Acute Coronary Syndrome For Student

急性冠心症和心臟衰竭診斷與治療

高雄長庚醫院胸腔內科 熙

王逸

急性心肌梗塞的診斷 持續胸痛 心電圖上有 ST 波段的位移 心肌酵素上昇

Chronic Stable Angina

Acute Coronary Syndrome

ER Patient Care Initial assessment (< 10 min)

Measure vital signs Measure SpO2 Obtain IV access Obtain 12-lead ECG Perform brief, targeted history and PE)

Obtain initial cardiac marker levels Evaluate initial electrolyte and coagulation studies Request, review portable chest x-ray (<30 min)

ER patient care Initial general treatment (memory aid: “MONA” greets all patients – Morphine, 2-4 mg repeated q 5-10 min – Oxygen, 4 L/min; continue if SaO2 < 90% – NTG, SL or spray, followed by IV for persistent or recurrent discomfort – Aspirin, 160 to 325 mg (chew and swallow)

Triage by ECG ST elevation or new LBBB – ST elevation ≧1 mm in 2 or more contiguous leads

ST depression or dynamic T-wave inversion – ST depression > 1 mm – Marked symmetrical T-wave inversion in multiple precordial leads – Dynamic ST-T changes with pain

Non-diagnostic ECG or normal ECG

Suspicious Chest Pains Classic angina - dull, pressure, substernal; arm or neck radiation; SOB, palpitations, sweating, nausea or vomiting Angina Equivalent - no pain but sudden ventricular failure or ventricular dysrhythmias Atypical chest pain - precordial area but with musculoskeletal, positional, or pleuritic features

Typical Chest Pain SAVEN 鑑別口訣 S: Substernal area A: Abrupt onset V: Vagus distribution E: Exertion-related N: NTG or Rest relieve it!

常見胸痛的輻射位置

Cardiac Markers Myoglobin – Nonspecific – Rapid-release kinetics – Useful for its negative predictive accuracy in the early hours after symptom onset – Useful marker for reperfusion

Inflammatory Markers – Can indicate plaque or systemic inflammation associated with ACS – CRP identifies a subgroup of patients with unstable angina at high risk for adverse cardiac events

Cardiac Markers CK-MB Isoforms – Improved sensitivity compared with CK-MB – Only one form in the myocardium – CK-MB2 > 1U/L or CKMB2/CK-MB1 > 2.5%

Troponins (cTnT or cTnI) – Troponin I/Troponin T – Increased sensitivity compared with CK-MB – Detect minimal myocardial damage – Useful in risk stratification – < 0.04 ng/ml (normal) – > 0.5 ng/ml (cut off value of MI)

ACS algorithm symptoms of acute ischemia ASA 325 mg initial dose; 160 mg qd

ST ↑, LBBB <12 h symptoms

≥12 symptoms

consider primary PTCA, IABP Cr >2.5 mg/dL UFH

pain-free, low-to-mod risk, neg or nonspecific ECG, neg CK-MB, TnT/I

non ST ↑ ACS, mod-to-high risk

chest pain unit

antithrombotic therapy

reperfusion therapy TT “ineligible,” shock

consider clinical trials

dynamic ST shifts, + cardiac markers

TT “eligible” TT TNK

direct PCI (TTB<90 min)

Cr <2.5 mg/dL enoxaparin

NSSTT ∆s, – cardiac markers

eptifibatide or tirofiban + heparin (consider enoxaparin)

no cath in 12 h

early cath

enoxaparin

heparin therapy cath in 12 h UFH

clopidogrel (reasonable certainty patient will not have early CABG)

ST Elevation Myocardial Infarction (STEMI)

Coronary Artery Anatomy

Acute Myocardial Infarction (STEMI, inferior wall)

Ventricular Tachyarrhythmia

RV Involvement ? Right Precordial Leads R

R

R

R

R

Heart Block and Bradycardia

Complete heart block

Anterior wall STEMI

Left bundle branch block

Post MI Mechanical Complications VSD 心室中隔缺損 Acute MR 急性二尖瓣閉鎖不全 Free wall rupture 心臟破裂 Cardiac tamponade 心包填塞 Dressler’s syndrome 心包膜炎 Cardiogenic shock / pumping failure 心因性休克 Malignant cardiac arrhythmia 惡性心律不整

IABP 主動脈內氣球幫浦 General Medical Indication: 5.

Left ventricular power failure

7.

Cardiogenic shock

9.

Pre-shock syndrome

11. Myocardial ischemia 12. Acute MR or VSD 13. Drug refractory - Malignant Ventricular arrhythmia recurrence due to Myocardial ischemia

 placement of the IAB in the descending aorta with it’s tip at the distal aortic arch (below the origin of the left subclavian artery)  helium -- lower density and a better rapid diffusion coefficient  carbon dioxide -- increased solubility in blood and reduces the potential consequences of gas embolization following a balloon rupture  the balloon is connected to a drive console (consists of a pressurized gas reservoir, a monitor for ECG and pressure wave recording, adjustments for inflation/deflation timing, triggering selection switches and battery back-up power sources)

a pressurized gas reservoir, adjustments for inflation/ deflation timing, triggering selection switches and battery back-up power sources

Monitor for a ECG and pressure wave recording

Intra-aortic balloon pump in Cardiogenic Shock

Reperfusion Strategy for STEMI 1. Thrombolytic (Fibrinolytic) Therapy 2. Primary PTCA 3. Emergency CABG

ST elevation or new LBBB Start adjunctive treatment If time < 12 hr – Select a reperfusion strategy based on local resources

If time > 12 hr – Assess clinical status, either high-risk or clinically stable

ST elevation or new LBBB Adjunctive treatments – β-blockers – NTG IV – Heparin IV – ACE inhibitors (after 6 hours or when stable)

ST elevation or new LBBB, time < 12 hr Reperfusion strategy based on local resources – Thrombolytics (< 30 min) TPA 15 mg bolus + 0.75 mg/Kg over 30 min + 0.5 mg/Kg over 60 min or SK 1.5 million IU over 1 h

– Primary percutaneous coronary intervention (PCI, angioplasty ± stent) (90 ± 30 min) – Cardiothoracic surgery backup

ST elevation or new LBBB, time > 12 hr Perform cardiac catheterization for high-risk patients – – –

Persistent symptoms Depressed LV function Widespread ECG changes – Prior AMI, PCI, CABG

Admit to CCU/ monitored bed if clinically stable – Continue or start adjunctive treatments – Serial serum markers – Serial ECG – Consider imaging study (2D echocardiography or radionuclide)

血栓溶解劑的臨床好處 Benefit of Thrombolytics Time Lives saved/1000 < 1h 65 1-2 h 37 2-3 h 29 3-6 h 26 6-12 18 12-24 9

Contraindications to Thrombolytics

Absolute ： – Previous hemorrhagic stroke – CVA within past 1 year – Brain neoplasm – Active internal bleeding – Suspected aortic dissection

血栓溶解劑的禁忌症 Contraindications to Thrombolytics Relative: – BP > 180/110 or chronic severe hypertension – On anticoagulants – Trauma or internal bleeding < 2-4 wks

– – – – – –

Traumatic CPR (>10 min) Major surgery < 3 wks Previous SK Active ulcer Pregnancy Hidden puncture

Reperfusion Evidence ST Elevation Subsides (> 50 %) Symptom of Angina Relieved Reperfusion rhythm (AIVR) Cardiac Enzyme early peak (12-20 hour after onset of chest pain)

AIVR (Accelerated Idio-Ventricular Rhythm) or Slow VT

介入性心導管術

PTCA (Balloon Angioplasty)

Stent Implant

Primary PTCA with Stent

冠狀動脈氣球擴張術前 狹窄處

氣球擴張術中

冠狀動脈氣球擴張術後

術後

Multivessel Disease CABG is Recommended

冠 狀 動 脈 繞 道 手 術

冠 狀 動 脈 繞 道 手 術

Unstable Angina NSTEMI

Definition of Unstable Angina Recurrent ischemic symptoms while on therapy High risk findings on stress test (see stress test section) Reduced LV function, with ejection fraction LVEF < 40% Clinical evidence of CHF during chest pain Hemodynamic instability Sustained ventricular tachycardia Percutaneous intervention within the past 6 months Prior CABG surgery Elevated troponin or other markers of necrosis Dynamic ECG changes at presentation

Unstable Angina & NSTEMI

ST depression or dynamic T-wave inversion Thrombolytics contraindicated Adjunctive therapy: – – – – –

Heparin (UFH/LMWH) Aspirin 160-325 mg qd Glycoprotein IIb/IIIa receptor inhibitors Clopidogrel (Plavix) NTG IV β-blockers

Cardiac catheterization for high-risk patients or monitoring for clinically stable patients

Lower dose of heparin To reduce the incidence of ICH Bolus dose: 60 U/kg (maximum 4000U) Maintenance dose: 12 U/kg/hr (maximum 1000 U/hr for patients weighing < 70 kg) Optimal aPTT: 50-70 sec

Clopidogrel (Plavix) blocks the platelet ADP receptor emerging as an important agent both in the acute and in the chronic phases of acute coronary syndromes. nearly universally used in conjunction with coronary stenting.

Platelet Aggregation

Glycoprotein IIb/IIIa receptor inhibitors Inhibits the GP IIb/IIIa receptor in the membrane of platelets Inhibits final common pathway activation of platelet aggregation Available approved agents – Abciximab (ReoPro) – Eptifibitide (Integrilin) – Tirofiban (Aggrastat)

Benefit of clopidogrel & glycoprotein IIb/IIIa inhibitors stratified by cardiac markers

ACS acute care algorithm

for centers with a cath lab and primary PCI capability symptoms of acute ischemia ASA 325 mg initial dose; 160 mg qd

ST ↑, LBBB <12 h symptoms

≥12 symptoms

emergent cath, PCI, IABP for shock

dynamic ST shifts, + cardiac markers

TT “eligible” thrombolysis (with TNK, consider enoxaparin)

Cr >2.5 mg/dL UFH

non-ST ↑ ACS, mod-to-high risk

chest pain unit

antithrombotic therapy

reperfusion therapy TT “ineligible,” shock

pain-free, low-to-mod risk, neg or nonspecific ECG, neg CK-MB, TnT/I

primary PCI (if time to balloon <90 min)

Cr <2.5 mg/dL enoxaparin

NSSTT ∆s, – cardiac markers

eptifibatide or tirofiban + heparin (consider enoxaparin)

no cath in 12 h

early cath

enoxaparin

heparin therapy cath in 12 h UFH

clopidogrel (reasonable certainty patient will not have early CABG)

什麼是心衰竭 ?? 心臟衰竭就是心臟功能發生問題 ，最常見的是無法輸出足夠的血 量，供應身體各部份組織器官的 需 要

NYHA classification for CHF

心衰竭有什麼症狀 ?? 喘 1.

呼吸困難：病人運動或工作時，就會 呼吸困難，嚴重時，甚至於躺在床上 或休息時，也會感覺呼吸困難。

2.

端坐呼吸：嚴重的心臟衰竭，病人平 躺時會感到呼吸困難；需藉著坐起來 或墊高枕頭才得以緩解。

3.

陣發性夜間呼吸困難：病人易從睡夢 中驚醒，呼吸較費力且有喘鳴聲，需 藉著坐起來或打開窗戶呼吸新鮮空氣 來緩解。

4.

肺水腫 ; 咳嗽

腫 1. 下 肢 水 腫 ： 開 始 出 現 在 身 體 下

2. 3.

端部份，典型是發生在下肢踝 部。 可能導致肝腫大，易出現腹水 及黃疸等肝臟受損的症狀。 可能導致頸靜脈怒張。

心臟方面的症狀 a. b. c.

心臟跳動加快出現奔馬律。 大部份的病人會出現心臟擴大的 情形。 心臟跳動有雜音或跳動不規則。

New Approach to the Classification Stage

Patient Description

A

High risk for developing CHF

Hypertension CAD, cardiotoxin exposure Diabetes mellitus Family history of cardiomyopathy

B C D

Asymptomatic CHF

Known structural heart disease Cardiomegaly, Previous MI, valvular disease, LV systolic dysfunction

Symptomatic CHF

Overt CHF Symptoms may be current or prior

Refractory end-stage CHF

Marked symptoms at rest despite maximal medical therapy (eg, those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions)

Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

但是很不幸的 , 有超過一半以上的末期

CHF 病人 , 在等待 heart transplantation 的過程當中 , 因為

CHF 引起的併發症 , 如 AMI 或是 VT 而死 亡。 在部份嚴重 congestive heart

failure 的病人 , 在用藥物之後 , 仍然 無法維持生命情形之下 , 所以使用 non-

Non-pharmacologic therapies of CHF (1) Automatic implantable cardioverter defibrillator (AICD) (2) Left Ventricular Assist Device (LVAD) (3) Intra Aortihc Balloon Pump (IABP) (4) Extracorporeal membrane oxygenator (ECMO) (5) Coronary revascularization ( hibernating and stunned myocardium) (6) Reconstructive cardiac surgery (been largely abandoned) (7) Mitral valve repair in dilated cardiomyopathy (8) LV aneurysmectomy in symptomatic patients

Left Ventricular Assist Device

 正常情形下 , 血液先經由

LV apex 的入口 , 經由 人工血管 (inflow graft) 流入血液幫浦的 血液室中 , 經 pump 壓縮

之後 , 再經由人工血管 (outflow graft) 流出

, 將血液送至 ascending aorta, 以供應身體所需 。  而 pump 之出入口中 , 各

有一個豬瓣膜 , 以維持血

Left Ventricular Assist Device  LVAD 在 1985 年正式獲得美國的通過 , 准許可

應用於臨床上嚴重心衰竭的病人 , 做為一個等待 心臟移植的橋 。並於 1986 年有了全世界首例 的使用。

 在一開始研發之時 , 目的就是在建立一個長期的

左心室輔助系統 , 希望病人能夠在等待心臟移植 的漫漫長路之中 , 有一個安全穩定的依靠。

 由於等待心臟移植的病人日益增加 , 而捐心者並

沒有成比例增加的情況之下 , 可以預期的是每一 位等待換心的病人 , 他的等待換心期間將會愈來

Left Ventricular Assist Device LVAD 主要是針對慢性心衰竭病患在等待換心 期，產生嚴重心衰竭時輔以高劑量強心劑，或 IABP 仍無法維持足 之心輸出量情況下，所 需考慮的治療方式。 病患的血液動力學狀況必需符合下列標準，才 考慮進行 LVAD 的植入手術 : (1) Pulmonary capillary wedge pressure > 20mmHg

Left Ventricular Assist Device LVAD 在美國而言，已經是通過 FDA 核准 ，在臨床上使用的醫療項目，而且醫療保 險公司也將此醫療支出納入給付項目之一 。 可是在國內而言，依然目前法律規定， HeartMate LVAD 及 Novacor LVAD 的 治療尚屬於人體臨床試驗的項目，健保不 給付，而必需由實驗經費來負擔， 大的 醫療經費支出，造成推廣的困難。

Left Ventricular Assist Device 據大規模的資料統計 , 接受 LVAD 植入的病人 , 比起對照組病人而言 ,LVAD 可以有意義的改善 : (1) 病人的 survival rate and length ,

(2) 病人 CHF 的症狀 : 接受 LVAD 的病人 術前皆為 NYHA Fc IV, 而接受完手術

之後 , 心臟功能幾乎都轉變為 NYHA Fc I (3) 因為 cardiac output 的大幅增加 ,

Left Ventricular Assist Device 嚴重心臟衰竭只用 LVAD 病人約有 20% 持續右心 衰竭，所以右心房壓力太高 ( 如 > 20mmHg)

或肺動脈阻力太大 ( 如 > 5 Wood Units) 或 右心收縮力太差 ( 如 RVEF < 10%) 者，不要單 獨使用 LVAD ，因嚴重右心衰竭會使 LVAD 無法 有效運作，需要 快再裝上右心室輔助器 (RVAD) 。 在使用雙心輔助器 (BVAD) 時，為避免 pulmonary edema ，通常將 RVAD 的流量調得

LVAD

AICD

Implantable cardioverter defibrillator Sudden death is a major cause of mortality

in patients with ventricular dysfunction. Current methods of risk stratification are inadequate, and a rational therapy for prevention of sudden death is not available. The implantable cardioverter-defibrillator (ICD) has proven to be more effective than drugs in reducing sudden-death risk in some subsets of patients.

IABP

Mechanism of IABP

Mechanism of IABP Improvement in coronary blood flow occurs

without an increase in myocardial work and results in a 10-20% reduction in oxygen consumption. Thus, the net effect of IABP in cardiogenic shock is to increase coronary blood flow and myocardial oxygen supply while reducing myocardial work and oxygen consumption. Cardiac output may increase by as much as 50%.

Thanks for your attention!