指南不稳定型心绞痛和非st段抬高型心肌梗死

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-SEGMENT ELEVATION MYOCARDIAL INFARCTION COMMITTEE MEMBERS,Elliott M. Antman, MD John W. Beasley, MD Robert M. Califf, MD Melvin D. Cheitlin, MD 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 Elevation,Unstable Angina,NQMI QwMI Myocardial 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升高心肌梗塞 三種主要表現,Rest Angina* Angina occurring at rest and prolonged, usually 20 minutes New-onset Angina New-onset angina of at least CCS Class III severity Increasing Angina Previously diagnosed angina that has become distinctly more frequent, longer in duration, or lower in threshold (i.e., increased by 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 9.0,9.0,831,174,148,134,67,50,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,1,0.98,0.96,0.94,0.92,0,0.9,0.88,0.86,0.84,0.82,0.8,30,60,90,120,150,180,2.0,6.4,3.3,1.7,6.9,5.0,0,1,2,3,4,5,6,7,1993,1057,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 I 1. Patients with suspected ACS with chest discomfort at rest for 20 min, hemodynamic instability, or recent syncope or presyncope should be referred immediately to an ED or a specialized chest pain unit. Other patients with a suspected ACS may be seen initially in an ED, a chest pain unit, or an outpatient facility.,危險評估,Class I 1. Noninvasive stress testing in low-risk pts free of ischemia at rest or with 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 expertise, 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), 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 angiography 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 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 low 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 without 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 perfusion or small myocardial perfusion defect at rest or with stress 3. 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 Time (5 x ST Deviation) (4 x Exercise Angina) 0=none, 1=nonlimiting, 2=exercise-limiting Low-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,EPISTENT,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 patients 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 cessation 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 I 1. Any of the following high-risk indicators: a. Recurrent angina/ischemia at rest or with low- level activities despite intensive anti-ischemic therapy b. Recurrent angina/ischemia with CHF symptoms, S3, pulmonary edema, increasing rales, or new or worsening MR c. High-risk findings on noninvasive stress testing d. Depressed LV systolic function (e.g., EF0.40 on noninvasive study) e. Hemodynamic instability,早期侵襲性治療,Class I f. Sustained ventricular tachycardia g. PCI within 6 months h. Prior CABG 2. In the absence of these findings, either an early conservative or an early invasive strategy in hospitalized patients 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 depression 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 revascularization.,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 = 1,482 FRAXIS 14 (nadroparin; n = 2,357 ESSENCE 14 (enoxaparin; n = 3,171) TIMI 11B 14 (enoxaparin; n = 3,910),0.75 1 1.5 LMWH better 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 counterpulsation 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 dihydropyridine 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 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 administered 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.,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 function,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 plaque Dynamic obstruction (coronary spasm or vasoconstriction) Progressive mechanical obstruction Inflammation and/or infection Secondary 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 ischemia Pulmonary edema; S3 or new rales New MR murmur Hypotension, bradycardia, tachycardia 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),History Clinical findings ECG Cardiac 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 studies,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 Diagnosis 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 6.4 12.5 0.0005 UFH + ASA vs ASA 999 2.6 5.5 0.018 LMWH + ASA vs ASA 2629 2.0 5.3 0.0005 All 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-Risk,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 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. 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 phone 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-MB 1. Lack of specificity with skeletal muscle disease/injury 2. Low sensitivity during early MI (36 h) after symptom onset and for minor myocardial damage,Myoglobin 1. Very low specificity with skeletal muscle injury or disease 2. 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, accurate assays 2. Ability to detect early reinfarction,Myoglobin 1. High sensitivity 2. Useful in early detection of MI 3. Detection of reperfusion 4. Most useful in ruling out MI,Troponins 1. Powerful for stratification 2. Greater sensitivity and specificity than CK-MB 3. Detection of recent MI up to 2 weeks after onset 4. Useful for selection of therapy 5. 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 ischemia Pulmonary edema; S3 or new rales New MR murmur Hypotension, bradycardia, tachycardia 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),History Clinical findings ECG Cardiac 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 pain 1.43m hospitalizations/year (1o diagnosis) 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 respiratory 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 administered 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.,抗缺血治療,Class Ila 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 counterpulsation for severe ischemia that is continuing or recurs frequently despite intensive medical therapy or for hemodynamic instability in pts before or after coronary angiography.,不穩定性心絞痛及非ST升高心肌梗塞是由阻塞性冠狀動脈疾病所引起的中度可能性,Chest or left arm pain reproducing prior reproducing prior documented angina. Known history of CAD, including MI Transient MR, hypotension, diaphoresis, pulmonary edema, or rales New, or presumably new, transient ST-segment deviation (0.05 mV) or T-wave inversion (0.2 mV) with symptoms Elevated cardiac Tnl, TnT, or CK-MB,History Examination ECG Cardiac markers,不穩定性心絞痛及非ST升高心肌梗塞是由阻塞性冠狀動脈疾病所引起的中度可能性,Chest or left arm pain or discomfort Age 70 Male sex Diabetes mellitus Extracardiac vascular disease Fixed Q waves Abnormal ST segments or T waves not documented to be new Normal,History Examination ECG Cardiac markers,Absence of high-likelihood features and presence of any of the following:,不穩定性心絞痛及非ST升高心肌梗塞 EMERGENCY ROOM TRIAGE,Chest pain or severe epigastric pain, typical of myocardial ischemia or MI: Substernal compression or crushing chest pain Pressure, tightness, heaviness, cramping, aching sensation Unexplained indigestion, belching, epigastric pain Radiating pain to neck, jaw, shoulders, back or to one or both arms Associated dyspnea, nausea and/or vomiting, diaphoresis,IF THESE SYMPTOMS ARE PRESENT, OBTAIN STAT ECG,FEATURE,HIGH LIKELIHOOD,INTERMEDIATE LIKELIHOOD,Absence of high-likelihood features,and presence of any of the following:,不穩定性心絞痛及非ST升高心肌梗塞是由阻塞性冠狀動脈疾病所引起的中或高度可能性,Chest or left arm pain reproducing prior documented angina. Known history of CAD, including MI Transient MR, hypotension, diaphoresis, pulmonary edema, or rales,History Examination,Chest or left arm pain or discomfort Age 70 Male sex Diabetes mellitus Extracardiac vascular disease,FEATURE,HIGH LIKELIHOOD,INTERMEDIATE LIKELIHOOD,Absence of high-likelihood features,and presence of any of the following:,不穩定性心絞痛及非ST升高心肌梗塞是由阻塞性冠狀動脈疾病所引起的中或高度可能性,New transient ST- segment deviation or T-wave inversion (0.2 mV) with symptoms Elevated cardiac Tnl, TnT, or CK-MB,ECG Cardiac markers,Fixed Q waves Abnormal ST segments or T waves not documented to be new Normal,不穩定性心絞痛及非ST升高心肌梗塞 血管生成術處置,Cardiac Catheterization,Medical Therapy PCI or CABG,1 or 2 VD,PCI or CABG,No,CABG,LV Dysfunction or Diabetes,CABG,Yes,Discharge from Protocol,No,3 VD or 2 VD with proximal LAD,Coronary Artery Disease,Yes,Left Main Disease,No,No,不穩定性心絞痛及非ST升高心肌梗塞 血管生成術方式,Extent of Disease,Treatment,Class/Level of Evidence,Left main disease, candidate for CABG,Left main disease not candidate,for CABG,Three-vessel disease with EF 0.50,Multivessel disease including proximal,LAD with EF 0.50 or treated