急性冠心症和心臟衰竭診斷與治療

高雄長庚醫院胸腔內科 王逸
熙
 急性心肌梗塞的診斷
持續胸痛
心電圖上有 ST 波段的位移
心肌酵素上昇
Chronic Stable Angina Acute Coronary Syndrome
 ER Patient Care
Initial assessment (< 10 Obtain initial cardiac
min) marker levels
Measure vital signs Evaluate initial
Measure SpO2 electrolyte and
Obtain IV access coagulation studies
Obtain 12-lead ECG Request, review
portable chest x-ray
Perform brief, targeted
(<30 min)
history and PE)
 ER patient care
Initial general treatment (memory aid:
“MONA” greets all patients
– Morphine, 2-4 mg repeated q 5-10 min
– Oxygen, 4 L/min; continue if SaO2 < 90%
– NTG, SL or spray, followed by IV for
persistent or recurrent discomfort
– Aspirin, 160 to 325 mg (chew and swallow)
 Triage by ECG
ST elevation or new LBBB
– ST elevation ≧1 mm in 2 or more contiguous leads
ST depression or dynamic T-wave inversion
– ST depression > 1 mm
– Marked symmetrical T-wave inversion in multiple
precordial leads
– Dynamic ST-T changes with pain
Non-diagnostic ECG or normal ECG
 Suspicious Chest Pains
Classic angina - dull, pressure,
substernal; arm or neck radiation; SOB,
palpitations, sweating, nausea or vomiting
Angina Equivalent - no pain but sudden
ventricular failure or ventricular
dysrhythmias
Atypical chest pain - precordial area but
with musculoskeletal, positional, or
pleuritic features
 Typical Chest Pain
SAVEN 鑑別口訣
S: Substernal area
A: Abrupt onset
V: Vagus distribution
E: Exertion-related
N: NTG or Rest relieve it!
常見胸痛的輻射位置
 Cardiac Markers
Myoglobin Inflammatory Markers
– Nonspecific – Can indicate plaque or
– Rapid-release kinetics systemic inflammation
– Useful for its negative associated with ACS
predictive accuracy in – CRP identifies a
the early hours after subgroup of patients
symptom onset with unstable angina at
– Useful marker for high risk for adverse
reperfusion cardiac events
 Cardiac Markers
CK-MB Isoforms Troponins (cTnT or cTnI)
– Improved sensitivity – Troponin I/Troponin T
compared with CK-MB – Increased sensitivity
– Only one form in the compared with CK-MB
myocardium – Detect minimal myocardial
– CK-MB2 > 1U/L or CK- damage
MB2/CK-MB1 > 2.5% – Useful in risk stratification
– < 0.04 ng/ml (normal)
– > 0.5 ng/ml (cut off value of
MI)
 ACS algorithm consider clinical trials

symptoms of acute ischemia pain-free, low-to-mod

risk, neg or nonspecific
ASA 325 mg initial ECG, neg CK-MB, TnT/I
dose; 160 mg qd chest
ST ↑, LBBB
non ST ↑ ACS, pain unit
<12 h ≥12 symptoms mod-to-high risk
symptoms
antithrombotic therapy

reperfusion therapy dynamic ST shifts, NSSTT ∆s,

+ cardiac markers – cardiac markers

TT TT
“ineligible,” “eligible” eptifibatide heparin
shock or tirofiban + therapy
direct PCI heparin
consider TT no cath cath in
(TTB<90 min) (consider
primary TNK in 12 h 12 h
enoxaparin)
PTCA, IABP
early cath enoxaparin UFH
Cr >2.5 mg/dL Cr <2.5 mg/dL
clopidogrel (reasonable certainty
UFH enoxaparin patient will not have early CABG)
ST Elevation Myocardial
Infarction (STEMI)
Coronary Artery Anatomy
Acute Myocardial Infarction
(STEMI, inferior wall)
Ventricular Tachyarrhythmia
RV Involvement ? Right Precordial Leads

R R

R R
Heart Block and Bradycardia
Complete heart block
Anterior wall STEMI
Left bundle branch block
Post MI Mechanical Complications
VSD 心室中隔缺損
Acute MR 急性二尖瓣閉鎖不全
Free wall rupture 心臟破裂
Cardiac tamponade 心包填塞
Dressler’s syndrome 心包膜炎
Cardiogenic shock / pumping failure 心因性休克
Malignant cardiac arrhythmia 惡性心律不整
IABP 主動脈內氣球幫浦

General Medical
Indication:

5. Left ventricular power failure

7. Cardiogenic shock

9. Pre-shock syndrome

11. Myocardial ischemia

12. Acute MR or VSD

13. Drug refractory - Malignant

Ventricular arrhythmia
recurrence due to Myocardial
ischemia
 placement of the IAB in the
descending aorta with it’s tip at the
distal aortic arch (below the origin of
the left subclavian artery)
 helium -- lower density and a better
rapid diffusion coefficient
 carbon dioxide -- increased
solubility in blood and reduces the
potential consequences of gas
embolization following a balloon
rupture
 the balloon is connected to a drive
console (consists of a pressurized
gas reservoir, a monitor for ECG and
pressure wave recording,
adjustments for inflation/deflation
timing, triggering selection switches
and battery back-up power sources)
a pressurized gas
reservoir, adjustments
for inflation/ deflation
timing, triggering
selection switches and
battery back-up power
sources
Monitor for a ECG
and pressure wave recording
Intra-aortic balloon pump in Cardiogenic Shock
 Reperfusion Strategy for
STEMI
1. Thrombolytic (Fibrinolytic) Therapy
2. Primary PTCA
3. Emergency CABG
 ST elevation or new LBBB
Start adjunctive treatment
If time < 12 hr
– Select a reperfusion strategy based on local
resources
If time > 12 hr
– Assess clinical status, either high-risk or
clinically stable
 ST elevation or new LBBB
Adjunctive treatments
– β-blockers
– NTG IV
– Heparin IV
– ACE inhibitors (after 6 hours or when stable)
ST elevation or new LBBB, time < 12 hr

Reperfusion strategy based on local

resources
– Thrombolytics (< 30 min)
TPA 15 mg bolus + 0.75 mg/Kg over 30 min + 0.5
mg/Kg over 60 min or
SK 1.5 million IU over 1 h
– Primary percutaneous coronary intervention
(PCI, angioplasty ± stent) (90 ± 30 min)
– Cardiothoracic surgery backup
ST elevation or new LBBB, time > 12 hr

Perform cardiac Admit to CCU/

catheterization for monitored bed if
high-risk patients clinically stable
– Continue or start
– Persistent symptoms
adjunctive treatments
– Depressed LV function – Serial serum markers
– Widespread ECG – Serial ECG
changes – Consider imaging
– Prior AMI, PCI, CABG study (2D
echocardiography or
radionuclide)
 血栓溶解劑的臨床好處
Benefit of Thrombolytics

Time Lives saved/1000

< 1h 65
1-2 h 37
2-3 h 29
3-6 h 26
6-12 18
12-24 9
Contraindications to Thrombolytics

Absolute ：
– Previous hemorrhagic stroke
– CVA within past 1 year
– Brain neoplasm
– Active internal bleeding
– Suspected aortic dissection
 血栓溶解劑的禁忌症
Contraindications to Thrombolytics

Relative:
– BP > 180/110 or – Traumatic CPR (>10 min)
chronic severe – Major surgery < 3 wks
hypertension – Previous SK
– On anticoagulants – Active ulcer
– Trauma or internal – Pregnancy
bleeding < 2-4 wks – Hidden puncture
 Reperfusion Evidence

ST Elevation Subsides (> 50 %)

Symptom of Angina Relieved
Reperfusion rhythm (AIVR)
Cardiac Enzyme early peak (12-20 hour
after onset of chest pain)
AIVR (Accelerated Idio-Ventricular Rhythm)
or Slow VT
介入性心導管術
PTCA (Balloon Angioplasty)
Stent Implant
Primary PTCA with Stent
冠狀動脈氣球擴張術前

狹窄處
氣球擴張術中
 冠狀動脈氣球擴張術後

術後
Multivessel Disease
CABG is Recommended
冠
狀
動
脈
繞
道
手
術
冠
狀
動
脈
繞
道
手
術
Unstable Angina
NSTEMI
Definition of Unstable Angina
Recurrent ischemic symptoms while on therapy
High risk findings on stress test (see stress test section)
Reduced LV function, with ejection fraction LVEF < 40%
Clinical evidence of CHF during chest pain
Hemodynamic instability
Sustained ventricular tachycardia
Percutaneous intervention within the past 6 months
Prior CABG surgery
Elevated troponin or other markers of necrosis
Dynamic ECG changes at presentation
Unstable Angina & NSTEMI
ST depression or dynamic T-wave inversion

Thrombolytics contraindicated
Adjunctive therapy:
– Heparin (UFH/LMWH)
– Aspirin 160-325 mg qd
– Glycoprotein IIb/IIIa receptor inhibitors
– Clopidogrel (Plavix)
– NTG IV
β-blockers
Cardiac catheterization for high-risk patients or
monitoring for clinically stable patients
 Lower dose of heparin
To reduce the incidence of ICH
Bolus dose: 60 U/kg (maximum 4000U)
Maintenance dose: 12 U/kg/hr (maximum
1000 U/hr for patients weighing < 70 kg)
Optimal aPTT: 50-70 sec
 Clopidogrel (Plavix)
blocks the platelet ADP receptor
emerging as an important agent both in
the acute and in the chronic phases of
acute coronary syndromes.
nearly universally used in conjunction with
coronary stenting.
Platelet Aggregation
Glycoprotein IIb/IIIa receptor inhibitors
Inhibits the GP IIb/IIIa receptor in the
membrane of platelets
Inhibits final common pathway activation
of platelet aggregation
Available approved agents
– Abciximab (ReoPro)
– Eptifibitide (Integrilin)
– Tirofiban (Aggrastat)
Benefit of clopidogrel & glycoprotein
IIb/IIIa inhibitors stratified by cardiac markers
 ACS acute care algorithm
for centers with a cath lab and primary PCI capability
symptoms of acute ischemia pain-free, low-to-mod
risk, neg or nonspecific
ASA 325 mg initial ECG, neg CK-MB, TnT/I
dose; 160 mg qd chest
ST ↑, LBBB
non-ST ↑ ACS, pain unit
<12 h ≥12 symptoms mod-to-high risk
symptoms
antithrombotic therapy
reperfusion therapy
dynamic ST shifts, NSSTT ∆s,
+ cardiac markers – cardiac markers
TT
“ineligible,” TT
shock “eligible” eptifibatide heparin
or tirofiban + therapy
emergent thrombolysis primary PCI heparin
cath, PCI, (with TNK, (if time to (consider no cath cath in
IABP for consider balloon enoxaparin) in 12 h 12 h
shock enoxaparin) <90 min) early cath enoxaparin UFH
Cr >2.5 mg/dL Cr <2.5 mg/dL
clopidogrel (reasonable certainty
UFH enoxaparin patient will not have early CABG)
 什麼是心衰竭 ??
心臟衰竭就是心臟功能發生問題
，最常見的是無法輸出足夠的血
量，供應身體各部份組織器官的
需 要
NYHA classification for CHF
 心衰竭有什麼症狀 ??
喘
1. 呼吸困難：病人運動或工作時，就會
呼吸困難，嚴重時，甚至於躺在床上
或休息時，也會感覺呼吸困難。
2. 端坐呼吸：嚴重的心臟衰竭，病人平
躺時會感到呼吸困難；需藉著坐起來
或墊高枕頭才得以緩解。
3. 陣發性夜間呼吸困難：病人易從睡夢
中驚醒，呼吸較費力且有喘鳴聲，需
藉著坐起來或打開窗戶呼吸新鮮空氣
來緩解。
4. 肺水腫 ; 咳嗽
 腫
1. 下 肢 水 腫 ： 開 始 出 現 在 身 體 下
端部份，典型是發生在下肢踝
部。
2. 可能導致肝腫大，易出現腹水
及黃疸等肝臟受損的症狀。
3. 可能導致頸靜脈怒張。
 心臟方面的症狀
a. 心臟跳動加快出現奔馬律。
b. 大部份的病人會出現心臟擴大的
情形。
c. 心臟跳動有雜音或跳動不規則。
New Approach to the Classification

Stage Patient Description

Hypertension
High risk for
A developing CHF
CAD, cardiotoxin exposure
Diabetes mellitus
Family history of cardiomyopathy
Known structural heart disease
Asymptomatic CHF
B Cardiomegaly, Previous MI, valvular
disease, LV systolic dysfunction
Overt CHF
Symptomatic CHF
C Symptoms may be current or prior

Marked symptoms at rest despite maximal

Refractory
D end-stage CHF
medical therapy (eg, those who are
recurrently hospitalized or cannot be safely
discharged from the hospital without
specialized interventions)

Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

但是很不幸的 , 有超過一半以上的末期
CHF 病人 , 在等待 heart
transplantation 的過程當中 , 因為
CHF 引起的併發症 , 如 AMI 或是 VT 而死
亡。
在部份嚴重 congestive heart
failure 的病人 , 在用藥物之後 , 仍然
無法維持生命情形之下 , 所以使用 non-
Non-pharmacologic therapies of CHF
(1) Automatic implantable
cardioverter defibrillator (AICD)
(2) Left Ventricular Assist Device (LVAD)
(3) Intra Aortihc Balloon Pump (IABP)
(4) Extracorporeal membrane oxygenator (ECMO)
(5) Coronary revascularization
( hibernating and stunned myocardium)
(6) Reconstructive cardiac surgery
(been largely abandoned)
(7) Mitral valve repair in dilated cardiomyopathy
(8) LV aneurysmectomy in symptomatic patients
Left Ventricular Assist Device

 正常情形下 , 血液先經由
LV apex 的入口 , 經由
人工血管 (inflow
graft) 流入血液幫浦的
血液室中 , 經 pump 壓縮
之後 , 再經由人工血管
(outflow graft) 流出
, 將血液送至 ascending
aorta, 以供應身體所需
。
 而 pump 之出入口中 , 各
有一個豬瓣膜 , 以維持血
Left Ventricular Assist Device

 LVAD 在 1985 年正式獲得美國的通過 , 准許可

應用於臨床上嚴重心衰竭的病人 , 做為一個等待
心臟移植的橋 。並於 1986 年有了全世界首例
的使用。
 在一開始研發之時 , 目的就是在建立一個長期的
左心室輔助系統 , 希望病人能夠在等待心臟移植
的漫漫長路之中 , 有一個安全穩定的依靠。
 由於等待心臟移植的病人日益增加 , 而捐心者並
沒有成比例增加的情況之下 , 可以預期的是每一
位等待換心的病人 , 他的等待換心期間將會愈來
Left Ventricular Assist Device

LVAD 主要是針對慢性心衰竭病患在等待換心
期，產生嚴重心衰竭時輔以高劑量強心劑，或
IABP 仍無法維持足 之心輸出量情況下，所
需考慮的治療方式。
病患的血液動力學狀況必需符合下列標準，才
考慮進行 LVAD 的植入手術 :
(1) Pulmonary capillary wedge pressure
> 20mmHg
Left Ventricular Assist Device

LVAD 在美國而言，已經是通過 FDA 核准

，在臨床上使用的醫療項目，而且醫療保
險公司也將此醫療支出納入給付項目之一
。
可是在國內而言，依然目前法律規定，
HeartMate LVAD 及 Novacor LVAD 的
治療尚屬於人體臨床試驗的項目，健保不
給付，而必需由實驗經費來負擔， 大的
醫療經費支出，造成推廣的困難。
Left Ventricular Assist Device

據大規模的資料統計 , 接受 LVAD 植入的病人 ,

比起對照組病人而言 ,LVAD 可以有意義的改善 :
(1) 病人的 survival rate and length
(2) 病人 CHF 的症狀 : 接受 LVAD 的病人
,
術前皆為 NYHA Fc IV, 而接受完手術
之後
, 心臟功能幾乎都轉變為 NYHA Fc I
(3) 因為 cardiac output 的大幅增加 ,
Left Ventricular Assist Device

嚴重心臟衰竭只用 LVAD 病人約有 20% 持續右心

衰竭，所以右心房壓力太高 ( 如 > 20mmHg)
或肺動脈阻力太大 ( 如 > 5 Wood Units) 或
右心收縮力太差 ( 如 RVEF < 10%) 者，不要單
獨使用 LVAD ，因嚴重右心衰竭會使 LVAD 無法
有效運作，需要 快再裝上右心室輔助器
(RVAD) 。
在使用雙心輔助器 (BVAD) 時，為避免
pulmonary edema ，通常將 RVAD 的流量調得
LVAD
AICD
Implantable cardioverter defibrillator

Sudden death is a major cause of mortality

in patients with ventricular dysfunction.
Current methods of risk stratification are
inadequate, and a rational therapy for
prevention of sudden death is not available.
The implantable cardioverter-defibrillator
(ICD) has proven to be more effective
than drugs in reducing sudden-death risk
in some subsets of patients.
IABP
Mechanism of IABP
 Mechanism of IABP

Improvement in coronary blood flow occurs

without an increase in myocardial work and
results in a 10-20% reduction in oxygen
consumption.
Thus, the net effect of IABP in cardiogenic
shock is to increase coronary blood flow and
myocardial oxygen supply while reducing
myocardial work and oxygen consumption.
Cardiac output may increase by as much
as 50%.
Thanks for your attention!