¼±Åà - È­»ìǥŰ/¿£ÅÍŰ ´Ý±â - ESC

 

Ischemic Heart Disease

1. Etiology & Pathophysiology

* Ischemia : oxygen supply¿Í demand»çÀÌÀÇ ºÒ±ÕÇüÀ¸·Î ÀÎÇÑ inadequate perfusionÀ¸·Î

¹ß»ýÇÑ´Ù.

mc cause : atherosclerotic ds of epicardial coronary a.

epicardial coronary a(=conductance vs) : constriction & relaxation°¡´É

intramyocardial arterioles(=resistance vs)

resistance vsÀÇ abnormal constriction or dilation failure¶ÇÇÑ ischemia¸¦ ÀÏÀ¸Å³¼ö

ÀÖ´Ù.(=microvascular angina)

* Coronary atherosclerosis

cross sectional area : 75%ÀÌ»ó °¨¼ÒÇÒ ¶§ ½É±ÙÀÌ ¿ä±¸ÇÏ´Â ÃÖ´ë flow°¡ ºÒ°¡´ÉÇÏ´Ù.

80%ÀÌ»ó °¨¼ÒÇÒ ¶§ rest½Ã blood flow°¡ °¨¼ÒÇϸç stenotic orifice¿¡¼­ Á»´õ

°¨¼ÒÇϸé coronary blood flow´Â ½ÉÇÏ°Ô °¨¼ÒÇϰí myocardial ischemia¸¦ ÀÏÀ¸Å²´Ù.

2. Chronic Stable AP

1) History

50-60¼¼ ³²ÀÚ È¤Àº 65-75¼¼ ¿©ÀÚ

heaviness, pressure, squeezing, smothering, or choking

crescending-decrescendo in nature

1-5ºÐ Áö¼Ó

Lt sholder, both arm, ƯÈ÷ forearm & hand radiationµÇ¸ç ¶ÇÇÑ back, neck, Jaw, teeth &

epigastriumÀ¸·Î radiationµÉ¼öµµ ÀÖ´Ù.

ÀüÇüÀûÀ¸·Î´Â exertion(¿¹, exercise, hurrying or sexual activity) or emotion(¿¹, stress,

anger, fright, or frustration)¿¡ ÀÇÇØ ¹ß»ýÇϰí rest½Ã relieveµÇÁö¸¸, rest½Ã¿¡ ¹ß»ýÇÒ

¼öµµ ÀÖ°í, ´©¿öÀÖ´Â ¹ã¿¡ ¹ß»ýÇÒ¼öµµ ÀÖ´Ù.

angina pectoris¹ß»ýÀÇ threshold´Â °³Àθ¶´Ù ´Ù¸£°í, ÇÏ·çÁß ½Ã°£¿¡ µû¶ó, emotional

state¿¡ µû¶ó ´Ù¸£´Ù.

anginal "equivalent" : anginaÀÌ¿ÜÀÇ myocardial ischemia sx

= dyspnea, fatigue, faintness : mc in the elderly

* IHD¸¦ ÀǽÉÇϴ ȯÀÚ¿¡¼­ ´ÙÀ½ »çÇ×À» ¹°¾îº¸¾Æ¾ß ÇÑ´Ù.

i) premature IHDÀÇ family Hx(M<45¼¼, F<55¼¼)

ii) DM

iii) hyperlipidemia

iv) hypertension

v) cigarette smoking

vi) coronary atherosclerosisÀÇ other risk factors

Atypical anginaȯÀÚ¿¡¼­´Â advanced age, male sex, postmenopausal state,

atherosclerosisÀÇ risk factor°¡ ÀÖÀ»¶§ important coronary ds°¡´É¼ºÀÌ Áõ°¡ÇÑ´Ù.

2) P/E

ÈçÈ÷ Á¤»óÀÌ¸ç µå¹°°Ô coronary atherosclerosis¿Í °ü·ÃÇÑ risk factor signÀÌ ³ªÅ¸³ª±âµµ

ÇÑ´Ù: xanthelasma, xanthoma, or diabetic skin lesions

ûÁø : arterial bruits, S3, S4

acute ischemia or previous infarctionÀ¸·Î papillary m. fxÀÌ ¼Õ»óµÇ¾úÀ»¶§ atypical

systolic murmur d/t MR

AS, AR, pul. HTN, HCM¸¦ ¹èÁ¦ÇØ¾ß ÇÑ´Ù: coronary atherosclerosis°¡ ¾ø´Â ȯÀÚ¿¡¼­

angina¸¦ ÀÏÀ¸Å³¼ö ÀÖ´Ù.

anginal attack½Ã ÁøÂû¼Ò°ßÀÌ À¯¿ëÇѵ¥ ischemia°¡ ÀϽÃÀûÀÎ LV failure¸¦ ÀÏÀ¸ÄÑ

S3, S4 sound°¡ ³ªÅ¸³ª°í dyskinetic cardiac apex, MR, pul. edemaµîÀÌ ³ªÅ¸³¯¼ö ÀÖ±â

¶§¹®ÀÌ´Ù.

3) Lab

- urine : DM & renal ds È®ÀÎ

- blood : lipid, glu, cre, Hct, thyroid fx

- CXR : cardiac enlargement, ventricular aneurysm, heart failure sign

(1) ECG

¹Ý¼ö¿¡¼­ Á¤»óÀÌÁö¸¸ OMI signÀÌ ³ªÅ¸³¯¼ö ÀÖ´Ù.

repolarization abnormality(¿¹, T-wave & ST-segment changes & Intraventricular

conduction disturbances at rest)°¡ IHD¸¦ ÀǽÉÇÏ°Ô ÇÏÁö¸¸ ºñƯÀÌÀûÀÌ´Ù.

: pericardial, myocardial, valvular heart ds³ª posture changes, drug, or esophageal

ds¿¡¼­µµ ÀϽÃÀûÀ¸·Î ³ªÅ¸³¯¼ö Àֱ⠶§¹®ÀÌ´Ù.

AP¶§ µ¿¹ÝµÇ´Â typical ST-seg & T wave changes´Â ±×ÈÄ »ç¶óÁö¹Ç·Î º¸´Ù ƯÀÌÀûÀÌ´Ù.

°¡Àå Æ¯Â¡ÀûÀÎ º¯È­´Â stress test¶§ À¯¹ßµÇ´Â ST-segment displacementÀÌ´Ù.

angina¶§ ST-segment´Â ÈçÈ÷ depressionµÇÁö¸¸ elevationµÉ¼öµµ ÀÖ´Ù(Prinzmetal's

angina¶§).

(2) Stress testing

¨ç CCST

* Sx limited : ´ÙÀ½°ú °°Àº ÀÌ»ó¼Ò°ßÀÌ ÀÖÀ» ¶§ °Ë»ç¸¦ Áß´ÜÇÑ´Ù.

i) chest discomfort, severe SOB, dizziness, fatigue

ii) ST segment 0.2mV(2mm)ÀÌ»ó depression

iii) systolic BP°¡ 10 mmHgÀÌ»ó °¨¼Ò

iv) Ventricular tachyarrhythmia¹ß»ý

* Ischemic ST segment depressionÀÇ Á¤ÀÇ

i) baselineº¸´Ù 0.1mVÀÌ»ó flat depressionµÇ¾î 0.08ÃÊ ÀÌ»ó Áö¼ÓÇÒ ¶§

ii) flat or downsloping

- upsloping or junctional ST segment depressionÀº ischemia·Î °£ÁÖÇÏÁö ¾Ê°í

positive test·Î ¿©±âÁöµµ ¾Ê´Â´Ù.

- targent heart rate(maximum HR [=220-age]ÀÇ 85%)¿¡ µµ´ÞÇÏÁö ¸øÇϸé

negative test & nondiagnostic.

* false positive(15%)

i) cardioactive drug : digitalis, quinidine

ii) intraventricular conduction disturbance

iii) ST, TÀÇ resting abnormality

iv) myocardial hypertrophy

v) abnormal serum K+ level

* false negative

heartÀÇ posterior portion ischemia(circumflex coronary a.¿¡ ±¹ÇÑµÈ obstructive

disease)

¡ñ heartÀÇ post. portionÀº surface 12-lead ECG¿¡¼­ Àß ³ªÅ¸³ªÁö ¾Ê±â ¶§¹®ÀÌ´Ù.

´ë·« Àüü sensitivity = 75%

* ÀÓ»óÀÇ´Â exercise testµ¿¾È ÀÚ¸®¿¡ ÀÖ¾î¾ß ÇÏ¸ç ´ÙÀ½»çÇ×À» ÃøÁ¤ÇÏ´Â °ÍÀÌ Áß¿äÇÏ´Ù.

i) total duration of exercise

ii) ischemic ST-seg change & chest discomfort onset±îÁöÀÇ ½Ã°£

iii) external work performed(ÀϹÝÀûÀ¸·Î stage·Î Ç¥Çö)

iv) internal cardiac work performed(BP, HR)

v) ST seg depression±íÀÌ, ECG recovery±îÁöÀÇ ½Ã°£ ¶ÇÇÑ Áß¿äÇÏ´Ù.

* ±Ý±â : acute MI(<4-5ÀÏ), rest angina(<4ÀÏ), unstable angina, severe AS, acute

myocarditis, acute infective endocarditis

- exercise¿¡ µû¶ó Á¡Â÷ BP & HRÀÇ »ó½ÂÇÏ´Â °ÍÀÌ Á¤»óÀûÀÎ ¹ÝÀÀÀÌ´Ù. °Ë»çÁß¿¡ Ç÷¾Ð

ÀÌ ¿À¸£Áö ¾Ê°Å³ª ¶³¾îÁö´Â°ÍÀº Áß¿äÇÑ adverse prognostic signÀε¥,

ischemia-induced global LV dysfunctionÀ» ¹Ý¿µÇϱ⠶§¹®ÀÌ´Ù.

- low workload¿¡¼­ angina and/or severe(>0.2mV) ST-seg depression

(¿¹, Stage IIÀü, exerciseÁ¾·áÈÄ 5ºÐÀÌ»ó ST seg depressionÁö¼Ó)

=> test specificity¡è, severe ischemic heart dsÀǹÌ,

further adverse eventÀÇ high risk

¨è Stress myocardial perfusion imaging

(radioisotope IVÈÄ 201Tl, 99mTc-sestamibi)

i) exerciseµ¿¾È : exerciseÁß´ÜÈÄ Áï½Ã ½ÃÇà

ii) pharmacologic(dipyridamole or adenosine)

¨é 2D-echo of the LV

stress(exercise or dobutamine) echocardiography

: rest½Ã ¾ø´ø akinesis or dyskinesisÀÇ ÃâÇö

stress myocardial perfusion imagingó·³ IHDÁø´Ü¿¡ ÀÖ¾î exercise ECGº¸´Ù ´õ

sensitive.

Tab 244-1. Stress Echo¿Í stress radionuclide perfusion imagingÀÇ ÀåÁ¡ ºñ±³

(3) CAG

¨ç CSAP : medical tx¿¡µµ ºÒ±¸ÇÏ°í ½ÉÇÑ Áõ»óÀ» º¸À̰ųª revascularization(PCI or

CABG)À» °í·ÁÇϰí ÀÖÀ»¶§ ½ÃÇà.

¨è IHDÁø´ÜÀ» È®ÁøÇϰųª ¹èÁ¦ÇÒ Çʿ䰡 ÀÖ´Â »ç¶÷¿¡¼­ Áø´ÜÇϱ⠾î·Á¿î Áõ»óÀ» º¸ÀÌ´Â

°æ¿ì

¨é sudden cardiac death·ÎºÎÅÍ »ýÁ¸ÇÑ known or possible AP

¨ê coronary event°¡ Áö¼ÓÇÒ À§ÇèÀÌ Å©´Ù°í ÆÇ´ÜµÇ´Â °æ¿ì

4) Prognosis

(1) Principle prognostic indicators(in IHD)

i) functional state of the LV

ii) coronary a. narrowingÀÇ location & severity

iii) myocardial ischemiaÀÇ severity or activity

* recent onset angina, unstable angina, medical tx¿¡ ¹ÝÀÀÇÏÁö ¾Ê´Â angina, CHFµ¿¹Ý

= adverse coronary event risk¡è

(2) Noninvasive test¿¡¼­ coronary event risk°¡ Áõ°¡ÇÏ´Â °æ¿ì

¨ç Strongly positive exercise test

i) low workload¿¡¼­ (+) : Bruce protocol stage II¸¦ ¸¶Ä¡±â Àü¿¡ 0.1mVÀÌ»óÀÇ depression

ii) ¡Ã0.2 mV depression in any stage

iii) ¿îµ¿Áß´ÜÈÄ 5ºÐÀÌ»ó ST depressionÁö¼Ó

iv) exerciseµ¿¾È systolic pressure°¡ 10 mmHgÀÌ»ó °¨¼Ò

v) exerciseµ¿¾È ventricular tachyarrhythmia¹ß»ý

¨è Stress radioisotope perfusion imaging

i) large or multiple perfusion defect

ii) lung uptake¡è

¨é RI ventriculography or stress echo¿¡¼­ LVEF¡é

¹Ý´ë·Î Bruce protocol stage III¸¦ ¸¶Ä¥¼ö Àְųª normal stress perfusion scan, negative

stress

echo´Â very low risk of future coronary event¸¦ ÀǹÌÇÑ´Ù.

(3) Cardiac cath¿¡¼­ poor prognosis

LVEDP¡è, LV volume¡è, EF¡é = LV dysfunctionÀÇ most important signs

* LAD proximalÀÌ RCA or LCXº¸´Ù risk°¡ ´õ ³ô´Ù.

Lt main 50%ÀÌ»ó stenosis°¡ ÀÖÀ»¶§ ¸Å³â »ç¸Á·üÀº 15%Á¤µµ µÈ´Ù.

5) Treatment

(1) Explanation & Reassurance

(2) Aggrevating conditionÀÇ ÀÎÁö ¹× Ä¡·á

Aortic valve ds, HCH¸¦ ¹èÁ¦Çϰųª Ä¡·áÇÏ¿©¾ß ÇÑ´Ù.

obesity, hypertension, hyperthyroidismÀÌ ÀÖ´Ù¸é Ä¡·áÇØ¾ß ÇÑ´Ù.

±Ý¿¬

(3) Adaptation of activity

(4) Risk factor Ä¡·á

family Hx, obesity, cagarette smoking, hypertension, DM, dyslipidemia

¨ç DyslipidemiaÄ¡·á

¨è IHD ¿©¼º¿¡¼­ÀÇ risk reduction

(5) Drug Tx

¨ç Nitrates : coronary a. vasodilation & collateral vs·ÎÀÇ blood flow¡è

mc S/E : headache & pulsating feeling

NTG¸¦ óÀ½ Åõ¿©ÇÑÈÄ ÅëÁõÀÌ ¼Ò½ÇµÇÁö ¾ÊÀ¸¸é 2nd or 3rd dose¸¦ 5ºÐ°£°ÝÀ¸·Î Åõ¿©

Çϰí,±×·¡µµ Áõ»óÀÌ °è¼ÓµÇ¸é º´¿ø ÀÀ±Þ½Ç·Î ÈļÛÇÏ¿© unstable angina or AMI°¡´É¼ºÀ»

Á¶»çÇØ¾ß ÇÑ´Ù.

*¿ë¹ý : isosorbide dinitrate(10-60mg PO bid or tid)

NTG ointment(0.5-2.0 in qid) or sustained-release transdermal patch(5-25mg/d)

*±âÀü : nitrate -> guanyl cyclase in vascular smooth m¿¡ °áÇÕ

-> sulfhydryl groupÀ» »êÈ­½ÃÄÑ S-nitrosothiols·Î Àüȯ

-> cGMP¡è

-> vascular smooth m. relaxation

* tolerance with loss of efficacy

i) long-acting nitrate¸¦ 12-24½Ã°£ ¿¬¼ÓÇØ¼­ ³ëÃâ½Ãų¶§ sulfhydryl groupÀÌ °í°¥µÇ¸é¼­

ii) intravascular fluid balaneÁ¶ÀýÀå¾Ö

-> ÀÌ·¯ÇÑ tolerance¸¦ ÃÖ¼ÒÈ­Çϱâ À§ÇØ ÃÖ¼ÒÇÑ 8½Ã°£ÀÇ drug-free timeÀÌ ÀÖ¾î¾ß ÇÑ´Ù.

¨è ¥â-blokcers

long-acting ¥â-blocker(atenolol 50-100 mg/d, nadolol 40-80 mg/d)

-> mortality & reinfarction°¨¼Ò

* Relative CIx : asthma, COPD¿¡¼­ reversible airway obstruction, severe bradycardia,

Raynaud's phenomenon, depression Hx(+)

* S/E : fatigue, impotence, cold extremities, intermittent claudication

AV conductionÀå¾Ö, LV failure, bronchial asthma, OHA¿¡ ÀÇÇØ À¯¹ßµÇ´Â

hypoglycemia¾ÇÈ­

¨é Ca antagonist

slow-release nifedipine 30-90 mg qd

Verapamil 80-120 mg tid

Diltiazem 30-90 mg qid

Amlodipine 2.5-10 mg daily

* combined pharmacologic effect ; È¿°úÀûÀÌ´Ù.

¥â-blocker °¡ ±Ý±âÀ̰í, poorly tolerated or ineffectiveÇÒ¶§

variant angina¶§´Â Ca antagonit¿¡ ƯÈ÷ Àß ¹ÝÀÀÇÑ´Ù.

verapamilÀº ¥â-blocker¿Í Á¶ÇÕÇØ¼­´Â ¾ÈµÈ´Ù(HR, contractilityÀÇ combined effect

¶§¹®)

DiltiazemÀº normal LV fx & conduction disturbance°¡ ¾øÀ»¶§ ¥â-blocker¿Í º´ÇÕÇØ¼­

Á¶½É½º·´°Ô »ç¿ëÇÒ¼ö ÀÖ´Ù.

Nifedipine or amlodipine, ¥â-blocker ; complementary action on coronary blood

supply & myocardial oxygen demands

short-acting dihydropyridineÀº ±Ý±â : precipitating infarction risk(ƯÈ÷, ¥â-blocker¸¦

¾²Áö ¾ÊÀ»¶§)

¨ê Initial tx·Î ¥â-blocker¿Í Ca antagonistÁß ¼±ÅÃ

* Ca antagonistÀûÀÀ

i) asthma or COPD Hx

ii) sick sinus syndrome or significant AV conduction disturbances

iii) Prinzmetal's angina

iv) symptomatic peripheral vascular ds

v) ¥â-blocker ºÎÀÛ¿ëÀÌ ÀÖÀ»¶§ : depression, sexual disturbances, fatigue

¨ë antiplatelet drugs

i) aspirin

ii) clopidogrel : ADP receptor-mediated platelet aggregation block

¨ì angina & heart failure

ACEI, diuretics & digitalis

3. Cornoary revascularization

1) PCI : PTCA or stenting = one or two vs disease, 3 vs¿¡¼­´Â ¼±ÅÃÀûÀ¸·Î.

±×·¯³ª Lt main & 3 vs CAD(ƯÈ÷ LV fxÀå¾Öµ¿¹Ý µÇ¾úÀ»¶§)´Â CABG¸¦ ½ÃÇàÇØ¾ß ÇÑ´Ù.

¨ç Indication & pt selection

mc Ix = AP(stable or unstable)

asymptomatic or mildly symptomatic pt´Â ÀϹÝÀûÀ¸·Î ´ë»óÀÌ µÇÁö ¾Ê´Â´Ù.

* advanced age, stenosis with thrombosis, LV dysfunction, myocardium large segment

¸¦ °ø±ÞÇÏ´Â a.(without collaterals), long eccentric or irregular stenosis, calcified

plaques

-> Cxºóµµ°¡ Áõ°¡ÇÏÁö¸¸ Àý´ëÀû ±Ý±â´Â ¾Æ´Ï´Ù. ±×·¯³ª Lt main coronary a. stenosis´Â

ÀϹÝÀûÀ¸·Î Àý´ëÀû ±Ý±âÀÌ´Ù.

¨è Risks

* major Cx : dissection or thrombosis with vs occlusion, uncontrolled ischemia,

ventricular failure

oral aspirin + IV heparinÀ» Ç×»ó Åõ¿©ÇØ¾ß ÇÑ´Ù.

unstable angina & intracoronary thrombus¹ß°ß½Ã specific plt Gp receptor antagonist

Åõ¿©·Î thrombotic CxÀ» ÁÙÀϼö ÀÖ´Ù.

* overall mortality < 0.5%

emergency coronary surgery¹ß»ý ºóµµ < 1%

clinical MI < 2%

minor Cx : 5-10%, brach occlusion, MI with CK-MBµî..

¨é Efficacy

Primary success(95%) = adequate dilation(residual stenosis<50%) + angina relief

recurrent stenosis : 30-45% (ù 6°³¿ù³»)

25% (6-12°³¿ù)

* restensosis°¡ Àß ¹ß»ýÇÏ´Â °æ¿ì

DM, unstable angina, incomplete dilatation, LAD, stenosis containing thrombi

* metal stent :10-30%(6°³¿ù)

vigorous antiplatelet txÇÊ¿ä(aspirin & clipidogrel) cf.Clipidogrel(Plavix 1T bid)

local radiationÀ¸·Î restenosis¸¦ ÁÙÀϼö ÀÖ´Ù.

ù 1³â³» restenosis rate°¡ ¹ß»ýÇÏÁö ¾ÊÀ¸¸é 4³âµ¿¾È ¿¹ÈÄ´Â excellent.

restenosis¹ß»ý½Ã PTCA¸¦ ´Ù½Ã ¹Ýº¹ÇÒ¼ö ÀÖÀ¸¸ç ¼º°ø·üÀº µ¿ÀÏÇÏ´Ù. ±×·¯³ª ¼¼¹øÂ°ºÎÅÍ

´Â restenosis rate°¡ Áõ°¡ÇÑ´Ù.

2) CABG - saphenous vein, internal mammary a. radial aÀÌ¿ë

- mortality < 1%

- ventricular dysfunction, comorbidities, 80¼¼¡è, surgical inexperience½Ã mortality¡è

- vein graft occlusion: ù 1³â³» 10-20%, ±×ÈÄ 5-7³â°£ ¸Å³â 2%, ±× ÈÄ·Ð ¸Å³â 4%

- long-term patency rate : inf. mammary a. & radial a > saphenous v

- ¼ö¼úÈÄ angina´Â 90%¿¡¼­ °¨¼ÒÇϳª 3³â³» 1/4ÀÌ Àç¹ßÇÑ´Ù.

- perioperative MI : 5-10%, ±×·¯³ª ´ëºÎºÐ ÀÛ°í, LV fx¿¡´Â ¿µÇâÀÌ ¾ø´Ù.

- surfival benefit : abnormal LV fx(EF<50%)¿¡¼­

* ´ÙÀ½ ȯÀÚ¿¡¼­ ¼ö¼ú·Î¼­ mortality¸¦ °¨¼Ò½Ãų¼ö ÀÖ´Ù.

i) one or two-vs CAD without significant P-LAD but high-risk criteria

on noninvasive testing

ii) sudden cardiac death¿¡¼­ »ýÁ¸ÇÏ¿´°Å³ª sustained VT¸¦ º¸ÀÌ´Â obstructive CAD

iii) previous CABG¸¦ ½ÃÇàÇÏ¿´°í multiple saphenous v graft stenosis(ƯÈ÷ LAG supply

ÇÏ´Â graft)

iv) prior PCI recurrent stenosis & high risk criteria

* Ideal candidates

75¼¼ ÀÌÇÏ, ³²ÀÚ, no other complicating ds, medical tx¿¡ Á¶Àý ¾ÈµÇ´Â disabling sx

more active life¿øÇÒ¶§, severe stenosis with chest discomfort

* higher periop mortality

CHF and/or LV dysfunction(EF<40%)

advanced age(>75¼¼), reoperation, urgent need for surgery, DM

3) PCI & CABG»çÀÌÀÇ ¼±ÅÃ

DM + 2°³ ÀÌ»óÀÇ vs ds = bypass surgery°¡ better outcome

single or 2-vs ds with normal or slightly depressed global LV fx

& anatomically suitable lesion = PCI

4. Unstable AP

1) °³¿ä

* 3 groups

i) new onset(<2mo) angina, severe and/or frequent(¡Ã3 episodes/day)

ii) accelerating angina

¿¹) chronic stable angina°¡ more frequent, severe, prolonged angina·Î ÁøÇà,

ȤÀº ÀÌÀüº¸´Ù ´úÇÑ ¿îµ¿¿¡µµ angina°¡ À¯¹ß

iii) resting angina

* 5 mechanisms

i) fissured atherosclerotic plaqueÀ§¿¡ nonocclusive thrombus(often a platelet plug)

ii) dynamic obstruction(Prinzmetal's variant angina¿Í °°Àº epicardial coronary a.

spasm ¶Ç´Â microvascular anginaó·³ coronary microcirculationÀÇ abnormal

vasoconstriction)

iii) severe, organic luminal narrowing : PCIÈÄ restenosis

iv) arterial inflammation leading to thrombosis

v) fixed, severe coronary obstructionÀÖ´Â »óÅ¿¡¼­ tachycardia, fever,

thyrotoxicosis¿Í °°Àº »óȲÀ¸·Î ÀÎÇÑ ½É±Ù »ê¼Ò¿ä±¸·®ÀÇ Áõ°¡.

chest pain½Ã transient myocardial ischemiaÀÇ ECGº¯È­(ST-segment changes

and/or T wave inversion)°¡ µ¿¹ÝµÈ´Ù¸é ¾à 85%¿¡¼­ ÇѰ³ ÀÌ»óÀÇ major epicardial

coronary a.ÀÇ critical stenosis°¡ ÀÖ´Ù.

2) Ä¡·á

- rest, sedation, reassurance

- ischemia¸¦ ¾ÇÈ­½ÃŰ´Â µ¿¹Ý»óŸ¦ Ä¡·á : tachycardia, hypertension, DM, cardiomegaly,

heart failure, arrythmia, thyrotoxicosis, any acute febrile illness

- serial ECG & cardiac enzymeÀ» checkÇÏ¿© AMI¸¦ ¹èÁ¦ÇØ¾ß ÇÑ´Ù.

- thrombus°¡ Çü¼ºµÉ¼ö ÀÖÀ¸¹Ç·Î IV heparinÀ» 3-5Àϰ£ »ç¿ëÇϵµ·Ï ÇÑ´Ù(PTT 2-2.5¹è)

±×ÈÄ oral aspirin 325mg/d

LMWH»ç¿ë°¡´É

- high risk(rest pain, ST seg deviation, troponin I or T(+)) -> Gp IIb/IIIa inhibitor IV

- ÅëÁõÀÌ »ç¶óÁöÁö ¾ÊÀ¸¸é ¥â-blocker, Ca antagonist¸¦ Á¶½ÉÇØ¼­ Åõ¿© : S/EÀß °üÂû

- IV NTG : quite effective

- initial stabilizationÈÄ invasive tx(CAG & revasculaization) or early conservative tx

(continued medical tx)¸¦ ÇÒ¼ö ÀÖ´Ù.

- ´ëºÎºÐ(80%) rest & medical tx·Î 48½Ã°£³» È£ÀüµÇ¸ç 24-48½Ã°£ Ä¡·áÈÄ¿¡µµ ÅëÁõÀÌ Áö¼Ó

µÈ´Ù¸é cardiac cath & CAG¸¦ ½ÃÇàÇØ¾ß ÇÑ´Ù.

- early conservative tx¿¡¼­ sx & signÀÌ Á¶ÀýµÇ¸é diagnostic exercise ECG or perfusion

scan(or pharmacologic stress test)À» Åð¿ø¿¡ ÀÓ¹ÚÇØ¼­ ½ÃÇàÇØ¾ß ÇÑ´Ù.

- severe myocardial ischemia and/or high risk of coronary event°¡ º¸À̸é cath &

revascularizationÀ» °í·ÁÇØ¾ß ÇÑ´Ù.

- Åð¿øÈÄ Ä¡·á´Â CSAP¿Í °°´Ù.

5. Prinzmetal's variant angina

- unstable anginaÀÇ uncommon form

- recurrent, prolonged attacks of severe ischemia

- episodic focal spasm of a epicardial coronary a.¿¡ ÀÇÇØ ¹ß»ý

- 3/4¿¡¼­ spasm siteÀÇ 1cm³»¿¡ mild or moderately severe fixed obstruction(Á¤»ó

Á÷°æÀÇ 50-75%)µ¿¹Ý

- ÁÖ·Î smoker, coronary atherosclerosis¿¡ ÀÇÇØ 2Â÷ÀûÀ¸·Î ¹ß»ýÇÑ unstable anginaȯÀÚ

º¸´Ù ÀþÀº ³ªÀÌ¿¡¼­ ¹ß»ý

- rest½Ã¿¡ ¹ß»ý, Àá¿¡¼­ ±ý¶§

- multilead ST-segment elevation

- Áø´Ü : CAG¿¡¼­ acetylcholine intracoronary injection, hyperventilationÁÖÀÔÈÄ¿¡

transient spasmÀ» detectÇÔÀ¸·Î½á È®Áø

- long term survival : excellent

- Cx : disabling pain, MI, severe ventricular arrhythmia, AV block, rarely sudden

death

- Ä¡·á i) acute attack½Ã NTG SL

IV infusion of NTG

Short-acting nifedipine(10-30mg)

hypotensionÀº ÇÇÇÒ°Í.

ii) chronic management ; long-acting nitrates, Ca antagonist

¥â-blocker : little value

selective ¥á-blocker(Prazocin) - useful

- ½ÉÇÑ ÇùÂøÀÌ ÀÖÀ»¶§´Â mechanical revascularizationÀÌ µµ¿òÀÌ µÈ´Ù.

6. Asymptomatic(silent) ischemia

Ä¡·á´Â °³º°È­ÇØ¾ß ÇϹǷΠ´ÙÀ½ »çÇ×À» °í·ÁÇØ¾ß ÇÑ´Ù.

i) stress test¿¡¼­ positivityÁ¤µµ

ii) positive response¸¦ º¸À϶§ ant°¡ infº¸´Ù less favorable prognosis

iii) pt's age, occupation, general medical conditionÀ» °í·Á

¿¹> 45¼¼, ºñÇà»ç, 0.4 mV ST depression(V1-4) => CAG

75¼¼, ÀºÅð, 0.1 mV depression(II, III) => Çʿ䡿

noninvasive test¿¡¼­ severe ischemia¸¦ º¸À϶§ CAG¸¦ ½ÃÇàÇØ¾ß ÇÑ´Ù.

silent ischemia, 3 vs CAD, LV functionÀå¾Ö => CABG´ë»óÀÌ µÊ.