Download Coronary Artery Disease

Current treatment of acute
coronary syndrome
林口長庚醫院 心臟內二科
謝宜璋醫師
March,6, 2012
心臟病
1. 冠狀動脈疾病（缺血性疾病）
2. 瓣膜疾病
狹窄
閉鎖不全
3. 心臟衰竭
4. 心肌病變
5. 心律不整
肥厚性
擴張性
心博過速
心博過慢
6. 心包膜疾病
7. 先天性心臟病（心房，心室中膈缺損-----）
Coronary Artery Disease (CAD)
Etiology:
• Atherosclerotic disease of epicardial coronary
arteries.
• Luminal narrowing by other mechanism, e.g.
coronary spasm, dissection of aorta, etc.
• Embolization.
• Arteritis of coronary arteries, e.g. Granulomatous
disease, kawasaki syndrome, SLE, RA, etc.
• Trauma to coronary arteries.
• Intimal proliferative disease, e.g. amyloidosis,
homocystinuria, etc.
Risk factors for CAD
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Male
Ageing
Hypertension
Diabetes Mellitus
Smoking
Obesity
Dyslipidemia
Family history
Sedentary
Uremia
Homocysteinemia
CAD--- Symptoms
• Exertional chest discomfort (squeezing,
pressure, heaviness sensation) --- typical
• Crescendo-decrescendo pattern
• May radiate to the left shoulder, both arms,
back, neck, or jaw
• Lasting 1-10 minutes, if AMI30 mins
• Relieved by rest or sublingual NTG, or not
Diagnosis of CAD
• History: typical symptoms
• Physical exam: non-specific signs
• Laboratory: Resting EKG
(electrocardiogram)
Exercise treadmill test
Thallium-201 scan
Dobutamine stress test (echo)
Multi-slices CT
Angiogram (coronary)
CAD --- Management
• Explanation and reassurance
• Reduction of risk factors: Hypertension, Diabetes,
dyslipidemia, smoking, exercise--• Treatment of coexisting condition capable of
aggravating angina
• Adaptation of activities
• Drug therapy
• Mechanical revascularization (PCI): PTCA,
stenting, atherectomy, etc.
• Coronary artery bypass surgery (CABG)
CAD --- Drug therapy
• Antiplatelet agents: Aspirin, Clopidogrel
• B-adrenoreceptor blockade: Propranolol,
Atenolol, Nadolol, Bisoprolol , Carvedilol,
Metoprolol
• ACEI/ARB
• Statin
• Nitrate
• Ca-channel blockers: Diltiazem, Nifedipine.
Clinical Manifestation of CAD (IHD)
• Asymptomatic (silent ischemia)
• Chronic stable angina pectoris
• Acute coronary syndrome (ACS):
unstable angina, non-ST elevation
myocardial infarction (NSTEMI)
• ST-elevation myocardial infarction
(STEMI).
Acute Coronary Syndrome
- Nomenclature
Acute Coronary Syndrome
No ST elevation
ST elevation
NSTEMI
Unstable
Angina
ST elevation Myocardial
Infarction
JACC 2000;36:970-1062
STEMI
--- Diagnostic Criteria
• Typical chest pain
• Serial ECG changes
• Serial cardiac enzymes changes
- At least fulfill 2 items in the above 3
criteria
STEMI
--- Management (1)
• Admit to coronary care unit
• Absolute bed rest
• Reperfusion therapy
- Pharmacologocal: thrombolytic therapy
- Mechanical: Primary PTCA, stenting
• Drug therapy:
- Analgesia, sedation
- Oxygen
- Anti-platelet agent and anticoagulants
- B-blockers
- Angiotensin-converting enzyme (ACE) inhibitor/ARB
- Antiarrhythmic agents
Unstable Angina
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New onset (< 2 months) angina
Accelerating angina (severity, frequency)
Resting angina
Pathophysiology:
- progression of atherosclerosis
- platelet aggregation
- thrombus formation
- changes in vasomotor tone (spasm)
Current therapy in acute coronary
syndrome (UA / NSTEMI)
1. Bed rest, oxygen, opiate analgesics to relief pain, and
anti-ischemic drugs (nitrates, β –blockers, calcium
antagonists),CCU admission
2. Aspirin
3. IV heparin or SQ low-molecular-weight heparin
4. Clopidogrel/Prasugrel/Ticagrelor
5. IV platelet glycoprotein IIb/ IIIa antagonist
6. Percutaneous coronary interventions (PCI),CABG
7. ACE inhibitor
8. Statin
2007 ESC NSTE-ACS Guideline Update
Key Recommendation on Clopidogrel Therapy
• Clopidogrel
• For all patients, immediate 300 mg loading dose of clopidogrel is
recommended, followed by 75 mg clopidorel daily (I-A). Clopidogrel
should be maintained for 12 months unless there is an excessive risk
of bleeding (I-A).
• For all patients with contraindications to aspirin, clopidogrel should be
given instead (I-B).
• In patients considered for an invasive procedure/PCI, a loading dose
of 600 mg clopidogrel may be used to achieve more rapid inhibition of
platelet function (IIa-B).
• In patients pretreated with clopidogrel who need to undergo CABG,
surgery should be postponed for 5 days for clopidogrel withdrawal if
clinically feasible (IIa-C).
Task Force Members et. al, European Heart Journal 2007;28(!3):1598-1660
2007 ACC/AHA UA/NSTEMI Guideline Update :
Key Recommendations on Anti-platelet Therapy
• Medical therapy without stenting
 ASA 75-162 mg/d indefinitely (Class I, A)
 Clopidogrel 75 mg/d, at least 1 mo (Class I, A), ideally up to
1 yr (Class I, B)
• Bare metal stent
 ASA 162-325 mg/d at least 1 mo, 75-162 mg/d indefinitely
(Class I, A)
 Clopidogrel 75 mg/d, at least 1 mo (Class I, A), ideally up to
1 yr (Class I, B)
• Drug-eluting stent
 ASA 162-325 mg/d at least 3 (sirolimus)-6 (paclitaxel) mo, 75162 mg/d indefinitely (Class I, A)
 Clopidogrel 75 mg/d > 1 yr (Class I, B)
Conclusions
• CAD is an important, life-threatening disease
• Risk factors control/life style modification are the
best policy for prevention
• Typical symptom is the keypoint for diagnosis,
which can be confirmed by (non)invasive tests
• Medications include anti-platelet agents, betablocker, ACEI/ARB, statin, nitrate
• ACS should be treated early and aggressively
• For STEMI patients, primary PCI (angioplasty) is
better than thrombolysis
• CABG is preserved for complicated/complex patient
• Early detect and early treatment are crucial for CAD