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» »êȽÃÄÑ 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¸¦ ¾ÇȽÃŰ´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.