- 1. 1 2 3 3 3 3 4 4 6 1. 9 2. 14 3. 15 4. 18 5. 20 1 23 24 25 25
1 26 ST elevation 2 27 1 28 2 noninvasive stress test 29 3 30 2 34
3 35 4 35 5 36 6 36 37
- 2. Cardiac imaging 1
- 3. . . . . . . . 2
- 4. Cardiac imaging () (Ischemic heart disease, IHD) (Coronary
arterydisease, CAD) 50 2 (Stable angina) (Acute coronary syndrome)
3
- 5. (stable angina) (chronic stable angina) (chronic ischemic
heart disease) 2 (Acute coronary syndrome, ACS) (Rest angina) 20 2
1. ST elevation acute coronary syndrome ST segment 2 leads LBBB
Acute ST elevation myocardial infarction (STEMI or Acute transmural
MI or Q-wave MI) 2. Non ST elevation acute coronary syndrome
STsegment elevation ST segment depression / T wave inversion 30
non-ST elevation MI ( NSTEMI, or Non-Qwave MI ) (Unstable angina)
4
- 6. 1. randomized control trials meta- analysis inclusion
criteria baseline 2. 5
- 7. - - - - - - - - - - - - - , - / , - - - - - (IABP) - general
chemistry / - general chemistry - general chemistry cardiac markers
- cardiac enzyme / cardiac - cardiac enzyme troponin - cardiac
troponin - - - - - - - - (CPR) - 6
- 8. - - - - - - ST - elevation - - - - - - - - - - ST elevation
- - - - 7
- 9. - (IABP) temporary pace maker 8
- 10. (silent myocardial ischemia or silentmyocardial infarction)
(Typical angina pectoris) 30 1. 2. 3. 4. 5. 1. (angina pectoris)
sternum 2 2-3 nitroglycerin 1. ( 50) (exercise stress test) 2.
(aortic dissection) (acute pulmonary embolism) 3. (acute coronary
syndrome) 20 9
- 11. 4. troponin troponin 2 4 1 9 5. (coronary angiography) 50 1
(echocardiography) (percutaneous coronary intervention) (coronary
artery bypass graft surgery) 2 2 1. (intensive care unit, ICU)
(coronary care unit, CCU) 2 1.1 non-ST elevation acute coronary
syndrome non-ST elevation myocardial infarction unstable angina 1)
aspirin thienopyridine thienopyridine aspirin clopidogrel aspirin
2) unfractionated heparin low molecular weight heparin 3-5
(antianginal drugs) nitrates, beta-blockers short acting
dihydropyridine calcium channel blockers 3) narcotics analgesics 4)
(cardiogenic shock), , 1.2 ST-elevation acute coronary syndrome
(ST-elevation myocardial infarction) 1) 1.1 2) (thrombolytic agent)
(primary percutaneous transluminal coronary angioplasty, primary
PTCA) 6 12 12 10
- 12. 3) heparin ( 3 )2. 1) oxygen demand supply , , 2) 3) 4) 1.
( 1 )2. 1. 1) 2) (risk stratification) 3) revascularization 3.1 3.2
3.3 11
- 13. 2. 2 2.1 non-ST elevation (non-ST elevation ACS) 1) ( .) 2)
revascularization 2.1 2.2 l 2.3 1) 2) ST depression 3) Ventricular
tachycardia 4) 5) 6) < 40 % 7) noninvasive stress test 8) 6 9)
10) revascularization 48 3) (risk stratification) ( ) 3 5 2.2 ST
segment elevation 1) 12 1.1 ( 12 ) 1.2 1.3 30 90 1.4 60 12
- 14. 2) reperfusion 90 ( ST elevation) 3) / (cardiogenic shock)
4) revascularization ruptured interventricular septum, ruptured
papillary muscle, pericardial effusion, intractable left
ventricular failure, intractable ventricular arrhythmia, post
myocardial infarction angina, recurrent myocardial infarction5) /
13
- 15. 2. 2 1 2 , , , , 3 Ischemic cardiomyopathy, valvular heart
disease,congenital heart disease chronic obstructive pulmonary
disease,pulmonary hypertension, , 1. / 2. 3. 3.1 (acute ischemia)
(acute MI) LBBB (OLD MI), LV aneurysm 3.2 4. (regional wall motion
abnormality), 14
- 16. 3. 3.1 1. S3 gallop Killips classification ( ) 2. (acute
ischemia infarction pattern) 3. 4. acute pulmonary emboli, acute
respiratory distress syndrome, acute pneumonia, acute asthmatic
attack rupture chordae tendinae, rupture sinus of valsava, acute
myocarditis 5. cardiac markers (cardiac enzyme, troponin) 6.
rupture papillary muscle rupture interventricular septum murmur ,
nitrate 1. 15
- 17. 2. nitroglycerine 90 3. morphine 90 4. 5. (intra-aortic
balloon pump, IABP) 6. ruptured papillary muscle, rupture
interventricular septum 3.2 1. (mitral regurgitation) 2. (Q wave
myocardial infarction pattern) non-ST elevation MI 3. (pulmonary
congestion) 4. 16
- 18. 5. , chronic pulmonary emboli, pulmonary arterial
hypertension cardiomyopathy, constrictive pericarditis 1.
revascularization 2. betablockers preload afterload nitrate ACEI 3.
betablockers betablocker 4. revascularization 17
- 19. 4. (cardiogenic shock Killip class IV) 1. (shock) 2. ,
cardiac enzyme troponin 3. cardiac arrhythmia, complete AV block,
rupture papillary muscle, rupture IVS, rupture free wall 4. central
venous pressure, arterial line, Swan Ganz cardiac output 1. 2.
250-500 . 3. dopamine 5-20 / dubutamine 10-40 4. 18
- 20. 4 5. revascularization 6. 7. ruptured papillary muscle,
ruptured interventricular septum 19
- 21. 5. (syncope) 1. (cardiac arrest) ventricular standstill
ventricular fibrillation 2. 12 lead (ischemic pattern) 3. 4.
(syncope) 24 (Holters monitoring) (tilt table test) (cardiac
electrophysiologic study) 1. (cardiac massage) (ventricular
standstill) adrenaline (1:1,000) 1 . 5-10 . (endotracheal tube)
calcium chloride calcium gluconate 2. Ventricular tachycardia
ventricular fibrillation 20
- 22. 3. (temporary pacemaker) 3 (3rd degree AV block) 4. 5.
21
- 23. 22
- 24. 1 - 1 20 - , aspirin 160 325 . Nitroglycerin EKG 12 lead
1,2 ( 90% Aspirin 160 320 mg () ECG 12 lead Nitroglycerin Morphine
cardiac marker, electrolyte Nitroglycerin EKG 12-lead ST elevation
LBBB ST elevation 5 (ST-Elevation ACS) (Non ST elevation ACS)
Nitroglycerin -Adrenergic receptor blockers -Adrenergic receptor
blockers ( 1) Thienopyridine Thienopyridine Troponin Heparin (UFH
or LMWH) Heparin (UFH or LMWH) No admission ICU/CCU admission ICU
/CCU 12 >12 hours EKG 12 lead cardiac markers (Serial cardiac
markers) 2) 8. (CPR) 10 9. 1. streptokinase streptokinase 2. /
streptokinase 3. 4. 24
- 26. 1. 2. 12 lead 30 ST segment 50 90-120 3. 90-120 1. 2. ST
(ST resolution) 120 3. - accelerated idioventricular rhythm -
frequent premature ventricular complexes ( 2 90 ) - nonsustained
ventricular tachycardia 4. cardiac enzyme CK-MB 12 ( reperfusion
CK-MB 24-36 ) 25
- 27. 1 ST elevation 1: 15 12 ? 2: EKG 12 lead ST segment 2 lead
/ LBBB ? (streptokinase) 1 1. 180/110 2. hemorrhagic stroke 2.
nonhemorrhagic stroke 1 3. 4. 6 5. 15 . 6. warfarin (INR > 2) 8.
(CPR) 10 9. ? 3: 1. > 100 100 . 2. 3. 90/60 . 4. 5.
streptokinase 26
- 28. 2 nitrate (sublingual spray) beta blockers beta blockers *
calcium antagonists / long-acting nitrates (HbA1c1C < 7%) ( <
140/90 . 130/80 . ) * calcium (BMI < 23 ..) antagonists /
long-acting nitrates ( < 80 . , 90 . ) (LDL-C < 100 ..) *
beta blockers calciumantagonists / long-acting nitrates beta
blockers Invasive procedure (ASA 75-325 ./) ACE inhibitor *
short-acting dihydropyridine calcium antagonists 27
- 29. 1 (HIGH RISK) (INTERMEDIATE RISK) (LOW RISK) - - 48 , , - -
- 20 - 20 ( CCS class III IV) 2 20 - - 70 75 - - S3 gallop (rales)
- , - 75 - - symmetrical T-wave - ST-segment inversion 0.2 .
depression > 0.05 . - pathologic Q waves - BBB - sustained VT
cardiac - Troponin ( > - Troponin ( > 0.01-0.1 - troponin
markers 0.1 ng/mL) ng/mL) - cardiac enzyme - cardiac enzyme -
cardiac enzyme 28
- 30. 2 noninvasive stress test Exercise treadmill test ischemic
ST-segment shifts 6.5 METs ischemic ST-segment shifts 120
ST-segment depression elevation 0.2 mV(2 mm) ST-segment shifts
leadsST-segment shifts 6 10 . 130 . ST-segment shifts ST-segment
elevation sustained ventricular tachycardia (VT) Stress
radionuclide imaging myocardial perfusion 1 reversible defect
anterior wall myocardial perfusion lung uptake resting ejection
fraction (EF) 0.35 exercise EF 0.50 EF stress 0.10 Stress
echocardiography resting EF < 0.35 wall motion abnormality 2
segments low dose dobutamine( < 10 mg/kg/min) 120 29
- 31. 3 /Aspirin (ASA) - - 160-325 . - 75-325 . bronchospasm,
angioedema, - anaphylaxis - (active bleeding) (secondary
prevention)Thienopyridine - - Clopidogrel 300 . rash, severe ASA (
75 . neutropenia, thrombotic ASA) - Ticlopidine 500 .
thrombocytopenic purpura - 250 . 2 (TTP) ticlopideine (coronary
clopidogrel stents) ASA 1 - ASA 1-9 Fibrinolytic - - SK 1.5 mU IV
drip 60 1Agents ST elevation 12 . - rt-PA 15 mg IV bolus 0.75 mg/kg
( 50 mg) IV 30 0.5 mg/kg ( 35 mg) IV 60 - APSAC 30 mg IV 5 - rPA 15
mU IV 2 30 - TNK-tPA 0.5 mg/kg IV bolus 30
- 32. /Heparin (UFH) - 50-70 U/kg ( 5000 - 3-5 U) IV bolus IV
drip - heparin-induced - 12-15 U/kh/hr ( 1000 thrombocytopenia
(HIT) U/hr) aPTT 24 1.5-2.5 - rt-PA, rPA, TNK-tPA, SAK 24-48 . -
systemic emboli Low molecular - - Enoxaparin 1 mg/kg SC - heparin
3-5 12 . - HIT UFH - Dalteparin 120 U/kg ( - - reperfusion therapy
10000 U) SC 12 . creatinine clearance 48-72 . - Nadroparin 0.1
cc/kg SC 30 12 .GP IIb/IIIa - - Abciximab 0.25 mg/kg IV -
immunogenicity receptor (Eptifibatide bolus 10 antagonists
Tirofiban) 0.125 Abciximab - g/kg/min ( 10 g/kg/min) IV drip 12 .
(Abciximab) - Eptifibatide 180 g/kg IV bolus 2.0 g/kg/min IV drip
72-96 . ( 24 . PCI) - Tirofiban 0.4 g/kg IV 30 0.1 g/kg/min IV drip
48-96 . ( 12-24 . PCI)Warfarin - - INR - drug-drug food- 2-3 drug
interaction systemic emboli ASA 31
- 33. /Beta-blockers - : - Beta- - Propanolol 1 . 5 blockers -
0.15 ./. - ( - Metoprolol 5 .IV 5 60 - x 3 ) - - Atenolol 5 .IV 10
x - ( 2 - 100 ) : . - - Atenolol 50-200 . - PR interval 0.24 -
Metoprolol 50-200 . sec - AF - Propanolol 20-80 . 2 - second third
degree ventricular rate AV block bifascicular - Bisoprolol 5-10 .
block - - Calcium - - Diltiazem 120-320 . - LVEF