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24. 急性冠状动脉综合征
概 述
急性冠状动脉综合征(acute coronary syndrome,ACS)特指冠心病中急性发病的临床类型,包括不稳定型心绞痛(UA)、非ST段抬高型心肌梗死(NSTEMI)和ST段抬高型心肌梗死(STEMI)。心肌缺血心电图上出现相应区域ST段抬高时,除变异型心绞痛外,以表明此时相应的冠状动脉已经闭塞而导致心肌全层损伤,伴有心肌坏死标志物升高,临床上诊断为ST段抬高型心肌梗死。患者出现胸痛不伴有ST段抬高,常提示相应的冠状动脉尚未完全闭塞,心肌缺血损伤尚未波及心肌全层,心电图表现为ST段下移和(或)T波倒置等。此类患者如同时有血中心肌标志物或心肌酶升高,说明尚未波及心肌全层的小范围坏死,临床上列为非ST段抬高型MI(NSTEMI)。以下是伴持续ST段抬高的急性冠状动脉综合征和非ST段抬高的急性冠状动脉综合征诊治的临床路径。
表24.1 ST段抬高的急性冠状动脉综合征的重点评估事项
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.1_18576.jpg?sign=1734458939-TiKmZYnqt3WjA0E8zoz5iN2UIwNTQhto-0-8d2067c448e924055ba5dd96cd71337e)
表24.2 ST段抬高的急性冠状动脉综合征能否成功行(PCI)的影响因素
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.2_18583.jpg?sign=1734458939-mxxTPKwEmUjta8lnDxgyvzRsWX7xVzRI-0-cf42b73bac35751b442c710b0586aab9)
表24.3 伴有ST段持续抬高或新出现的左束支传导阻滞的急性冠状动脉综合征溶栓的禁忌证和注意事项
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.3_18590.jpg?sign=1734458939-yPIx1R5NDzBxkHifruRaBvr4662JkDWT-0-a92a5274ec6370eba7ad6b32b28f6b3b)
续表
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.3_1_18631.jpg?sign=1734458939-b6vB7rsN4xVUMEnqJSCAe9YTLQw8ittS-0-33f97f32385e93b0d096d2c6f9c59858)
表24.4 ST段抬高的急性冠状动脉综合征的检查
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.4_18638.jpg?sign=1734458939-zRGroe6eW54iIkC2FbO0tTH1xT4VAlV6-0-61e84b17601eda21a169e9ec8bd03afd)
表24.5 ST段抬高的急性冠状动脉综合征主要的药物治疗
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.5_60000.jpg?sign=1734458939-Tx3rJoJHTpC2yaVo6MiVU7biMiP9rKFw-0-ffdd425436691a859d683603336467de)
续表
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.5_1_60001.jpg?sign=1734458939-DRywcqhGMGjiEdyWTB8r3VMAAFvBXhVl-0-39c5f9f3c91134de254519f30708df1b)
表24.6 溶栓方案
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.6_60002.jpg?sign=1734458939-VdebHFSFoIQVNGbSL1zzyLJMzdb895R4-0-3bc29d497107978717bf4322611abe3e)
表24.7 纤溶治疗的一些问题
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.7_18771.jpg?sign=1734458939-cLVrMnEhihmSYAW3KMMN4FRO0HQQliBM-0-a15fa36a71c4b48cb9765cd2540ec508)
表24.8 ST段抬高的急性冠状动脉综合征后期的风险评估
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.8_60003.jpg?sign=1734458939-nngxcqo1Ogl3U29op6G1c37mH3B9lutO-0-b6945ebcf49838cd9d831c42a1763737)
续表
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.8_1_60004.jpg?sign=1734458939-Ri2oPk28qjemekjHehQzyiVQo9q3S5Yp-0-02a6b7cb138d1d4e0cc03c761f086aaa)
表24.9 急性冠状动脉综合征后期的药物治疗
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.9_60005.jpg?sign=1734458939-iKHoW6fHTdvXtWGwLc9MFMA1hvcFhN9s-0-74a443cba37e1b11526db91b2bac2f22)
表24.10 非ST段抬高的急性冠状动脉综合征的重点评估
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.10_18916.jpg?sign=1734458939-lQVyiSOznb2zORH1W6MMXRDyejGhmUin-0-f2a8bb23a3cce8da03ebaa9c423b7ef0)
续表
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.10_1_59693.jpg?sign=1734458939-ByBdOpPjedAV4o75qhIWRqs9Xw0bXox8-0-edf0b31a85db30601d158d1a9d8105ed)
注:心电图正常也不能除外急性冠状动脉综合征
表24.11 非ST段抬高的急性冠状动脉综合征的检查
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.11_18985.jpg?sign=1734458939-fsKQ8dYFTz2pWiPNvXKIUIcyRQXasRqw-0-912077100a0b9197c1690074dd38df0a)
表24.12 不稳定的非ST段抬高的急性冠状动脉综合征的药物治疗
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.12_60006.jpg?sign=1734458939-XndlkgfKph1fcsEhGiae9XZPQXqa2l8o-0-8e06d826a48a00d8c503a6f7560ac1ef)
续表
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.12_1_60007.jpg?sign=1734458939-RQVzj0DnGZnqmVPyn1TTkrMcw0a7AXcC-0-eabb759fab562c0b56aeb1f5760f6197)
表24.13 非ST段抬高的急性冠状动脉综合征后期风险评估
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.13_19085.jpg?sign=1734458939-nYyAabzmBthLU0oIlXgsoJbuiLD3M5cC-0-d382ccc32e9915befa05093868024ef6)
表24.14 急诊冠状动脉介入治疗的指征
![](https://epubservercos.yuewen.com/1C1403/19400084308706906/epubprivate/OEBPS/Images/T24.14_59696.jpg?sign=1734458939-AFI3lJfcsnbWsJaeSFozUXi9TusYDfyR-0-21b140bca1b87b2f16953ce1179beea2)