1、ACC/AHA GUIDELINES: UNSTABLE ANGINA & NONST-SEGMENT ELEVATION MYOCARDIAL INFARCTION,王宗倫 醫師 講述引用 Wang, Tzong-Luen,MD, PhD, FACC, FESC,UNSTABLE ANGINA & NONST-SEGMENTELEVATION MYOCARDIAL INFARCTION COMMITTEE MEMBERS,Elliott M. Antman, MD John W. Beasley, MD Robert M. Califf, MD Melvin D. Cheitlin, MD
2、Judith S. Hochman, MD Robert H. Jones, MD Dean Kereiakes, MD,Joel Kupersmith, MD Thomas N. Levin, MD Carl J. Pepine, MD John W. Schaeffer, MD Earl E. Smith, III, MD David E. Steward, MD Pierre Theroux, MD,Eugene Braunwald, MD, Chair,ACC/AHA GUIDELINES,ACUTE CORONARY SYNDROME,No ST Elevation,ST Eleva
3、tion,Unstable Angina,NQMI QwMIMyocardial Infarction,NSTEMI,不穩定性心絞痛及非ST升高心肌梗塞原因,Thrombosis,Thrombosis,Mechanical Obstruction,Mechanical Obstruction,Dynamic Obstruction,Dynamic Obstruction,Inflammation/ Infection,Inflammation/ Infection, MVO2, MVO2,Braunwald, Circulation 98:2219, 1998,.,.,不穩定性心絞痛及非ST升
4、高心肌梗塞 三種主要表現,Rest Angina* Angina occurring at rest and prolonged, usually 20 minutesNew-onset Angina New-onset angina of at least CCS Class III severityIncreasing Angina Previously diagnosed angina that hasbecome distinctly more frequent, longer in duration, or lower in threshold (i.e., increased by
5、 1 CCS)class to at least CCS Class III severity.,Braunwald Circulation 80:410; 1989,* Pts with NSTEMI usually present with angina at rest.,Changes in Focus on Heart Failure,TROPONIN I濃度預測不穩定性心絞痛及非ST升高心肌梗塞原因死亡的危險,1.0,1.7,3.4,3.7,6.0,7.5,0,2,4,6,8,0 to 0.4,0.4 to 1.0,1.0 to 2.0,2.0 to 5.0,5.0 to 9.0,9
6、.0,831,174,148,134,67,50,Cardiac Troponin I (ng/ml) Risk Ratio 1.0 1.8 3.5 3.9 6.2 7.8 Antman N Engl J Med. 335:1342, 1996,Mortality at 42 Days (% of patients),N Engl J Med. 339:436-43, 1998,PURSUIT TRIAL: 死亡或心肌梗塞,Prob of Event-Free Survival,Days,1,0.98,0.96,0.94,0.92,0,0.9,0.88,0.86,0.84,0.82,0.8,3
7、0,60,90,120,150,180,2.0,6.4,3.3,1.7,6.9,5.0,0,1,2,3,4,5,6,7,1993,1057,RR,1641,792,RR,Total Mortality,Cardiac Mortality,6,PTS,7,No. Trials,Trop.,Neg Pos,Neg Pos,TROPONINS T 及 I 作為死亡率的預測指標,建議,Class I1. Patients with suspected ACS with chest discomfort at rest for 20 min, hemodynamicinstability, or rec
8、ent syncope or presyncopeshould be referred immediately to an ED or a specialized chest pain unit. Other patients with a suspected ACS may beseen initially in an ED, a chest pain unit, oran outpatient facility.,危險評估,Class I1. Noninvasive stress testing in low-risk pts free of ischemia at rest or wit
9、h low-level activity and of CHF for a minimum of 12 to 24 h.2. Noninvasive stress testing in pts at intermediate risk who have been free of ischemia at rest or with low-level activity and of CHF for a minimum of 2 or 3 days.,危險評估,Class I 3. Choice of stress test is based on the resting ECG, local ex
10、pertise, and technologies. Treadmill exercise in pts able to exercise in whom the ECG is free of baseline ST-segment abnormalities, BBB, LVH, intraventricular conduction defect, paced rhythm, pre-excitation, and digoxin effect. 4. An imaging modality in pts with resting ST-segment depression (0.1 mV
11、), LVH, BBB, IVCD, pre-excitation, or digoxin who are able to exercise.,危險評估,5. Pharmacological stress testing with imaging when physical limitations (e.g., arthritis, amputation, severe peripheral vascular disease, severe COPD, general debility) preclude adequate exercise stress. 6. Prompt angiogra
12、phy without noninvasive risk stratification for failure of stabilization with medical treatment.,Class I,非侵襲性危險評估,1. Severe LV dysfunction (LVEF 0.35), rest or exercise 2. High-risk treadmill score (score -11) 3. Stress-induced large perfusion defect 4. Stress-induced multiple perfusion defects,High
13、 risk (3% annual mortality rate),Gibbons et al JACC 33:2092, 1999,非侵襲性危險評估,5. Large, fixed perfusion defect with LV dilation or increased lung uptake 6. Stress-induced moderate perfusion defect with LV dilation or increased lung uptake 7. Echocardiographic wall motion abnormality (2 segments) at a l
14、ow dose of dobutamine ( 10 mgkg-1 min-1) or at a low heart rate (120 bpm),High risk (3% annual mortality rate),Gibbons et al JACC 33:2092, 1999,1. Mild/moderate resting LV dysfunction (LVEF 0.35-0.49) 2. Intermediate-risk treadmill score (-11 score 5) 3. Stress-induced moderate perfusion defect with
15、out LV dilation or increased lung intake 4. Echocardiographic ischemia with wall motion abnormality involving 2 segments only at higher doses of dobutamine,Intermediate Risk (1-3% annual mortality rate),非侵襲性危險評估,Gibbons et al JACC 33:2092, 1999,非侵襲性危險評估,1. Low-risk treadmill score (score 5)2. Normal
16、 perfusion or small myocardial perfusion defect at rest or with stress3. Normal echocardiographic wall motion or no change of limited resting wall motion abnormalities during stress,Low Risk (1% annual mortality rate),Gibbons et al JACC 33:2092, 1999,非侵襲性危險評估,Duke Treadmill Score (DTS) =Exercise Tim
17、e (5 x ST Deviation) (4 x Exercise Angina)0=none, 1=nonlimiting, 2=exercise-limitingLow-risk: +5 Moderate-risk: -10 to +4 High-risk: -11,Mark DB et al. NEJM 1991;325:849-853,在30 天時死亡或心肌梗塞率,Percent of Patients,10.9,1.8,9,4.8,10.1,3.6,14.1,3.9,10.2,5.9,16.7,11.6,0,2,6,10,14,18,EPIC,CAPTURE,EPILOG,EPIS
18、TENT,PRISM-PLUS,PURSUIT,Placebo,GP IIb-IIIa Inhibitor,在30 天時死亡,心肌梗塞或緊急繞道手術率,Percent of Patients,12.8,4.8,15.9,11.3,12.2,4.9,14.8,4.5,11.5,10.3,10.5,8,0,4,8,12,16,EPIC,CAPTURE,EPILOG,EPISTENT,IMPACT II,RESTORE,Placebo,GP IIb-IIIa Inhibitor,出院時藥物,1. Aspirin 75 to 325 mg/d 2. Clopidogrel 75 mg/qd for p
19、atients with contraindication to ASA 3. -Blocker 4. Lipid-lowering agent and diet in patients with LDL cholesterol 130 mg/dL 5. Lipid-lowering agent if LDL cholesterol level after diet is 100 mg/dL 6. ACEI for patients with CHF, LV dysfunction (EF0.40) hypertension, or diabetes,Class I,1. Smoking ce
20、ssation and achievement or maintenance of optimal weight, daily exercise, and diet. 2. HMG-CoA reductase inhibitor for LDL cholesterol 130 mg/dL. 3. Lipid-lowering agent if LDL cholesterol after diet is 100 mg/dL. 4. Hypertension control to a BP 200 mg/dL.,出院時對危險因素改善的指導,Class I,早期侵襲性治療,Class I1. Any
21、 of the following high-risk indicators:a. Recurrent angina/ischemia at rest or with low-level activities despite intensive anti-ischemic therapyb. Recurrent angina/ischemia with CHF symptoms, S3, pulmonary edema, increasing rales, or new or worsening MRc. High-risk findings on noninvasive stress tes
22、tingd. Depressed LV systolic function (e.g., EF0.40 on noninvasive study)e. Hemodynamic instability,早期侵襲性治療,Class If. Sustained ventricular tachycardiag. PCI within 6 monthsh. Prior CABG2. In the absence of these findings, either an early conservative or an early invasive strategy in hospitalized pa
23、tients without contraindication for revascularization.Class IIa 1. An early invasive strategy in pts with repeated presentation for ACS despite therapy and without evidence for ongoing ischemia or high risk.,早期侵襲性治療,Class IIa 2. An early invasive strategy in pts 65 years or pts with ST-segment depre
24、ssion or elevated cardiac markers and no contraindication to revascularization.Class III 1. Coronary angiography in pts with extensive comorbidities, in whom risks of revascularization are not likely to outweigh benefits, in pts with a low likelihood of ACS and in pts who will not consent to revascu
25、larization.,GP IIb/IIIa 抑制在不穩定性心絞痛 及非ST升高心肌梗塞的使用: CAPTURE, PURSUIT, PRISM-PLUS,Boersma et al. Circulation 100:2045, 2000,低分子量肝素用於不穩定性心絞痛: 對三種終點的效應*,Day FRISC 6 (dalteparin; n = 1,482FRAXIS 14 (nadroparin; n = 2,357ESSENCE 14 (enoxaparin; n = 3,171)TIMI 11B 14 (enoxaparin; n = 3,910),0.75 1 1.5LMWH b
26、etter UFH better,* Triple endpoint: death, MI, recurrent ischemia + urgent revascularization,(P = 0.029),(P = 0.032),抗缺血治療,Class IIa 1. Oral long-acting Ca2+ blocker for recurrent ischemia when -blocker and nitrate fully used. 2. ACEI for all post-ACS patients. 3. Intra-aortic balloon pump counterpu
27、lsation for severe ischemia that is continuing or recurs frequently despite intensive medical therapy or for hemodynamic instability in pts before or after coronary angiography.Class IIb 1. Extended-release form of nondihydropyridine Ca2+ blocker instead of a -blocker. 2. Immediate-release dihydropy
28、ridine Ca2+ blocker in the presence of a -blocker.,抗缺血治療,Class I 1. Bed rest with continuous ECG monitoring in pts with ongoing rest pain. 2. NTG, sublingual tablet or spray, followed by IV administration for ongoing chest pain. 3. Supplemental O2 for pts with hypoxemia, cyanosis or respiratory dist
29、ress; finger pulse oximetry or arterial blood gas determination to confirm SaO290%. 4. Morphine sulfate IV when symptoms are not immediately relieved with NTG or when acute pulmonary congestion and/or severe agitation is present.,抗缺血治療,Class I 5. A -blocker with the first dose administered IV if the
30、re is ongoing chest pain, followed by oral administration. 6. A nondihydropyridine Ca2+ blocker (e.g. verapamil or diltiazem) as initial therapy in pts with continuing or frequently recurring ischemia when -blocker is contraindicated. 7. An ACEI when hypertension persists despite treatment with NTG
31、and a -blocker in pts with LV systolic dysfunction or congestive heart failure and in ACS patients with diabetes.,不穩定性心絞痛及非ST升高心肌梗塞的 醫院處理流程,Monitoring (rhythm and ischemia) blocker Nitrate Heparin GP IIb/IIIa inhibitor (?),12-48 hour angiography,Patient stabilizes,Immediate angiography,Evaluate LV f
32、unction,EF.40,Stress Test,Not low risk,Low risk,Medical Rx,Recurrent symptoms/ischemia Heart failure Serious arrhythmia,EF.40,Early invasive strategy,Early conservative strategy,不穩定性心絞痛及非ST升高心肌梗塞 病理機轉 (無排他性),Nonocclusive thrombus on pre-existing plaqueDynamic obstruction (coronary spasm or vasoconst
33、riction)Progressive mechanical obstructionInflammation and/or infectionSecondary UA,Braunwald Circulation 98:2219, 1998,在急診所作的危險評估,Prolonged ischemic discomfort (20 min), ongoing rest pain, accelerating tempo of ischemiaPulmonary edema; S3 or new rales New MR murmur Hypotension, bradycardia, tachyca
34、rdia Age 75 years Rest pain with transient ST-segment changes 0.05 mV; new bundle-branch block, new sustained VT Elevated (e.g. TnT or TnI0.1 ng/mL),HistoryClinical findingsECGCardiac markers,HIGH RISK-FEATURES (RISK RISES WITH NUMBER),急診對不穩定性心絞痛 及非ST升高心肌梗塞的處理流程,No recurrent pain; Neg follow-up stud
35、ies,Nondiagnostic ECG Normal serum cardiac markers,Observe Follow-up at 4-8 hours: ECG, cardiac markers,Neg: nonischemic discomfort;low-risk UA/NSTEMI,YES,NO,ST and/or T wave changes Ongoing pain + cardiac markers Hemodynamic abnormalities,Recurrent ischemic pain or + UA/NSTEMI follow-up studies Dia
36、gnosis of UA/NSTEMI confirmed,ADMIT,+ UA/NSTEMI confirmed,Outpatient follow-up,Evaluate for Reperfusion,ST ?,Stress study to provoke ischemia prior to discharge or as outpatient,抗血小板及抗凝血治療,P-value,Patients with event (%),N,% Death or MI,Risk ratio (95% CI),Trials,Active Placebo,ASA vs placebo 2448 6
37、.4 12.5 0.0005UFH + ASA vs ASA 999 2.6 5.5 0.018LMWH + ASA vs ASA 2629 2.0 5.3 0.0005All GP IIb/IIIa + UFH + ASA vs UFH + ASA 17044 5.1 6.2 0.0022,Active Treatment Inferior,Active Treatment Superior,抗血小板治療,Class I,Definite ACS with continuing,Possible ACS,Likely/Definite ACS,Ischemia or Other High-R
38、isk,Features or planned PCI,Aspirin,Aspirin,Aspirin,+,+,Subcutaneous LMWH,IV heparin,or IV heparin,IV platelet GP IIb/IIIa antagonist,+,抗血小板治療,Class I 1. Administer ASA as soon as possible after presentation and continue indefinitely. 2. A thienopyridine (clopidogrel or ticlopidine) in pts unable to
39、 take ASA. 3. Add IV UFH or subcutaneous LMWH to antiplatelet therapy with ASA, clopidogrel, or ticlopidine. 4. Add platelet GP IIb/IIIa receptor antagonist in pts with continuing ischemia or with other high-risk features and in pts in whom early PCI is planned.,急診對急性冠狀動脈症候群的評估,Selker Ann Intern Med
40、. 129:845, 1998,Pain in chest, left arm, jaw, epigastrium, dyspnea, dizziness, palpitations,10,689 Pts with suspected ACS,Evaluation for acute ischemia,7,996 pts (75%),2,672 pts (25%),Neg.,Pos.,電話檢傷分類,Class I 1. Patients with symptoms that suggest possible ACS should not be evaluated only over the p
41、hone but should be referred to a facility that allows evaluation by a physician and the recording of a 12-lead ECG.,疑似急性冠狀動脈症候群 而無ST上升病患的生化心肌標記,CK-MB1. Lack of specificity with skeletal muscle disease/injury2. Low sensitivity during early MI (36 h) after symptom onset and for minor myocardial damage
42、,Myoglobin 1. Very low specificity with skeletal muscle injury or disease2. Rapid return to normal,Troponins 1. Low sensitivity in early phase of MI(6 h after symptom onset)2. Limited ability to detect late minor reinfarction,Disadvantages,疑似急性冠狀動脈症候群 而無ST上升病患的生化心肌標記,CK-MB 1. Rapid, cost-efficient,
43、accurate assays2. Ability to detect early reinfarction,Myoglobin 1. High sensitivity2. Useful in early detection of MI3. Detection of reperfusion4. Most useful in ruling out MI,Troponins 1. Powerful for stratification2. Greater sensitivity and specificity than CK-MB3. Detection of recent MI up to 2
44、weeks after onset4. Useful for selection of therapy5. Detection of reperfusion,Advantages,在急診所作的危險評估,Prolonged ischemic discomfort (20 min), ongoing rest pain, accelerating tempo of ischemiaPulmonary edema; S3 or new rales New MR murmur Hypotension, bradycardia, tachycardia Age 75 years Rest pain wi
45、th transient ST-segment changes 0.05 mV; new bundle-branch block, new sustained VT Elevated (e.g. TnT or TnI0.1 ng/mL),HistoryClinical findingsECGCardiac markers,HIGH RISK-FEATURES (RISK RISES WITH NUMBER),不穩定性心絞痛及非ST升高心肌梗塞: 重大醫療問題,5.32m ED visits for chest pain1.43m hospitalizations/year (1o diagno
46、sis)60% 65 years, 46% women,National Center for Health Statistics,抗缺血治療,Class I 1. Bed rest with continuous ECG monitoring in pts with ongoing rest pain. 2. NTG, sublingual tablet or spray, followed by IV administration for ongoing chest pain. 3. Suplemental O2 for pts with hypoxemia, cyanosis or re
47、spiratory distress; finger pulse oximetry or arterial blood gas determination to confirm SaO290%. 4. Morphine sulfate IV when symptoms are not immediately relieved with NTG or when acute pulmonary congestion and/or severe agitation is present.,抗缺血治療,Class I 5. A -blocker with the first dose administ
48、ered IV if there is ongoing chest pain, followed by oral administration. 6. A nondihydropyridine Ca2+ blocker (e.g. verapamil or diltiazem) as initial therapy in pts with continuing or frequently recurring ischemia when -blocker is contraindicated. 7. An ACEI when hypertension persists despite treatment with NTG and a -blocker in pts with LV systolic dysfunction or congestive heart failure and in ACS patients with diabetes.,
