myocardial infarction · 2017-04-19 · classification type 1 myocardial infarction...
TRANSCRIPT
Acute Coronary Syndromes
王翊嘉
106/04/18
- Myocardial Infarction
Outline
O Introduction
O Classification
O Pathophysiology
O Symptoms
O Diagnosis
O Treatment
O Summary
2
Introduction
O 心臟是全身血液的主幫浦，其結構是由強而有力的心肌及結締組織所構成。
O 這些心肌能維持不斷地收縮，完全依賴心臟表面的冠狀動脈供應血液、氧氣、及營養物質。
O 心臟肌肉細胞因其供給營養及氧氣的冠狀動脈，突發幾近完全或完全阻塞，使得供給心肌的血流中斷，而心肌因血流受阻、缺血、缺氧，而發生局部或廣泛的壞死。
3
Introduction
O 心臟肌肉細胞因其供給營養及氧氣的冠狀動脈，突發幾近完全或完全阻塞，使得供給心肌的血流中斷，而心肌因血流受阻、缺血、缺氧，而發生局部或廣泛的壞死。
O 若持續阻塞，則會導致心肌缺氧受損或壞死，進而使得心臟功能減低，若短時間內無法打開血流受阻的血管，將造成心臟肌肉細胞的永久損傷甚至死亡，並產生後續併發症 (如惡性心律不整、心臟衰竭等….)，更可能造成死亡或不可逆的傷害。
4
Introduction
O 當冠狀動脈血管壁的粥樣硬化斑塊破裂時，會產生血管內栓塞而導致急性堵塞，這時其下游的心臟肌肉便開始逐漸壞死，除非經由緊急血栓溶解劑治療或心導管氣球擴張術打通血管，否則該血管所供應之心臟肌肉會在六至十二小時內完全壞死。
O 壞死的肌肉將無法再生，壞死的部位只會結疤，而永久喪失功能。當心肌壞死範圍越大，心臟功能即越差，死亡率也越高。
5
Classification
Type 1 Myocardial Infarction 血管阻塞使得供應心肌細胞的血流減少，或血管末端的血小板栓塞引起心肌壞死。
Type 2 Myocardial Infarction Secondary to an
Ischemic Imbalance
在疾病狀態下，心肌耗氧量需求增加遠超過血流供應量。在如此血流供需失衡之下，造成心肌缺氧，時間過久，便形成心肌梗塞。
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Classification
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Type 3 Cardiac Death Due to
Myocardial Infarction
病人發生心臟死亡，但在尚未抽血檢驗心肌生化標記，或心肌生化標記還未上升之前，就已發生死亡
Type 4a Myocardial Infarction
related to PCI
實施血管再通暢之介入性治療(PCI)
及手術 (CABG)的過程中間與術後，由於儀器及縫合直接碰觸心臟，也可能造成心肌缺氧
Type 4b Myocardial Infarction
related to stent
thrombosis
診斷標準是出現心肌缺氧的症狀，及心肌生化標記升高或降低，且至少一值大於URL之99百分位值，後經由冠狀動脈攝影或解剖證實。
Type 5 Myocardial Infarction
related to CABG
如果病人原先cTn值正常，術後48
小時內，cTn值大於10倍的URL之99
百分位值。
Classification
O ECG
O ST-segment elevation (STEMI)
O 通常代表供應心臟的冠狀動脈血管發生完全被血栓阻塞之現象
O non ST-segment elevation (NSTEMI)
8
Pathophysiology
O NSTEMI usually occurs by developing a partial
occlusion of a major coronary artery or a
complete occlusion of a minor coronary artery
previously affected by atherosclerosis.
O Atherosclerosis is a disease of artery in which
mainly cholesterol deposition occur within
the wall of the artery. This deposited
cholesterol ultimately forms a plaque called
atherosclerotic plaque.
9
Pathophysiology
O The most common mechanism of NSTEMI is rupture or erosion of an atherosclerotic plaque that triggers platelet aggregation, which lead to formation of a thrombus (blood clot) in a coronary artery.
O This arterial thrombus causes interruption of blood supply to part of the heart muscle; profound changes take place in the heart muscle that lead to irreversible changes and death of myocardial cells.
10
Pathophysiology
O
90%的心肌梗塞患者在供應梗塞區的動脈的近端部位有血栓;常發生在粥樣斑塊破裂或潰瘍處。90%~100%的急性心肌梗塞患者中可見到冠脈粥樣斑塊崩潰造成血管阻塞的現象。
11
Pathophysiology
O
反覆而持久的冠狀動脈痙攣可引起血管中血流停滯和阻斷，進而損傷血管內膜引起破裂、出血，使具有強烈血小板聚集和血管收縮作用的血栓素A2在體內含量相對增多，引起血小板聚集促進血栓形成。
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Symptoms
O Chest pain
O Difficulty in breathing
O Nausea, vomiting, and sweating
O Palpitation
O Cardiogenic shock
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Epidemiology
14
104年
15
16
Risk factors
Major High serum cholesterol level Diabetes mellitus
Hypertension Cigarette smoking
Minor Increasing age Family history
Male gender Physical inactivity
Obesity Competitive and stressful lifestyle
Excess alcohol/carbohydrates consumption
Diets deficient in fresh vegetables, fruit and polyunsaturated
fatty acids
17
Diagnosis
O Electrocardiography (ECG)
18
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Diagnosis
O Cardiac markers
O CK-MB、Troponin-I
O Full blood count
O Chest X-ray
O Echocardiography
20
Complication
Immediate complications
Heart arrhythmia
Acute heart failure
Cardiogenic shock
Mitral regurgitation
Late complications
Dressler’s syndrome
Chronic heart failure
21
Treatment
NSTEMI
22
Treatment
O Relief of ischemic discomfort
O Return of ECG changes to baselines
O Absence or resolution of HF sign
23
24
How to select
management
strategy?
25
侵入性治療 即使已用藥物治療再稍微活動或休息時仍產生多次心臟缺血或心絞痛
有心臟衰竭之症狀或徵象，或二尖辦閉鎖不全程度嚴重
在六個月內曾接受冠狀動脈介入治療（PCI）
過去曾接受冠狀動脈繞道手術
TIMI score 或GRACE score之分數較高
在心室功能異常（LVEF＜40%）
腎功能不全(eGFR< 60 mL/min/ 1.73m2 )
有新的心電圖ST波下降 心臟標記（troponin）
非侵入性檢查發現有高危險性發現
血行力學不穩
保守性治療 TIMI score 或GRACE score之分數低
醫師或病人認為他不是高危險性
TIMI(Thrombolysis in Myocardial Infarction) score
Risk factor
Age ≥65 years
at least 3 risk factors for CHD Hypertension Diabetes
Dyslipidemia Smoking
family history of early MI
Use of aspirin in past 7 days
angina episodes in recent At least 2 times in past 24 hrs
Elevated serum cardiac biomarkers CK-MB or Troponin
Presence of ST segment deviation on
admission electrocardiogram
Prior coronary stenosis of ≥50
percent 26
GRACE(The Global Registry of Acute Coronary Events) score
27
x
28
29
x
30
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Early pharmacotherapy
O Morphine sulfate
O Analgesic, decrease the pain and anxiety due to myocardial infarction
O 2-5mg IV，5-15 mins PRN
O Oxygen
O If O2 saturation < 90%，give 4 -8 L /min
O Nitroglycerin
O SL：0.6mg/tab，3 doses for every 5 minutes
O relieve chest pain and myocardial ischemia
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Early pharmacotherapy
O Aspirin
O antithrombotic effect
O Inhibit COX-1 → decrease the generation of
thromboxane A2
O Dose
O Acute：160-325 mg
O Maintenance：75-325 mg QD
O Side effect
O GI discomfort、bleeding
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Early pharmacotherapy
O P2Y12 receptor inhibitors
O inhibit adenosine diphosphate (ADP)-dependent
platelet function by irreversible modification of
the platelet P2Y12 receptor
O Irreversible：Ticlopidine Clopidogrel
Prasugrel
O Reversible：Ticagrelor Cangrelor
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Clopidogrel Prasugrel Ticagrelor Cangrelor
Administration oral oral oral intravenous
Classification Thienopyridine Thienopyridine Triazopyrimidin
e
ATP analog
Prodrug ○ ○ Χ X
Loading dose 300 or 600 mg 60 mg 180 mg 30 μg/kg bolus
Maintenance 75mg QD 10 mg QD 90 mg BID4 μg/kg/min
infusion
CKD
Dosing
Stage3No dose
adjustment
No dose
adjustment
No dose
adjustment
No dose
adjustment
Stage4No dose
adjustment
No dose
adjustment
No dose
adjustment
No dose
adjustment
stage5
Use only for
selected
indication
Not
recommended
Not
recommended
No dose
adjustment
Onset 2-6 hours 30 mins 30 mins 2 mins
Duration 3-10 days 7-10 days 3-5 days 1-2 hours
Withdrawal
before surgery
5 days 7 days 5 days 1 hour
Early pharmacotherapy
O GP IIb/IIIa receptor inhibitors
O prevent fibrinogen binding to activated GP
IIb/IIIa receptors and inhibit platelet
aggregation
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GP IIb/IIIa receptor inhibitors
38
Normal renal
function or CKD
stage 1&2
Stage3
(eGFR 30-59
ml/min/1.73 m2)
Stage4
(eGFR 15-29
ml/min/1.73 m2)
Stage5
(eGFR <15
ml/min/1.73 m2)
Eptifibatide
Bolus 180 μg/kgNo dose
adjustment Not
recommended
Not
recommendedInfusion 2
μg/kg/min
Reduce infusion
rate to 1
μg/kg/min
Tirofiban
Bolus 10 or 25
μg/kg No dose
adjustment
No dose
adjustment Not
recommendedInfusion 15
μg/kg/min
Reduce infusion
to 0.05
μg/kg/min
Abciximab
Bolus 0.25 μg/kgNo specific recommendation for the use of abciximab, or
for dose adjustment in the case of renal failure.
Careful evaluation of haemorrhagic risk is needed.
Infusion 0.125
μg/kg/min (Max.
10μg/min)
Tirofiban+ aspirin + UFH/enoxaparin → high risk NSTEMI (PCI)
Early pharmacotherapy
O Anticoagulant
O prevent reinfarction
O reduces the risk of thromboembolic
complications
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Enoxaparin Dalteparin Heparin Fondaparinux Bivalirudin
SC 1 mg/kg
BID for 8
days
SC 120
units/kg
BID for 8
days
IV bolus 60
units/kg, then
IV infusion 12
units/kg/hr
SC 2.5 mg QD IV
bolus 0.1 mg/kg,
then IV infusion
0.25 mg/kg/hr
Rivaroxaban v.s NSTEMI
(VTE) 10 mg
5 2
(1)曾發生有症狀之靜脈血栓症病史（須於病歷詳細說明發生之時間與診療過程）之病患；(2)經靜脈超音波檢查（Venous ultrasonography）、靜脈攝影（Venography）或血中 D-dimer 檢測，診斷為靜脈血栓症之病患。
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Rivaroxaban v.s NSTEMI
(1)曾發生中風或全身性栓塞。(2)左心室射出分率小於40%。 (3)有症狀之心臟衰竭：收案前依紐約心臟協會衰竭功能分級為第二級或以上。 (4)年齡75歲(含)以上。(5)年齡介於65歲至74歲且合併有糖尿病、高血壓或冠狀動脈疾病。6)每日1次，每次限1顆。（103/5/1)
(7)排除標準：Ⅰ病人曾有嚴重心臟瓣膜疾病。Ⅱ14 天內發生中風。Ⅲ收案前的6個月內發生嚴重中風。Ⅳ有增加出血風險的情況。Ⅴ肌酸酐清除率小30 mL/min。Ⅵ活動性肝病和懷孕。
41(1)須經影像學或血管超音波檢查診斷。(2)第1日至21日，每日早晚各一次，每次限用一粒。(3)第22日起，每日一次，每次限用一粒，每6個月評估一次。
Early pharmacotherapy
O -blockers
O reduce arrhythmias, heart rate, blood pressure
and myocardial oxygen demand, and relive
pain
42
Early pharmacotherapy
43
Non selective β1 selective Mixed α and β blocker
Drug Propranolol Bisoprolol Metoprolol Atenolol Carvedilol
Dose 40-160 mg
BID
1.25-10 mg
QD
50-100 mg
BID
25-100 mg
QD
3.125-25 mg BID
Daily
maximum
dose
640 mg 10 mg 200 mg 100 mg 50 mg
Secondary prevention after MI
O Control CHD risk factors
O Prevent development of systolic HF
O Prevent recurrent MI and stroke
O Prevent death, including sudden cardiac
death
44
Secondary prevention after MI
O Aspirin
O Decrease the risk of death, recurrent MI, and
stroke after MI
O P2Y12 receptor inhibitors
O Clopidogrel Ticagrelor
O Anticoagulation
O Long-term Warfarin for selected patients with
aspirin and P2Y12 receptor inhibitors
45
Secondary prevention after MI
O -blockers
O ACEIsO Reduce mortality, decrease reinfarction, and prevent the
development of heart failure
O Captopril 50 mg BID or TID
O Enalapril 10 mg BID
O ARBsO Patients with ACEIs cough and a low LVEF and heart failure
after MI
O Valsartan 160 mg BID
O Candesartan 32 mg QD
O StatinsO LDL < 100 mg/dL
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生活衛教
47
改變生活習慣
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三多：多吃蔬果和全穀類、多吃深海魚肉、多攝取大豆蛋白質。三少：少飽和脂肪、少熱量、少鹽。
每天進行30 分鐘的有氧運動，如：游泳、慢跑、快走、騎腳踏車等，可常保心血管健康。
根據統計，戒煙能減少50％的心血管疾病死亡率，在戒煙後3 年，罹病率就和從未抽煙者相當。
據研究顯示，壓力會增加腎上腺素的分泌，使血壓升高，也會活化血小板凝集，形成血栓，促使心血管疾病發作，因此平時應學習緩和情緒、以輕鬆的心態面對壓力，並且經常保持開朗的心情。
40 歲以上應每年定期進行健康檢查，隨時監測自己的健康狀況，而有高血壓等慢性疾病的人，至少應每個月追蹤檢查1 次，以了解病情是否控制良好。
寒冷氣候會讓人減少飲水，但水分不足會增加血液黏度，提高血管栓塞的機會，因此適時補充足夠的水分也很重要。
吃對食物也能對抗心血管疾病!
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玉米富含不飽和脂肪酸，有助於人體脂肪及膽固醇的正常代謝，可以減少膽固醇在血管中的沉積、軟化動脈血管
可消除自由基等體內廢物，保護血管彈性，有預防血栓形成的作用
所含營養成分可促使體內脂肪分解，對延遲和預防動脈硬化有明顯作用
海帶中含有豐富的岩藻多糖、昆布素，能防止血栓並降膽固醇、脂蛋白，抑制動脈硬化
含有茶多酚，能提高抗氧化能力，降低血脂
含揮發性辣素，可消除積存在血管中的脂肪，具有降脂作用
含有能使血管擴張的前列腺素A，可舒張血管，降低血液黏度，減少血管壓力
含豐富的維生素P，有軟化血管的作用，能保護心血管、降血壓
Summary
O In patients NSTEMI, early diagnostic and therapeutic interventions, such as antiplatelet therapy and early reperfusion in selected patients, are associated with improved early outcomes.
O After the patient has been stabilized and these early interventions carried out, other short- and long-term interventions aimed at improving both in-hospital and long-term outcomes need to be considered.
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ReferenceO UpToDate
O European society of cardiology
O ACUTE CORONARY SYNDROMES (ACS) IN PATIENTS PRESENTING WITHOUT PERSISTENT ST-SEGMENT ELEVATION (MANAGEMENT OF) - ESC Clinical Practice Guidelines
O Applied Therapeutics - The Clinical Use Of Drugs
O Pharmacotherapy : A Pathophysiologic Approach
O ESC/ACCF/AHA/WHF EXPERT CONSENSUS DOCUMENT-Third Universal Definition of Myocardial Infarction
O 內科學誌-心肌梗塞之重新定義與臨床分類-郭綜合醫院內科部心臟內科-林世崇呂炎原徐漢仲
O 藥學雜誌 116冊 Vol.29 No.3 P2Y12 receptor 於急性冠心症之治療O 全民健康保險雙月刊第113期 (104年1月號 )
http://www.nhi.gov.tw/epaper/ItemDetail.aspx?DataID=3994&IsWebData=0&ItemTypeID=7&PapersID=355&PicID=
O 衛福部中央健康保險署-全民健康保險醫療品質資訊公開網O 全球心肌梗塞照護網O 臺南市立安南醫院-心肌梗塞之照護O 亞東紀念醫院-常見心血管疾病
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