1) history: history is typical of severe and persistent chest pain. Sometimes, history is not typical, the pain can be mild or no, you can mainly other symptoms.
(2) ECG: electrocardiogram positive change is abnormal, persistent Q wave or QS wave and continuing the evolution of more than 1 day injury current. When these positive changes in ECG, the ECG alone can make the diagnosis. In other cases, there is uncertainty ECG showed changes including: resting the injury current wave inversion symmetry, a single ECG record with a pathological Q wave, conduction disturbances.
(3) positive serum enzyme changes in serum enzyme levels, including the sequence changes, or began to increase and subsequent decrease. This change must be a specific enzyme and time of onset of symptoms and to take blood samples linked interval. The increase of cardiac-specific isoenzyme is also considered a positive change, are not sure changes to the beginning of concentration, but not associated with the subsequent reduction of the curve of enzyme activity can not be achieved.
Note 1: positive acute myocardial infarction: positive if ECG changes and (or) positive enzyme changes, can be diagnosed as definite acute myocardial infarction, history may be typical or not typical.
Note 2: possible acute myocardial infarction: When the sequence of uncertainty ECG changes lasting more than 24h or more, with or without the uncertainty associated with changes in enzyme, can be diagnosed as cho myocardial infarction, history may be typical or typical.
Note 3: In the recovery phase of acute myocardial infarction, some patients may show spontaneous chest pain, sometimes accompanied by ECG changes, but no new enzyme changes, which in some cases can be diagnosed as Dressier infarction syndrome, some of the spontaneous angina pectoris, acute myocardial infarction compared with other recurrence or may have expanded. Other diagnostic measures may help to establish the exact diagnosis.
2, old myocardial infarction: old myocardial infarction electrocardiogram changes often based on certainty, there is no history of acute myocardial infarction and enzyme changes in diagnosis. If there is no residual ECG changes, according to the typical ECG changes or earlier certainty based on past changes in serum enzyme diagnosis.
(D) of heart failure in ischemic heart disease
Ischemic heart disease may occur due to heart failure for many reasons, it can be acute myocardial infarction or complications of previous myocardial infarction or angina pectoris, or arrhythmia can be induced. Ischemic heart disease in the absence of previous clinical or ECG evidence of heart failure patients (exclusion of other reasons), the diagnosis of ischemic heart disease is an speculative.
(E) arrhythmia
Arrhythmia bite Yishi the only manifestation of ischemic heart disease. In this case, unless proven coronary angiography coronary artery occlusion, or ischemic heart disease diagnosis is speculative in nature.
"Preinfarction angina" and "intermediate coronary syndrome" in these two names are not included in this report because, according to the of this group, recalled the former diagnosis is diagnosis, only a few cases can be confirmed, then a diagnosis ownership of all cases described in this report, ischemic heart disease in one category. Disease, primary cause of cardiac arrest due to death. World Health Organization on the naming of ischemic heart disease and diagnostic criteria (1980 First National Conference on Internal Medicine suggested that when the diagnosis of coronary heart disease by the World Health Organization adopted the name and diagnostic criteria of coronary heart disease). Ischemic heart disease was defined as changes in the coronary circulation and myocardial coronary blood flow caused by the imbalance between demand resulting from myocardial damage. Ischemic heart disease, including acute, transient and chronic three, or may be due to functional changes caused by organic disease. Non-coronary hemodynamic changes caused by ischemia, such as aortic stenosis are not included. "Ischemic heart disease," "coronary heart disease" are synonymous. Other names should not be used. Named on coronary heart disease diagnostic tests and diagnostic standard recommendations (February 1980 the first National Conference on Cardiovascular Medicine Professional Group)
1, ECG exercise test (including the double two ladders, and pedal his tmill test), a false positive, the false positive rate with the inspection object in the level of the prevalence of coronary heart disease are closely related. For example, in the general asymptomatic population, assuming that 4% of people have coronary heart disease, namely 1,000 people, 40 people have coronary heart disease; and assuming that the exercise test a sensitivity of 80%, specificity 90%, while coronary heart disease positive in 40 out of 32, 960 people without coronary heart disease and 96 were positive, a total of 128 positive and false-positive, accounting for 96/128, or 75%, false positive rate among women is particularly high. In contrast, patients diagnosed as angina, assume that 80% of coronary heart disease, 1,000 people, 800 people have coronary heart disease, which accounted for 640 tests were positive, no positive cases of coronary heart disease among 20 200 people, a total of about positive 3% false-positive people. Similarly, the shock ECG ST-T changes in the specificity is also poor. Therefore, in the general population should not be based on ECG exercise test results alone, or rest ECG ST-T changes to determine coronary heart disease, coronary heart disease should not be using them in the census. Positive exercise test can only be used for diagnosis, or as a kind of "risk factors."
2, in clinical diagnosis, especially for patients with atypical angina, or heart failure, arrhythmia was the only performance of the patients, can be combined with rest or exercise ECG test, and with reference to age, sex, blood pressure, blood lipids, determine such factors as diabetes mellitus. Men over the age of 40, women over 45 years old, accompanied by one or more risk factors (hypertension, hyperlipidemia, diabetes) who, although no obvious symptoms, such as the exercise test can also be diagnosed with coronary heart disease . The following situations, when necessary, and can also be conditional echocardiography and radionuclide, and other checks to assist in diagnosis. However, the epidemiological investigation of coronary heart disease, the diagnostic criteria can not be added in the various risk factors.
3, in the epidemiological or clinical studies, should indicate the type of coronary heart disease. Evaluation of efficacy of Western medicine should not be used when symptoms or possible coronary heart disease.
4, on the name, agreed to coronary heart disease and ischemic heart disease can be used as a synonym for applications, other names suggested are no longer in use. Treatment (a) Principles
Acute myocardial infarction should be after the race against time, trying to shorten thrombolysis in patients admitted to the beginning of time, the purpose is to get early infarct related artery, adequate and sustained recanalization.
(B) Select the condition of the object
1, persistent chest pain 30min, sublingual nitroglycerin do not relieve symptoms.
2, adjacent two or more leads ST segment elevation in limb l 0.1mV, chest l 0.2mV.
3, the incidence of 6h persons.
4, if the patient to the hospital when the disease is 6 ~ 12h, significant ST-segment elevation with or without severe chest pain may still thrombolysis.
5, aged 70 years of age. Senior citizens over the age of 70 AMI patients, should be based on infarct size, general condition of patients, with or without hypertension, diabetes and other factors, vary carefully chosen.
(C) contraindications
1, within two weeks of active bleeding (gastrointestinal ulcers, hemoptysis, etc.), done visceral surgery, biopsy, there is traumatic cardiopulmonary resuscitation, can not use compression methods to stop bleeding puncture and a history of trauma.
2, high blood pressure in patients before thrombolytic therapy after treatment of blood pressure is still 21.3/13.3kPa (160/100mmHg) persons.
3, were highly suspected dissection.
4, a history of cerebral hemorrhage or subarachnoid hemorrhage,> 6h to six months of ischemic stroke (including TIA).
5, there is a history of retinal hemorrhage.
6, blood disease, bleeding disorders or bleeding tendencies.
7, severe liver and kidney dysfunction or malignancy patients.
(Iv) thrombolysis steps
Check blood before thrombolysis, platelet count, a clotting time and blood.
1, immediate oral administration of water-soluble aspirin 0.15 ~ 0.3g, after the 0.15 ~ 0.3g / d, 3 ~ 5d change clothes after the 50 ~ 150mg, long-term use after discharge, low-dose aspirin.
2, the type and method of intravenous drug
(1), urokinase (UK): 150 IU (approximately 22,000 IU / kg) with 10ml normal saline solution, then add 5% to 10% glucose in 100ml, 30min during intravenous infusion. After urokinase drip 12h, subcutaneous heparin 7500U, every 12h 1, lasting 3 ~ 5d.
(2) streptokinase (SK) or recombinant streptokinase (rSK): 150 U with 10ml normal saline solution, then add 5% to 10% glucose in 100ml, 60min during intravenous infusion.
(3) recombinant tissue plasminogen activator (rt-PA): the former give with rt-PA intravenous heparin 5000U. Press the F state Methods rt-PA: accelerate delivery of international conventional law: 15mg intravenous bolus, 0.75mg/kg (no more than 50mg) 30min intravenous infusion within, then 0.5mg/kg (not more than 35mg) 60min in intravenous drip. Total 100mg. In recent years, low-dose trial of domestic law: 8mg intravenous injection, 42mg at 90min the intravenous drip. Total of 50mg. Drop in the completion of these two methods after rtPA heparin 700 ~ 1000U / d, intravenous infusion of 48h, monitoring APTT maintained at 60 ~ 80s, after subcutaneous heparin 7500U, every 12h 1, lasting 3 ~ 5d.(1) signs and symptoms: frequently asked whether patients with chest pain and reduce the degree of ease, carefully observe the skin, mucous membranes, mucus, vomit and urine without signs of bleeding.
(2) ECG: thrombolysis should be done before the 18-lead ECG, thrombolysis within 3h after the start of each re 30min 12-lead ECG, (posterior wall, right ventricular infarction is still doing 18-lead ECG). After a full set of ECG leads regular electrode position should be strictly fixed.
2, are required to monitor the heparin clotting time, the available LeeWhite three methods, the normal is 4 ~ 12min; or APTT method, the normal for the 35 ~ 45s.
3, 6,8,,20 h after the onset of investigation CK, CK-MB.
(Vi) the clinical indications for coronary artery recanalization
1, direct indications: coronary revascularization observed the situation, according to TIMl grade, to achieve , is that recanalization grade.
2, indirect indications
(1) ECG ST segment elevation after the start of the infusion of thrombolytic agents within 2h, most notably in the elevated ST segment lead quickly back down 50%.
(2) chest pain from the input after the start of thrombolytic agents disappeared within 2 ~ 3h.
(3) Enter 2 ~ 3h after thrombolytic agents, the emergence of autonomy accelerated ventricular rhythm, atrioventricular or bundle branch block suddenly improve or disappear, or inferior wall infarction had transient sinus bradycardia, sinoatrial block with or without low blood music.
(4) the peak serum CK-MB enzyme within 14h in advance or at the onset of CK in 16h or less.
With the above item 4, 2 or more to consider re-pass, but the first 2 and No. 3 can not be judged combination of recanalization. 6 ~ 12h after the onset of thrombolytic therapy by temporary application of these indirect indications (Article 4 does not apply), to be further explored later.
(Vii) complications of thrombolytic therapy
1, bleeding
(1) mild bleeding: skin, mucous membranes, eyes and shovel urine under a microscope, or a small amount of hemoptysis, hematemesis, etc. (a small puncture or injection site ecchymosis not as complications).
(2) major bleeding: a large number of hemoptysis or gastrointestinal bleeding, retroperitoneal bleeding caused by hemorrhagic hypotension or shock, need for blood transfusion.
(3) parts of life-threatening bleeding: intracranial arachnoid Bu cavity, mediastinum or pericardial bleeding.
2, transient hypotension and other allergic reactions (more common in SK or rSK) and so on.
(Viii) the infarct-related coronary artery recanalization after occlusion of the week and then the indications
1, the recurrence of chest pain, persistent 30min, sublingual nitroglycerin tablets can not be mitigated.
2, ST segment re-elevation.
3, serum CK-MB enzyme levels increased again
Two of these three have to consider in the re-occlusion of coronary artery. If there is no obvious bleeding, consider re-application of thrombolytic drugs, doses, according to circumstances. But can not be repeated with SK or rSK can use other thrombolytic agents.(1) ST segment elevation acute early lead, R wave did not disappear, suggesting that there are still viable myocardium.
(2) As the disease advances, the number of abnormal Q wave guide joint is not increased. Tip no infarct expansion.
2 hospitalized after thrombolysis, the incidence of complications (5 weeks)
(1) acute pulmonary edema, with obvious clinical symptoms or X-ray findings.
(2) cardiogenic shock.
(3) severe arrhythmias: ventricular tachycardia, ventricular fibrillation or bundle branch block degree atrioventricular block.
(4) aneurysm.
(5), ventricular septal perforation, papillary muscle rupture, free wall perforation.
3, heart function and left ventricular remodeling
(1) X ray as far as films: observation of heart shadow size and shape, pulmonary congestion and cardiothoracic ratio.
(2) echocardiography and (or) blood pool radionuclide examination: observe whether the left ventricular expansion, wall motion abnormality, aneurysm, ventricular contraction and (or) diastolic dysfunction and so on.
4, mortality and follow-up study
(1) hospital mortality (5 weeks) and Dead Gang (cardiac death or cardiac death).
(2) Long-term follow-up, 1 time every six months a comprehensive reincluding heart function tests, registration of working capacity and activity level, and re-infarction angina situation, the death inquest to do).
Secondary prevention of myocardial ischemia after thrombolysis assessed and further intervention (PTCA) or coronary artery bypass grafting (CABG) and other treatment options need, in the follow-up period on a regular basis.



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