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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-SEGMENT ELEVATION 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 Elev
3、ation,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S
4、T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., increas
5、ed 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
6、 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
7、,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
8、, 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
9、 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
10、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 depre
11、ssion (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. Pr
12、ompt 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
13、 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 seg
14、ments) 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 perfusio
15、n 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 Tr
