64排螺旋CT在冠心病診斷上的應用

主任醫師

ST.MICHAELHOSPITAL1在新加坡。。。

在中國。。。英年早逝震驚中國

河南17歲高中生兩周前突然出現心臟猝死，2

沒有任何跡象

沒有胸部疼痛

發生在健康的人群中

在慢跑或長跑時

心臟病發作與突發性猝死

什么原因呢？。。。

3如何控制心臟病的發生如何預防冠心病的發生如何了解自己是否患有冠心病患有冠心病如何治療健康活到100歲4傳說

心臟病及中風只會發生在那些血管有嚴重阻塞的人身上

通常會發生在那些上了年紀的人群

5事實動脈血管的阻塞程度是由多年的累積所造成的大多數心臟病發作是由于血管壁的屯積物然破裂，血小板凝聚形成斑塊而造成血管阻塞6LikelihoodofPlaqueRuptureDoesNOTcorrelatewiththeSeverityofCoronaryArteryStenosis冠狀動脈狹窄的嚴重程度與血栓破裂沒有關系7動脈粥樣硬化管腔變窄血栓形成正常血管血管內皮損傷膽固醇聚集8原因。。。2/3的心臟病突然發作是因為心臟血管只有40-60%的阻塞阻塞不嚴重時是沒有明顯癥狀的對那些心血管阻塞程度已經超過70%的病患更需要例行常規檢查9TopicsRiskFactorsofHeartDiseaseLatestFindingsinReducingHeartDiseaseLatestAdvancesinMedicalTechnologyinPreventingHeartDiseaseConclusion10Riskfactorsforstrokethatcan'tbechanged:不能改變的原因Age

年齡Heredity(familyhistory)

家族史Priorstroke,TIAorheartattack

以前發生過中風，一過性腦缺血，心臟病11Riskfactorsthatcanbechanged,treatedorcontrolled:可控制的因素Highbloodpressure

高血壓Cigarettesmoking

吸煙Diabetesmellitus

糖尿病Carotidorotherarterydisease

頸動脈和其他血管疾病Otherheartdisease

心臟病Highbloodcholesterol

高血脂Poordiet

不健康的飲食習慣Physicalinactivityandobesity

缺乏運動及肥胖12MainCauseofHeartAttackisPlaque(FatDeposit)Rupture13心肌梗塞14EvolutionofNHLBISupportedGuidelinesAngiographictrials(FATS,POSCH,SCOR,STARS,Ornish,MARS)Meta-analyses

(Holme,Rossouw)NCEPATPI1988NCEPATPII1993NCEPATPIII2001HPS

PROVE-ITASCOT-LLAPROSPERALLHAT-LLTUpdatedNCEPATPIII2004Framingham

MRFIT

LRC-CPPT

Coronary

DrugProject

HelsinkiHeart

CLAS4S

WOSCOPS

CARE

LIPID

AFCAPS/

TexCAPSTNTIDEALAHA/ACCUpdate2006MoreIntensiveTreatmentRecommendationsNCEPATP=NationalCholesterolEducationPanelAdultTreatmentPanel.NHLBI=NationalHeart,Lung,andBloodInstitute.AHA=AmericanHeartAssociation.ACC=AmericanCollegeofCardiology.15AHA/ACCguidelinesforpatientswithCHD*,2<100mg/dL:GoalforallpatientswithCHD?,2<70mg/dL:AreasonablegoalforallpatientswithCHD?,2ATPIIIUpdate20041<100mg/dL:PatientswithCHDorCHDriskequivalents(10-yearrisk>20%)1<70mg/dL:Therapeuticoptionforveryhigh-riskpatients1IntensiveLDL-CGoalsfor

High-RiskPatients<100mg/dL<70mg/dL* Andotherformsofatheroscleroticdisease.2? Factorsthatplaceapatientatveryhighrisk:establishedcardiovasculardisesase(CVD)plus: multiplemajorriskfactors(especiallydiabetes);severeandpoorlycontrolledriskfactors(eg,cigarettesmoking);metabolicsyndrome(triglycerides[TG]≥200mg/dL+non–HDL-C≥130mg/dLwithHDL-C<40mg/dL);andacutecoronarysyndromes.11.GrundySMetal.Circulation.2004;110:227–239.2.SmithSCJretal.Circulation,2006;113:2363–2372.2006

UpdateRecommendedLDL-CtreatmentgoalsIfitisnotpossibletoattainLDL-C<70mg/dLbecauseofahighbaselineLDL-C,itgenerallyispossibletoachieveLDL-Creductionsof>50%withmoreintensiveLDL-C─loweringtherapy,includingdrugcombinations.1617WhichTestCan

DetectHeartDisease

EarlyandAccurately運用什么測試可以盡早的發現心臟病并得到精確的結論18METHODSOFDETECTIONSomeexamples:Electrocardiogram(ECG)EchocardiographyNuclearMyocardialPerfusionInvasiveCoronaryAngiography19以往的檢查方式驗血膽固醇血壓的檢查心電圖檢查侵入性冠狀動脈血管造影術20跑步機測試特點：可達到60%-70%的準確度簡單、易用然而：負值并不是指您沒有患上心臟病的風險只可以診斷您的心血管沒有超過70%的阻塞但仍有40%-60%阻塞的可能性21三維立體超聲波心動掃描22NuclearMyocardialPerfusion23介入性冠狀動脈血管造影術

的血管影像24侵入性冠狀動脈血管造影術25磁共振MRI26磁共振的心臟影像27最新的檢查方法

四維立體冠狀動脈CT血管造影術28Limitationsofcurrentnon-invasivetestsindetectingblockedheartarteriesO’RourkeRAetal,metanalysisinAmericanCollegeofCardiology/AmericanHeartAssociationExpertConsensusDocumentonelectron-beamcomputedtomographyforthediagnosisandprognosisofcoronaryarterydisease.JAmCollCardiol.2000;36:326–340.29AuthorJournalYearMSCTSnSpPPVNPVPuglieseFetalEurRadiol.2006Mar6499967899FineJJetalAmJCardiol.2006Jan6495969792LimMetalClinicalRadiology2006Feb4099989499CordeiroMAetalHeart2005Oct3276947196MolletNRetalCirculation.2005Oct6499957699RaffGLetalJAmCollCardiol.2005Aug6486956698LeschkaSetalEurHeartJ.2005Aug6494978799RecentPublicationsusingMDCT30CoronaryArteryDisease

ComparisonbetweenMDCTandCoronaryAngiographyaAabbb31LumenPlaquePlaque“NormalAngiogram”byICAPlaquesdetectedbyCTAbutare“invisible”inICA32多功能電腦斷層掃描儀

——精確度有多少？在影像分析方面的經驗決定著CT掃描的準確程度資深的放射學醫師通過對影像數據透徹的分析可使準確度提高我們中心能夠提供98-99%的精確度33四維立體冠狀動脈CT血管造影術

-適合哪類人群？患有多種慢性病的人群有嚴重家族史的人群有患心臟中風疾病風險的中年人群34心臟影像35心臟影像

36多功能CT掃描的優勢無創傷性簡單快速的檢查程序門診檢查，無需住院清晰的心臟血管影像四維立體影像精確到以毫米計算較少的輻射無需開刀37CommonRiskFactors常見病因Extensiveclinicalandstatisticalstudieshaveidentifiedseveralfactorsthatincreasetheriskofstroke.Mostofthemcanbemodified,treatedorcontrolled.Somecan’t.

38HowCardiovascular&StrokeRisksAreRelated:

心臟病和中風為什么是相關聯的

Bothcoronaryheartdiseaseandstrokesharemanyofthesameriskfactorssuchascholesteroldisorders,highbloodpressure,smoking,diabetes,physicalinactivity,andbeingoverweightorobese.3964排CT適應人群男性年齡大