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1 Vol.11 No ISSN
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4 Copyright 2009 Cardiovascular Update Editorial Board. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without permission in written form from the copyright holder. This publication is published by MMK Co., Ltd. under continuing medical educational grant from AstraZeneca Ltd. and Novartis Korea. AP-CVUP-09-04
5 Continuing Medical Education inquiry@mmkgroup.co.kr
6
7 TOPIC 1. 8 TOPIC TOPIC TOPIC 4. 28
8 SECTION TOPIC 1 Total Male Female p Age (yrs) <0.001 Height (cm) <0.001 Weight (kg) <0.001 BMI (kg/m 2 ) <0.001 Typical symptom (%) <0.001 Pain (%) <0.001 Dyspnea (%) <0.001 Past IHD (%) Hypertension (5) <0.001 Diabetes (%) <0.001 Dyslipidemia (%) Smoking (%) <0.001 Family History (%) <0.001 BMI: body mass index, IHD: ischemic heart disease 8 Cardiovascular Update
9 Number of patients Percent NSTEMI (n=5,422) Early invasive treatment 2, % Early conservative treatment 2, % STEMI (n=8,156) Primary PCI 6, % Facilitated PCI % Thrombolytic therapy % Early conservative therapy 1, % NSTEMI: non ST-segment elevation myocardial infarction, STEMI: ST-segment elevation myocardial infarction Cardiovascular Update 9
10 SECTION TOPIC 1 STEMI (n=4,019) P-PCI ThX ConTx (n=2,847) (n=501) (n=625) Methods of PCI, n(%) <0.001 Balloon only 203 (7) 52 (13) 87 (19) Stent implantation 2,526 (93) 356 (88) 372 (81) Type of deployed stent, n (%) DES 2,292 (92) 329 (91) 336 (91) Bare metal stent 202 (8) 33 (9) 34 (9) P Death rate 0.4% Date rate 2.1% Fail Success rate 93% Fail Success rate 72% Result of P-PCI ConTx: conservation treatment, DES: drug-eluting stent,thx: thrombolytic treatment, STEMI: ST-segment elevation myocardial infarction, PCI: percutaneous coronary intervention Result of ThX 10 Cardiovascular Update
11 Variables 95% CI Hazard ratio P Age < < <0.001 Medical history Myocardial infarction Percutaneous coronary intervention Heart failure Clinical complication during hospitalization Heart failure Shock Major bleeding episode Ventricular tachycardia & fibrillation <0.001 LV ejection fraction <0.001 Multi-vessel disease LV: left ventricular Cardiovascular Update 11
12 SECTION TOPIC 1 1. Lee SR, Jeong MH, Ahn YK, et al; Korea Acute Myocardial Infarction Registry Investigators. Clinical safety of drug-eluting stents in the Korea acute myocardial infarction registry. Circ J 2008;72: Song YB, Hahn JY, Gwon HC, Kim JH, Lee SH, Jeong MH; KAMIR investigators. The impact of initial treatment delay using primary angioplasty on mortality among patients with acute myocardial infarction: from the Korea acute myocardial infarction registry. J Korean Med Sci 2008;23: Jeong HC, Ahn YK, Jeong MH, et al; Korea Acute Myocardial Infarction Registry Investigators. Intensive pharmacologic treatment in patients with acute non ST-segment elevation myocardial infarction who did not undergo percutaneous coronary intervention. Circ J 2008;72: Lee SH, Kim YJ, Kim W, et al; Korean Acute Myocardial Infarction Registry Investigators. Clinical outcomes and therapeutic strategy in patients with acute myocardial infarction according to renal function: data from the Korean Acute Myocardial Infarction Registry. Circ J 2008;72: Lee SH, Park JS, Kim W, et al; Korean Acute Myocardial Infarction Registry Investigators. Impact of body mass index and waist-to-hip ratio on clinical outcomes in patients with ST-segment elevation acute myocardial infarction (from the Korean Acute Myocardial Infarction Registry). Am J Cardiol 2008;102: Lee KH, Jeong MH, Ahn YK, et al; Other Korea Acute Myocardial infarction Registry Investigators. Gender differences of success rate of percutaneous coronary intervention and short term cardiac events in Korea Acute Myocardial Infarction Registry. Int J Cardiol 2008;130: Kwon TG, Bae JH, Jeong MH, et al; Korea Acute Myocardial Infarction Registry Investigators. N- terminal pro-b-type natriuretic peptide is associated with adverse short-term clinical outcomes in patients with acute ST-elevation myocardial infarction underwent primary percutaneous coronary intervention. Int J Cardiol 2009;133: Lee JH, Chae SC, Yang DH, Park HS, Cho Y, Jun JE, Park WH, Kam S, Lee WK, Kim YJ, Kim KS, Hur SH, Jeong MH; other Korea Acute Myocardial Infarction Registry Investigators. Influence of weather on daily hospital admissions for acute myocardial infarction (from the Korea Acute Myocardial Infarction Registry). Int J Cardiol Apr 27. [Epub ahead of print] 9. Lee JH, Park HS, Chae SC et al; Korea Acute Myocardial Infarction Registry Investigators. Predictors of 6-month Major Adverse Cardiac Events among 30-day Survivors after Acute Myocardial Infarction (from the Korea Acute Myocardial Infarction Registry). Am J Cardiol. 2009;104: Chen KY, Rha SW, Li YJ, et al; Korea Acute Myocardial Infarction Registry investigators. Triple versus dual antiplatelet therapy in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Circulation. 2009;119: Sim DS, Jeong MH, Ahn YK, et al; Korea Acute Muocardial Infartion Registry (KAMIR) Investigators. ty and benefit of early elective percutaneous coronary intervention after successful thrombolytic therapy for acute myocardial infarction. Am J Cardiol : Cardiovascular Update
13 SECTION TOPIC 2 Cardiovascular Update 13
14 SECTION TOPIC 2 Clinical classification of different types of myocardial infarction Type 1 Spontaneous myocardial infarction related to ischaemia due to a primary coronary event such as plaque erosion and/or rupture, fissuring, or dissection Type 2 Myocardial infarction secondary to ischemia due to either increased oxygen demand or decreased supply, e.g. coronary artery spasm, coronary embolism, anemia, arrhythmia, hypertension, or hypotesion Type 3 Sudden unexpected cardiac death, including cardiac arrest, often with symptoms suggestive of myocardial ischemia, accompanied by presumably new ST elevation, or new LBBB, or evidence of fresh thrombus in a coronary artery by angiography and/or at autopsy, but death occurring before blood samples could be obtained, of at a time before the appearance of cardiac biomarkers in the blood Type 4a Myocardial infarction associated with PCI Type 4b Myocardial infarction associated with stent thrombosis as documented by angiography or at autopsy Type 5 Myocardial infarction associated with CABG CABG: coronary artery bypass grafting, LBBB: left bundle-branch block, PCI: percutaneous coronary intervention 14 Cardiovascular Update
15 ECG manifestations of acute myocardial ischemia (in absence of LVH and LBBB) ST elevation New ST elevation at the J-point in two contiguous leads with the cut-off points: 0.2 mv in men or 0.15 mv in women in leads V2-V3 and/or 0.1 mv in other leads ST depression and T-wave changes New horizontal or down-sloping ST depression 0.05 mv in two contiguous leads; and/or T inversion 0.1 mv in two contiguous leads with prominent R-wave or R/S ratio >1 ECG: electrocardiogram, LBBB: left bundle branch block, LVH: left ventricular hypertrophy Cardiovascular Update 15
16 SECTION TOPIC 2 Common ECG pitfalls in diagnosing myocardial infarction False positives Benign early repolarization LBBB Pre-excitation Brugada syndrome Peri-/myocarditis Pulmonary embiolism Subarachnoid haemorrhage Metaboilc disturbances such as hyperkalaemia Failure to recognize normal limits for J-poin displacement Lead transposition or use of modified Mason-Likar configuration Cholecystitis False negatives Prior myocardial infarction with Q-waves and/or persistent ST elevation Paced rhythm LBBB ECG: electrocardiogram, LBBB: left bundle branch block 16 Cardiovascular Update
17 ECG changes associated with prior myocardial infarction Any Q-wave in leads V2-V s or Qs complex in leads V2 and V3 Q-wave 0.03 s and 0.1 mv deep or QS complex in leads I, II, avl, avf, or V4-V6 in any two leads of a contiguous lead grouping (I, avl, V6; V4-V6; II, III, and avf) a R-wave 0.04 s in V1-V2 and R/S 1 with a concordant positive T-wave in the absence of a conduction defect Elevations of troponin in the absence of overt ischemic heart disease Cardiac contusion, or other trauma including surgery, ablation, pacing, etc. Congestive heart failure-acute and chronic Aortic dissection Aortic valve disease Hypertrophic cardiomyopathy Tachy-or bradyarrhythmias, or heart block Apical ballooning syndrome Rhabdomyolysis with cardiac injury Pulmonary embolism, severe pulmonary hypertension Renal failure Acute neurological disease including stroke or subarachnoid haemorrhage Infiltrative diseases, e.g. amyloidosis, haemochromatosis, sarcoidosis, and scleroderma Inflammatory diseases, e.g. myocarditis or myocardial extension of endo-/pericarditis Drug toxicity or toxins Critically ill patients, especially with respiratory failure or sepsis Burns, especially if affecting >30% of body surface area Extreme exertion Cardiovascular Update 17
18 SECTION TOPIC 2 18 Cardiovascular Update
19 Cardiovascular Update 19
20 SECTION TOPIC 2 1. Thygesen K, Alpert JS, White HD, on behalf fo the Joint ECS/ACCF/AHA/WHF Task Force for th Redefinition of Myocardial Infarction, TASK FORCE MEMBERS. Universal Definition of Myocardial Infarction. Circulation 2007;116: The Joint European Society of Cardiology/ American College of Cardiology Committee. Myocardial Infarction Redifined - A Consensus Document of the Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction. JACC 2000;36: Fergusone JL, Beckett GJ, Stoddart M, Walker SW, Fox K. Myocardial infarction redefined: the new ACC/ESC definition, based on cardiac troponin, increases the apparent incidence of infarction. Heart 2002;88: Nomenclature and criteria for diagnosis of ischemic heart disease. Report of the Joint International Society and Federation of Cardiology/World Health Organization Task Force on standardization of clinical nomenclature. Circulation 1979;59; Blackburn H, Keys A, Simonson E, Rautaharju P, Punsar S. The electrocardiogram in population studies: A classification system. Circulation 1960; 21; Jeremias A, Gibson CM. Narrative review: Alternative causes for elevated cardiac troponin levels when acute coronary syndromes are excluded. Ann Intern Med 2005;142: Eggers KM, Lind L, Venge P, Lindahl B. Will the Universal Definition of Myocardial Infarction Criteria Result in an Over Diagnosis of Myocardial Infarction? Am J Cardiol 2009;103: Eggers KM, Lagerqvist B, Venge P, Wallentin L, Lindahl B. Persistent Cardiac Troponin I Elevation in Stabilized Patients After an Episode of Acute Coronary Syndrome Predicts Long-Term Mortality. Circulation 2007;116; Critchley J, Liu J, Zhao D, Wei W, Capewell S. Explaining the Increase in Coronary Heart Disease Mortality in Beijing Between 1984 and Circulation 2004;110; Abildstrom SZ, Rasmussen S, Madsen M. Chabges in hospitalization rate and mortality after acute myocardial infarctio in Denmark after diagnostic criteia and methods changed. Eur Heart J 2005;26: Cardiovascular Update
21 SECTION TOPIC 3 Call 119 Call fast Hospital fibrinolysis: Door-to-needle 30 min Note PCI capable Onset of symptoms of STEMI 119 EMS dispatch EMS on-scene Encourage 12-lead ECGs Consider prehospital fibrinolytic if capable and EMS-to-needle 30 min EMS triage plan Inter hospital transfer GOALS 5 min Patient Dispatch 1 min 8 min EMS EMS Transport Prehospital fibrinoysis EMS transport EMS-to-needle 30 min EMS-to-balloon 90 min Patient-self-transport Hospital door-to-balloon 90 min PCI capable Golden hour=first 60 min Total ischemic time: within 120 min ECG: electrocardiogram, EMS: emergency medical service, PCI: percutaneous coronary intervention, STEMI: ST-segment elevation myocardial infarction Cardiovascular Update 21
22 SECTION TOPIC 3 22 Cardiovascular Update
23 Cardiovascular Update 23
24 SECTION TOPIC 3 Ticopidine Clopidogrel Abciximab Eptifibatide Tirofiban ADP-receptor TXA 2 COX Arachidonic acid Aspirin GP IIb/IIIa receptor complex Collagen thrombin TXA 2 Dense granules -Granules 24 Cardiovascular Update
25 Cardiovascular Update 25
26 SECTION TOPIC 3 26 Cardiovascular Update
27 1. Antman EM, Hand M, Armstrong PW, et al Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2008;51; Anderson JL, Adams CD, Antman DM, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST- Elevation Myocardial Infarction. J Am Coll Cardiol 2007;50; Keeley EC, Hillis LD. Primary PCI for myocardial infarction with ST-segment elevation. N Eng J Med 2007;356: Svilaas T, Vlaar PJ, van der Horst IC, et al. Thrombus Aspiration during Primary Percutaneous Coronary Intervention. N Engl J Med 2008;358: Afilalo J, Roy AM, Eisenberg MJ. Systematic review of fibrinolytic-faciliatated percutaneous coronary intervention: potential benefits and future challenges. Can J Cardiol 2009:25; Stenestrand U, Wallentin L, Swedish register of cardiac intensive care (RIKS-HIA). Early statin treatment following acute myocardial infarction and 1-year survival. JAMA 2001;285: Amit Kumar, Christopher P. Cannon. Importance of intensive lipid lowering in acute coronary syndrome and percutaneous coronary intervention. J Interven Cardiol 2007;20: Cardiovascular Update 27
28 SECTION TOPIC 4 28 Cardiovascular Update
29 Acute coronary syndrome Invasive or non-invasive treatment Intensive care unit Uncomplicated infarction Complicated infarction Stage I rehabilitation Hospital (Day 2-3) Day 5-7 Exercise test (70-85% of maximal HR, evaluation of complication risk) Hospital (Day 4-7) Day Ambulatory rehabilitation In-hospital rehabilitation Stage II rehabilitation Week 12 Week 4-6 Home-based rehabilitation with transtelephonic ECG monitoring Week 6-8 Symptom-limited exercise test Week 2-4 ECG: electrocardiogram Stage III rehabilitation Cardiovascular Update 29
30 SECTION TOPIC 4 Risk Risk factor Low Moderate High Left ventricular systolic function No significant dysfunction Moderate dysfunction Significant dysfunction EF >50% EF=40-49% EF <40% Complex ventricular arrhythmia Absent at rest and Resting and during exercise exercise-induced Exercise-induced cardiac ischemia No Yes Yes Exercise capacity 7 METs METs < 5METs Hemodynamic response Normal No increase or decrease to exercise in SBP or HR with increasing load Clinical data Uncomplicated NYHA class II Infarction or invasive procedure infarction/cabg/ptca complicated by cardiogenic shock NYHA class I and/or pulmonary edema. Persistent ischemia following invasive treatment. NYHA class III- CABG: coronary artery bypass grafting, EF: ejection fraction, HR: heart rate, MET: metabolic equivalent of task, NYHA: New York Heart Association, PTCA: percutaneous transluminal coronary angioplasty, SBP: systolic blood pressure 30 Cardiovascular Update
31 Cardiovascular Update 31
32 SECTION TOPIC 4 32 Cardiovascular Update
33 1. Dalal H, Evans PH, Campbell JL. Recent developments in secondary prevention and cardiac rehabilitation after acute myocardial infarction. BMJ 2004;328): Lavie CJ, Thomas RJ, Squires RW, Allison TG, Milani RV. Exercise training and cardiac rehabilitation in primary and secondary prevention of coronary heart disease. Mayo Clin Proc 2009;84: Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation and secondary prevention of coronary heart disease. Circulation 2005;111: Piotrowicz R, Wolszakiewicz J. Cardiac rehabilitation following myocardial infarction. Cardiol J. 2008;15: Mora S, Cook N, Buring JE, Ridker PM, Lee I. Physical activity and reduced risk of cardiovascular events: potential mediating mechanisms. Circulation. 2007;116: Taylor RS, Brown A, Ebrahim S, et al. Exercisebased rehabilitation for patients with coronary heart disease: systemic reviews and meta-analysis of randomized controlled trials. Am J Med 2004; Thompson PD, Buchner D, Pina IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease. Circulation 2003;107: Vanhees L, Stevens A, Schepers D, Defoor J, Rademakers F, Fagard G. Determinants of the effects of physical training and of the complications requiring resuscitation during exercise in patients with cardiovascular disease. Eur J Cardiovasc Prev Rehabil 2004;11: Walther C, Mobius-Winkler S, Linke A, et al. Regular exercise training compared with percutaneous intervention leads to a reduction of inflammatory markers and cardiovascular events in patients with coronary artery disease. Eur J Cardiovasc Prev Rehabil 2008;15: Williams MA, Ades PA, Hamm LF, et al. Clinical evidence for a health benefit from cardiac rehabilitation: An update. Am Heart J 2006;152: Cardiovascular Update 33
34 THE MOST ADVANCED CONTINUING MEDICAL EDUCATION SERVICE VOL 1 NO VOL 1 NO VOL 2 NO VOL 2 NO VOL 2 NO VOL 2 NO VOL 3 NO VOL 3 NO VOL 4 NO VOL 4 NO VOL 4 NO VOL 4 NO VOL 5 NO VOL 5 NO VOL 5 NO VOL 5 NO VOL 6 NO VOL 6 NO VOL 6 NO VOL 6 NO VOL 6 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 11 NO VOL 11 NO VOL 11 NO VOL 11 NO VOL 11 NO
35 Cardiovascular Update
36 1. Elmfeldt D et al. Blood Press 2002;11: Bönner, Fuchs. Curr Med Res Opin 2004; 20: McMurray et al. Lancet 2003; 362: Mcmurray J et al. Am Heart J 2006; 151: Ogihara T. CASE-J study. Presented at the ISH, Oct Mogensen CE, BMJ 2000;321: Rossing K et al. Diabetes Care 2003; 26: Susan C Fagan et al. J Hypertens 2006; 24: Papademetrious V et al. JACC 2004;44: P [ ]-V2.1
37 쉽고 편한 콜레스테롤 관리 % Achievemen4t LDL-C goal % H A CYP Increase in HDL-C % LDL-C Reduction1 Anytime2 References 1. Jones PH et al., Am J Cardiol 2003;92: Davison MH et al., Expert Opin Investig Drugs. 2002;11(1): Cziraky M et al., Am J Cardiol 2006;97(s):61C-68C. 4. Schuster H et al., Am Heart J 2004; 147: 크레스토 정 CRESTOR Tab (전문의약품/218) 한국아스트라제네카 AstraZeneca Korea 조성 : Rosuvastatin calcium 5.2mg 10.4mg 20.8mg 효능/효과 : 고콜레스테롤혈증, 고콜레스테롤혈증 환자에서 죽상동맥경화증의 진행지연 용법/용량 : 초회용량은 1일1회 5mg, 필요시 유지용량 10mg으로 투여할 수 있음, 유지용량은 10mg이며 필요시 4주후 20mg 증량. 식사와 상관없이 하루 중 아무때나 복용 금기 : 본제 과민증 기왕력자, 불명의 지속적인 혈장 트랜스아미네이즈 상승이나 정상 상한치의 3배를 초과하는 혈장 트랜스아미네이즈 상승을 포함하는 활동성 간질환, 근병증, 사이크로스포린 병용. 서울시 강남구 대치 3동 해성 2빌딩 12층 TEL: (02) FAX: (02) 보다 자세한 정보는 아스트라제네카 마케팅부 ( )로 문의하시기 바랍니다. P [ ]
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Vol.12 No.4 55 2010 ISSN 1229-5272 Copyright 2010 Cardiovascular Update Editorial Board. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted
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Pharmacotherapeutics Application of New Pathogenesis on the Drug Treatment of Diabetes Young Seol Kim, M.D. Department of Endocrinology Kyung Hee Univ
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2014-16 1 39 1: 9-2014,. Copyright 2014 by Lee Jong Je ALL RIGHTS RESERVED. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means- electronic,
Fluoroscopic anatomy for supraventricular tachycardia ablation Hui-Nam Pak, MD, PhD Division of Cardiology, Yonsei Cariovascular Center and Cardiovascular Research Institute, Yonsei University College
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Original Articles Korean Circulation J 1998;28 9 : WPW 증후군환자에서성공적인전극도자절제술후재분극이상 배장호 1 김윤년 1 한성욱 1 현대우 1 신이철 1 김기식 1 김권배 1 이상민 2 Repolarizatio
Original Articles Korean Circulation J 1998;289:1493-1501 WPW 증후군환자에서성공적인전극도자절제술후재분극이상 배장호 1 김윤년 1 한성욱 1 현대우 1 신이철 1 김기식 1 김권배 1 이상민 2 Repolarization Abnormalities after Successful Radiofrequency Catheter
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The e-business Studies Volume 17, Number 6, December, 30, 2016:275~289 Received: 2016/12/02, Accepted: 2016/12/22 Revised: 2016/12/20, Published: 2016/12/30 [ABSTRACT] SNS is used in various fields. Although
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A Study on the Relationships between Self-Differentiation and Adaptability Factors for Senior Dementia Patients Care Givers Department of Social Welfare, Seoul Welfare Graduate University Full-time Lecturer
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Original Articles Korean Circulation J 1999;293:276-284 급성심근경색증으로발현한변이형협심증환자의 임상적, 관동맥조영검사상특성및장기추적관찰 두영철 김재삼 채경수 송관욱 홍경순 박대균 한규록오동진 유규형 임종윤 고영박 이광학 이영 Clinical and Angiographic Characteristics and Long-term
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Lee, Kyungbae (E-mail : kblee6078@ex.co.kr) Lee, Jaehoon (E-mail : ranian74@ex.co.kr) Sohn, Duecksu (E-mail : mgsds@ex.co.kr) Kwon, Soonmin (E-mail : soonmini2@ex.co.kr) ABSTRACT PURPOSES : The purpose