순환기질환의총론 I. 총론 1. EKG 1)Lead system A)Standard limb lead: I, II, III. B)Precordial lead: V1, V2, V3, V.4, V5, V6. C)Unipolar limb lead: avl, avr, avf. 2)Rate A)Arrhythmia 가없을때 : QRS ( 혹은 P) 와바로다음의 QRS ( 혹은 P) 사이의큰칸수를세어서칸수가 1,2,3, 이면 HR 는각각 300,150,100 /min 4,5,6, 이면 HR 는각각 75, 60, 50 /min 7,8, 이면 HR 는각각 43, 37 /min 9,10 이면 HR 는각각 33, 30 /min B)Arrhythmia 가있을때 : 3초 ( 혹은 5초또는 6초 ) 간의 cycle 수를세어서 20 ( 혹은 12 또는 10) 을곱하여 HR 을계산. 3)Rhythm : regular 한지 irregular 한지를따져서, irregular 하면 arrhythmia 편을참조할것. ( 작은칸으로 3칸까지는 regular한것으로생각할수있다.) 4)Complexes and intervals A)P wave Axis: 0~75 (upright in I,II,F,V4 - V6) (inverted in avr) (V1: diphasic or entirely positive or entirely negative) Width : 0.11 sec. 이하, notching이있을때는 n-n' 간격은 0.03 sec. 이하 Absent: in junctional rhythm or SA block, sinus arrest Reversed: in ectopic atrial or junctional rhythm RAE: P in II > 3mm, P in III > P in I LAE: P terminal force > 0.04 mm sec Width > 0.11 sec Notching이있을때는 n-n' 간격이 0.04sec 이상 B)PR interval 1
순환기질환의총론 PR segment isoelectric하나, atrial repolarization때문에약간 depression(0.8 mm 이내 ) 혹은 elevation( 0.5 mm 이내 ) 될수있다. Normal : 0.12 ~ 0.20 sec. ( AH Interval + HV Interval ) Prolonged : first degree AV block Shortened : WPW Syndrome. LGL Syndrome. ectopic low atrial rhythm Variable : With a regular pattern : 1 AV block Without a regular pattern : 3 AV block, AV dissociation C)QRS complex Activation 순서 : IVS( 좌에서우로 ) free wall posterobasal portion of LV free wall, basal portion of IVS QRS duration: widest QRS complex 를보이는곳에서측정, 0.06 ~ 0.10 sec ( 평균 0.08 sec, 드물게 0.11 sec 까지도 ) QRS axis: 40세미만 0 ~ 105 ; 40세이상 -30 ~ +90 *Lead I 과 lead avf 의 QRS 를비교함으로서대강의 axis를정한다. lead I (+), avf (+) 이면 normal axis lead I (+), avf (-) 이면 left axis deviation lead I (-), avf (+) 이면 right axis deviation lead I (-), avf (-) 이면 extreme right axis deviation *LAD : LAFB, LVH, LBBB, COPD, marked obesity *RAD : Normal, mechanical shift ( inspiration, emphysema ) LPPB, RVH, high lateral MI, chronic constrictive pericarditis *Transitional zone : V2 와 V4 사이에존재 ; cf. CWR vs CCWR *Low voltage : Limb lead - in all lead < 5 mm or Limb lead I + II + III < 15 mm or Precordial lead V1,V6 <5 mm & V2,V5 <7 mm & V3,V4 <9 mm *Abnormal Q Myocardial infarction Pseudoinfarction: LVH (poor R progression simulating ant. MI) 2
순환기질환의총론 RVH (qr in V1,V2 simulating ant. MI) Chronic cor pulmonale (poor R progression) Acute cor pulmonale (Q in III, F simulating inf. MI) Pneumothorax, left side (poor R progression or loss of R simulating ant. MI) Myocardial disease CMP, myocarditis (poor R progression or deep septal q in V4, V5, V6, I) Conduction abnormality LBBB poor R progression LAH mimic inferior or anterior MI WPW syndrome mimic inferior or anterior or lateral MI CVA ICH, SAH Myocardial contusion Hyperkalemia (mimic anterior MI) MVP (mimic anterior or inferior MI ) Acute pancreatitis* (ST elevation, but no abnormal q) 5)ST segment Isoelectric 하지만정상적으로도약간은 depression 또는 elevation 될수있다. Depression < 1 mm Elevation : limb lead < 1mm; precordial lead < 2 mm cf. V2,V3 < 3 mm; V5,V6 < 1 mm *ST depression : Myocardial (subendocardial) injury-ischemia LVH, RVH strain pattern Digitalis effect sagging Acute cor pulmonale *ST elevation : Myocardial (subepicardial or transmural ) injury-ischemia Pericarditis Early repolarization Acute pancreatitis 6)T wave -Axis : Upright in I, II, V3 -V6 Upright in avl and avf (when R > 5 mm) Inverted in avr. 3
순환기질환의총론 Inverted in V1 in 30% of female and 1% of male cf. Right precordial lead에서 diphasic T 가능 : shape : +/- (not -/+ ) cf. Right precirdial lead의 2-3개까지 T wave inversion 이있을수있다 : *Persistent juvenile pattern ( normal ) -Amplitude : > 0.5 mm < 5 mm (limb lead) and 10 mm (chest lead) V2,V3,V4 에서 tallest T 를보임 7)QT interval : 대개 preceding R-R interval 의 1/2 이내 Normal QT interval = k R-R interval (k = (0.40 in female, 0.37 in male ) measured QT interval QTc = R-R interval *QTc < 0.41 (Female), <0.39 (Male) if QTc > 0.44, pronged QTc 4
순환기질환의총론 2. Echocardiography 1) 개요초음파를이용하여심근벽, 심장의내부구조, 주변조직의위치나운동을기록하는방법으로임상에서다양한목적으로널리이용되고있는검사방법이다. 도플러 (Doppler) 심초음파 (Pulsed waved doppler; 간헐파형도플러, Continuous wave Doppler; 연속파형도플러, Color flow mapping; 색도플러 ), M-mode(Motion mode) 심초음파, 이면성 (2D) 및삼차원 (3D) 심초음파, 조영 (Contrast) 심초음파, 부하 (Stress) 심초음파등다양한심초음파기법이존재한다. 이에가장흔히이용되는이면성심초음파의개요와정상창및축, 이면성심초음파에서분석가능한각종측정치및정상치에대하여기술한다. 2) 정상경흉부심초음파창 (Window) 및축 (Axis) A) 창 (Window) 흉골연창 (Parasternal window) 심첨창 (Apical window) 늑골하창 (Subcostal window) 흉골상창 (Suprasternal window) B) 축 (Axis) 장축 (long axis) 장축단면도 (long axis view) 4방단면도 (4 chamber view) 5방단면도 (5 chamber view) 2방단면도 (2 chamber view) 단축 (short axis) 이와같이창과축을이용하여초음파영상을기술하게된다. Suprasternal Subcostal Parasternal Apical 5
순환기질환의총론 3) 이면성심초음파의정상영상 A) 흉골연장축단면도 (Parasternal long axis view) B) 흉골연단축단면도 (Parasternal short axis view) B-1) 대동맥판수준 (Aortic valve level) B-2) 승모판수준 (Mitral valve level) B-3) 유두근수준 (Papillary muscle level) RV Ant. leaflet Post. leaflet RV LV Ant. Papillary m Post. Papillary m 6
순환기질환의총론 C) 심첨 4 방단면도 (Apical 4 chamber view) RV LV Probe를잡는방법에따라심초음파검사실마다 view가다르다. 본원에서는 LV 가사진에서도왼쪽에위치한다. TV RA MV LA D) 심첨장축단면도 ; 심첨 5 방단면도 (Apical long axis view; Apical 5 chamber view) LV AV Ao LA E) 심첨 2 방단면도 (Apical 2 chamber view) LV MV LA 7
순환기질환의총론 F) 늑골하단면도 (Subcostal view) F-1) 늑골하장축단면도 (Subcostal long axis view) Liver RV RA LV LA F-2) 늑골하단축단면도 (Subcostal short axis view) Liver RV LV F-3) 하대정맥및간정맥 (Inferior venacava & Hepatic vein) Liver IVC RA HV ` G) 흉골상부단면도 (Suprasternal view) 8
순환기질환의총론 참고 1)Segmental analysis of LV walls 참고 2)Coronary territories & Myocardial segments 참고 3)Image acquisition View protocol 9
순환기질환의총론 3) 대한민국성인의정상심초음파측정치 10
순환기질환의총론 3. 운동부하검사 1) 운동부하검사의적응증 Class I 성별, 연령, 증상을고려한관상동맥질환가능성이중등도에해당하는경우완전우각차단이나안정시심전도의 ST 분절하강이 1 mm 미만인경우는적응이되지만, 아래 class II, III에명시된예외는제외한다. Class IIa 변이형협심증 (variant angina) Class IIb 1. 연령, 증상, 성별을고려할때관상동맥협착증가능성이높은경우 (High pretest probability of CAD by age, symptoms, and gender) 2. 연령, 증상, 성별을고려할때관상동맥협착증가능성이낮은경우 (Low pretest probability of CAD by age,symptoms, and gender) 3. 디곡신을복용하는환자로안정시심전도의 ST 분절변화가 1 mm 미만인경우 4. 심전도상좌심실비대소견이면서 ST 분절변화가 1 mm 미만인경우 Class III 1. 안정시심전도가다음에해당하는경우 조기흥분증후군 (Pre-excitation(Wolff-Parkinson-White) syndrome) 심실조율박동 ST분절변화가 1 mm 이상 완전좌각차단 2. 심근경색증이이미확인되었거나이전의관상동맥조영술에서심한협착이증명된경우. 단, 위험도평가목적으로는검사할수있다. 2) 운동부하검사의금기증 (contraindications to exercise testing) 절대적금기증 급성심근경색증 ( 발병 2일이내 ) 불안정성협심증으로고위험군 * 에해당할때 증상이있거나혈역학적인영향이있는부정맥이조절되지않은상태 증상이있는중증의대동맥협착증 증상이있는심부전증이조절되지않은상태 급성폐동맥색전증및폐경색증 급성심근염및심낭염 급성대동맥박리증 상대적금기증 관상동맥좌주간지협착 11
순환기질환의총론 중등도의협착성판막증 전해질이상 중증의고혈압 빈맥성부정맥, 서맥성부정맥 비후성심근증및유출로폐쇄성병변 (outflow tract obstruction) 신체적, 정신적장애로인하여충분한운동을할수없는경우 고도의방실차단 *: ACC/AHA 지침의불안정형협심증위험도분류에의함, : 수축기혈압 >200 mmhg, 또는이완기혈압 >110 mmhg 3) Indications for terminating exercise testing ( 검사를끝내야하는경우 ) 절대적적응증 운동중수축기혈압이운동전에비하여 10 mmhg 이상감소하면서심근허혈의징후가동반되는경우 중등도이상의허혈성흉통 불균형, 어지럼증등신경계증상이진행할때 (Increasing nervous system symptoms, eg: ataxia, dizziness, or near-syncope) 청색증등혈액순환장애의징후 (Signs of poor perfusion; cyanosis or pallor) 심전도나수축기혈압감시가곤란한경우 환자가검사중지를요구할때 지속적인심실빈맥 (Sustained ventricular tachycardia) 1 mm 이상의 ST분절상승이안정시심전도에서 Q파가없는유도에서관찰될때 ( 단, V1, avr 유도는제외 ) 상대적적응증 운동중수축기혈압이운동전에비하여 10 mmhg 이상감소하나, 심근허혈의징후는동반하지않는경우 ST분절, QRS 파형의심한변화 (2 mm 이상의수평형및하강형 ST 분절하강, 전기축의심한전위 ) 기타부정맥 : 다양한모양의 PVC, 3개의연속된 PVC, 상심실성빈맥, 전도차단, 서맥성부정맥 (multifocal PVCs, triplets of PVCs,supraventricular tachycardia, heart block, or bradyarrhythmias) 피로감, 호흡곤란, 휘성 (wheezing), 다리근육경련및파행 (leg cramp or claudication) 각차단, 심실내전도지연이발생하여심실성빈맥과감별이어려운경우 흉통이점점심해질때 고혈압성반응 * 12
순환기질환의총론 *: 수축기혈압 >250 mmhg, 또는이완기혈압 >115 mmhg 4) Protocol for Dobutamine Stress Echocardiography (2007 ASE guideline) Graded dobutamine infusion in five three-minute stages starting at 5 µg/kg/min, followed by 10, 20, 30, and 40 µg/kg/min. An initial dose of 2.5 µg/kg/min is sometimes employed in tests evaluating viability. Low-dose stages facilitate recognition of viability and ischemia in segments with abnormal function at rest, even when viability evaluation is not the main aim of the test. End points are achievement of target heart rate (defined as 85 percent of the agepredicted maximum heart rate), new or worsening wall-motion abnormalities of moderate degree, significant arrhythmias, hypotension, severe hypertension, and intolerable symptoms. Atropine, in divided doses of 0.5 mg to a total of 2.0 mg, should be administered as needed to achieve target heart rate. Atropine increases the sensitivity of dobutamine echocardiography in patients receiving beta-blockers and in those with single-vessel disease. Evaluation of recovery wall motion abnormalities after administration of beta blocker (eg, intravenous metoprolol 1 to 5 mg) after peak stress imaging may increase test sensitivity. 13
순환기질환의총론 4. 관상동맥조영술 (Coronary angiography) 및기본영상판독 1) 해부학 (Anatomy) A)Sternocostal surface B)Atrioventricular & Interventricular plane *RCA - AcM : Acute marginal branch; CB : Conus branch; PD : Posterior descending branch; PL : Posterolateral branch; RV : RV branch; SN : Sinus nodal branch *LAD D : Diagonal branch; S : Septal perforating branch / LCX OM : Obtuse marginal branch 14
순환기질환의총론 2) 각관상동맥별촬영방향및혈관의분포 15
순환기질환의총론 참고 1)TIMI(Thrombolysis in myocardial infarction) grading -TIMI 0 : Complete occlusion of the infarct-related artery -TIMI 1 : Some penetration of the contrast material beyond the point of obstruction but without perfusion of the distal coronary bed -TIMI 2 : Perfusion of the entire infarct vessel into the distal bed but with delayed flow compared with a normal artery -TIMI 3 : Full perfusion of the infarct vessel with normal flow 5. Pericardiocentesis 1)Objectives of Pericardiocentesis Relief of tamponade, when present Obtaining fluid for appropriate biochemical, cytologic, bacteriologic, and immunologic analysis Assessment of hemodynamics after pericardial pressure has been lowered to exclude effusive constrictive pericarditis 2)Technique A)Subcostal approach with fluoroscopy 16
순환기질환의총론 After sterilizing the area, the skin and subcutaneous tissues a few millimeters below and to one side of the xiphoid process are infiltrated with lidocaine The puncture needle is advanced posteriorly until it is below the costal margin. The needle is then directed cephalad and with much less posterior orientation To accomplish this, the syringe is pressed toward the patient's abdomen and cautiously advanced cephalad Sometimes when the pericardium is penetrated, frequent gentle aspiration is attempted until pericardial fluid enters the syringe effortlessly. B) Echocardiographic guidance Mostly subcostal approach is used, but when the apical route is chosen, the needle is directed parallel with the long axis of the left ventricle towards the aortic valve For parasternal insertion, the puncture is made one cm lateral to the sternal edge, thus avoiding both inadvertent puncture of the internal mammary artery when too medial, and pneumothorax when too lateral The procedure should be performed in the cardiac catheterization laboratory, even if fluoroscopy is not used, because invasive hemodynamics are usually more readily and accurately monitored and recorded in this environment Complications are rare - bleeding, infection, incisional hernia, anesthetic complications, and cardiac injury have been reported 17
순환기질환의총론 6. CPR protocol and inotropic drug use (Reference : 2005 AHA guidelines) Major changes 1. Emphasis on effective chest compression 1)Push hard & push fast compress the chest at a rate of about 100 compressions per minute for all victims except newborns 2)Allow the chest to recoil(return to normal position) completely after each compression 18
순환기질환의총론 and use equal compression and relaxation time 3)Try to limit interruptions in chest compressions Every time you stop chest compression, blood flow stops 2. One universal compression-to ventilation ratio for all lone rescuers Compression-to-ventilation ratio of 30:2 for all lone (single) rescuers to use all victims from infants(except newborns) through adults 3. One-second breaths during all CPR Each rescue breath should be given over 1 second & make the chest rise 4. Attempted defibrillation : 1-shock then immediate CPR When attempting defibrillation, deliver 1 shock followed by immediate CPR and check rhythm after giving about 5 cycles( about 2 minutes) Overall CPR algorithm 19
순환기질환의총론 ACLS pulseless arrest algorithm 20
순환기질환의총론 Bradycardia algorithm 21
순환기질환의총론 ACLS tachycardia algorithm 22
순환기질환의총론 Atropine 23
순환기질환의총론 : Anticholinergic drug (muscarinic acetylcholine receptor blocker) : Increases firing of the SA node and conduction through the AV node of the heart block the actions of the vagus nerve and decreases bronchiole secretions. : Used in the treatment of bradycardia (an extremely low heart rate), asystole and pulseless electrical activity (PEA) in cardiac arrest : Dosage In bradyasystolic arrest : 0.5 to 1 mg IV push every three to five minutes, up to a maximum dose of 0.04 mg/kg In symptomatic bradycardia : 0.5 to 1.0 mg IV push, may repeat every 3 to 5 minutes up to a maximum dose of 3.0 mg Epinephrine : Sympathomimetic monoamine : Increase peripheral vascular resistance via α 1 -adrenoceptor vasoconstriction : Increase cardiac rate and output via β 1 -adrenoceptor response used in the treatment of cardiac arrest and other cardiac dysrhythmias Norepinephrine : Catecholamine with dual roles as a hormone and a neurotransmitter : Increase blood pressure by increasing vascular tone via α-adrenergic activation(dose- dependent) 24
순환기질환의총론 : Used in the treatment of severe hypotension refractory to volume infusion & other Inotropics : Dosage : initially 2μg/min titration upward to desired effect Dopamine : Acts on the sympathetic nervous system increasing heart rate and blood pressure : Used when cardiac stimulation & peripheral vasoconstriction are desired (ex. Cardiogenic shock) : Dosages <2 μg/kg/min (Renal dose) : Increase blood flow to renal, mesenteric, and coronary arteries and increasing overall renal perfusion by dilating blood vessels with binding D 1 receptors 2 to 10 μg/kg/min (Cardiac dose) : Increase myocardial contractility, heart rate by stimulating β 1 receptor (positive inotropic and chronotropic) 10 to 50 μg/kg/min (Pressor dose) : Increase blood pressure through α 1 receptor activation causing systemic & pulmonary vasoconstriction Dobutamine : Synthetic catecholamine that is used as a positive inotropic agent : Positive inotropic and chronotropic effects by predominant β 1-stimulation & peripheral vasodilatation by weak β 2-stimulation 25
순환기질환의총론 : Used primarily in decompensated heart failure due to systolic dysfunction with a normal BP : Dose range : 3 to 10μg/kg/min 26
II. 각론 1. 허혈성심질환 1) Chronic Stable Angina A) 흉통의임상적분류 a. 전형적흉통 (3가지모두해당될때 ) 특징적인양상및기간동안흉골하부의통증 운동시나정신적스트레스에의해유발 니트로글리세린에의해호전 b. 비전형적흉통 위사항중 2가지에만족할때 c. 심장외요인에의한흉통 위사항중해당사항이없거나 1가지에해당할때 B)NYHA & CCS functional classification Class I : 일상적인생활에는전혀문제가없고심한운동시에발생 Class II : 일상적인생활에조금문제가있는경우로 2블럭이상걷거나계단을일상적속도로 2층이상올라갈때흉통발생 Class III: 일상적인생활에상당한지장이있어서계단을한층오르거나 2블럭이하는걸어도쉬어가야함 Class IV: 안정시에도흉통이발생함 C) 비침습적위험도평가 (Risk Stratification) 고위험군 ( 연간사망률이 33% 이상 ) 안정시심한좌심실기능부전 ( 심박출율 < 35%) Treadmill score상고위험군 (score -11) 운동시심한좌심실기능부전 ( 운동시심박출율 < 35%) 부하검사에서큰관류결손 ( 특히전벽 {anterior wall} 일경우 ) 부하검사에서다중의중등도크기관류결손 좌심실이완혹은폐섭취율증가 (thallium-201) 를동반한불변의큰관류결손 좌심실이완혹은폐섭취율증가 (thallium-201) 를동반한부하검사상중등도관류결손 저용량의도부타민 ( 10 mg/kg/ 분 ) 혹은낮은심박수 (<120회/ 분 ) 에서심초음파상관찰되는 2구획이상을침범하는심벽기능이상 부하심초음파상광범위한허혈증거가있는경우 중등도위험군 ( 연간사망률 1-3%) 안정시중증 / 중등도좌심실기능부전 ( 심박출율 =35-49%) 27
Treadmill score상중등도위험군 (-11< score < 5) 좌심실이완혹은폐섭취율증가 (thallium-201) 를동반한스트레스성중등도관류결손 제한성부하심초음파상고용량의도부타민에서만관찰되는 2구획이하의심벽운동장애를동반한허헐성질환 저위험군 ( 연간사망률 1% 미만 ) Treadmill score에서저위험군 (score 5) 안정시혹은스트레스시, 정상이거나작은관류결손 부하심초음파에서스트레스때에심벽운동장애가없거나안정시와비교하였을때변화가없는경우 심근경색과사망을예방하고증상을호전시키기위한약물치료의지침 Class I 금기증이없는경우아스피린의사용 (Level of evidence: A) 심근경색병력이있는경우 (Level of evidence A) 나병력이없는경우 (Level of evidence B) 에금기증이없을때베타차단제의사용 당뇨그리고 / 혹은좌심실기능부전이있는관상동맥질환환자에서안지오텐신효소억제제의사용 (Level of evidence: A) 관상동맥질환이진단된모든환자에서스타틴의사용 (Level of evidence: A) 협심증의신속한경감을위한설하니트로글리세린이나스프레이를사용하는경우 (Level of evidence: B) 베타차단제가금기인경우증상호전을위하여칼슘길항제나지속성질산염제를사용하는경우 (Level of evidence: B) 베타차단제가초치료로서성공적이지못할경우칼슘길항제나지속성질산염제를사용하는경우 (Level of evidence: B) 베타차단제에심각한부작용을보이는경우에그대체제로칼슘길항제나지속성질산염제를사용하는경우 (Level of evidence: C) Class IIa 아스피린이금기인경우 clopidogrel 사용 (Level of evidence: B) 초치료로서베타차단제를대신하여지속성비dihydropyridine계열의칼슘길항제의사용 (Level of evidence: B) 관상동맥질환이확인되는경우혹은의증이면서저밀도지단백농도가 100~129 mg/dl로측정되는경우에서아래의치료시행 (Level of evidence: B) 저밀도지단백콜레스테롤저하 (100 mg/dl) 를위한생활습관조절및약물 대사증후군인환자에서체중감소및신체운동의증진 상승된중성지방이나감소된고밀도지단백의치료를위한니코틴산이나 28
피브레이트치료 다음에해당하는최고위험군에서는저밀도지단백콜레스테롤수치를 70 mg/dl로억제시키는것이도움이될수있다 (Level of evidence: A). 다중의주요위험인자들 ( 특히, 당뇨 ) 을가진경우 심각하거나조절되지않는위험인자들 ( 특히흡연 ) 을가진경우 대사성증후군에해당하는다중의위험인자를가진경우 관상동맥질환이나기타혈관질환을가진환자에서안지오텐신전환효소억제제의사용 (Level of evidence: B) Class IIb 아스피린에더하여와파린으로시행하는저강도의항응고치료요법 (Level of evidence: B) Class III Dipyridamole 사용 (Level of evidence: B) Chelation 치료 (Level of evidence: B) 29
위험인자에대한치료방법및치료에대한권고사항 2)Variant Angina 30
A)Risk factors a. Cocain, amphetamine abuser b. Cigarette smoking c. Hyperinsulinemia, insulin resistance B)Clinical characteristics a. Younger b. Transient spasm within plaque 1cm c. RCA > LAD d. Good prognosis e. 심전도상여러 lead에서 ST 분절의상승이온다 C)Provocation test drug : Ergonovine / Aethylcholine / Hperventilation D)Drug of choice a. CCB and nitrares b. prazosin : Selective alpha blocker c. Aspirin은악화, Beta blocker는 variable 3)Unstable Angina / NSTEMI A)Causes of UA/NSTEMI (2007 ACC/AHA UA/NSTEMI Guideline Revision) 31
B)Classical 3 Symptoms - Rest angina : Angina occurring at rest and prolonged, usually greater than 20 min - New-onset angina : New-onset angina of at least CCS class III severity - Increasing angina : Previously diagnosed angina that has become distinctly more frequent, longer in duration, or lower in threshold (i.e., increased by 1 or more CCS class to at least CCS class III severity) Algorithm for Evaluation and Management of Patients Suspected of Having ACS 32
불안정형협심증환자에서사망또는심근경색재발에대한단기간위험도 TIMI risk score for UA/NSTEMI 33
Class I Recommendations for Use of an Early Invasive Strategy - Recurrent angina at rest/low-level activity despite Rx - Elevated TnT or TnI - New ST-segment depression - Rec. angina/ischemia with CHF symptoms, rales, MR - Positive stress test - EF < 0.40 - Decreased BP - Sustained VT - PCI < 6 months, prior CABG Dosing Table for Antiplatelet and Anticoagulant Therapy in Patients With UA/NSTEMI 34
Algorithm for Patients With UA/NSTEMI Managed by an Initial Invasive Strategy 35
Algorithm for Patients With UA/NSTEMI Managed by an Initial Conservative Strategy 36
Long-Term Anticoagulant Therapy at Hospital Discharge After UA/NSTEMI 37
4) STEMI 38
Killip classification Class I No sign of pul or venous congestion 0 5% Class II Moderate heart failure Lung base의 rale, S3 gallop, tachypnea, Rt heart failure sign 10 20% Class III Severe heart failure, pul edema 35 45% Class IV Shock with systolic pressure < 90mmHg pph. vasoconstriction, cyanosis, mental confusion and oliguria 85 95% 39
Grading of myocardial perfusion MBG (myocardial blush grade) MBG 0 MBG 1 MBG 2 MBG 3 No myocardial blush or staining of blush Minimal myocardial blush Moderate myocardial blush, less than obtained during angiography of a contralateral or ipsilateral non-infarct related artery Normal myocardial blush, compatible with that obtained during angiography of a contralateral or ipsilateral non-infarct related artery ST 분절상승심근경색증환자에서재관류요법전략을결정하기위한평가 40
ST 분절상승심근경색증환자에서혈전용해제사용시금기증및주의사항 Thromobolysis - Reperfusion 지표 - 흉통의소실 - ST elevation의소실 - CK washout phenomenon - Reperfusion arrhythmia (esp AIVR) PCI is preferred - Diagnosis is in doubt - Cardiogennic shock - Increased bleeding risk - Presentation >2~3h (mature clot) 41
ST 분절상승심근경색증환자의이차예방 2. 심부전 (Heart failure) 1) 개요 42
미국심장학회지침인 ACC/AHA guideline에서는 심실이혈액을충만시키거나구출해내는데장애를초래하는심장상태 를심부전이라정의하고있으며, 유럽심장학회지침인 ESC guideline에서는 안정상태나운동시심부전의특징적인증상을가지고있으면서심장기능장애의객관적인증거를가진경우 로심부전을정의하고있다. 즉, 심부전은심장기능의이상으로대사조직의요구를충족시킬수있는만큼의충분한혈액을구출해낼수없거나또는비정상적으로확장기압이나용적을증가시켜야만충분한혈액을구출해낼수있는상태를의미한다. 과거부터심부전의기작에대한많은연구가진행되었고, 현재는심장의펌프기능장애, 심근재형성, 각종 cytokine 및자율신경조절장애등으로인하여순환부전을일으키는상태로알려져있다. 2) 심부전의분류 A) 급성심부전 (Acute heart failure) vs 만성심부전 (Chronic heart failure) 급성심부전은처음으로심부전이발생하였거나, 만성심부전이급성악화한경우를 통칭한다. 원인또는중등도에따라다양한임상경과를가지며, 이러한급성심부전의 형태로는폐부종 (pulmonary edema), 고혈압성심부전, 심인성쇽 (cardiogenic shock), 우 심부전 (Right heart failure) 등을들수있다. 만성심부전은여러심부전증상이비교적 안정한상태로오래지속된상태를의미한다. B) 수축기심부전 (Systolic heart failure) vs 확장기심부전 (Diastolic heart failure) Systolic heart failure Diastolic heart failure Heart size Dilated LV Small LV Blood pressure or Predisposition Male, Young Female, Old Ejection fraction or Auscultation S3 S4 Echo- findings Systolic & Diastolic dysfunction Diastolic dysfunction Treatment strategy Well established Not established Prognosis Bad Better than systolic HF 수축기심부전은좌심실수축기능장애를동반한전형적인심부전의형태이며 확장기심부전을동반하는경우가많다. 확장기심부전은심부전의증상을보유하면 서안정시좌심실구혈율 (Ejection fraction) 이정상범위로유지되고있는경우이다. C) 보상된심부전 (Compensated heart failure) vs 보상부전심부전 (Decompensated heart failure) 심실확장기말용적이나압력이상승되어있고구혈율이저하되어있는등심장기능의 장애가있더라도치료나다른보상기전을통하여심부전증상이해소된상태이다. 43
반면, 적절하고충분한치료가이루어져도심부전의증상이남아있는경우를보상부전심부전 (Decompensated heart failure) 이라고한다. 3) 심부전의원인및평가원인질환을정확하게파악하는것은적절한진단과치료방침을수립할수있는기본이된다. 이전에보고된외국의연구결과들은대부분허혈성심장질환이심부전의원인질환가운데절반이상을차지하는것으로보고하고있다. 국내연구에서도관동맥질환이가장흔한원인질환이고고혈압성심장질환, 심장판막증, 심근증등이그뒤를따르는형태를보였다. 따라서다음과같은사항을반드시자세히병력청취하여야한다. 심부전증의악화시는다음의악화요인을고려해야한다. 1 심근허혈혹은심근경색증 2고혈압 3부정맥 4 감염 ( 특히호흡기감염 ) 5 빈혈 6 임신 7 갑상선기능이상 8 수분및염분의과다섭취 9 폐동맥색전증 10 해로운약제의복용 ( 비스테로이드성소염제등 ) 11 알코올섭취 12 치료약제내성혹은복용태만 참고 1) 좌심실기능이보존된환자의원인질환감별 44
참고 2) 좌심실기능이감소된환자의원인질환감별 4) 심부전의진단 45
A) 증상및증후에따른고전적진단기준고전적으로사용되던 Framingham criteria는다음과같다. A) Major criteria : 1 발작성야간호흡곤란 2 경정맥확장 3 수포음 4 심비대 5 S3 gallop 6 폐부종 7 중심정맥압증가 8 간정맥역류 B) Minor criteria : 1 하지부종 2 야간기침 3 노작성호흡곤란 4 간비대 5 늑막삼출 6 빈맥 ( 분당 120회이상 ) C) Major 혹은 Minor : 5일째치료시체중이 4.5 kg 이상감소 * 진단 : Major criteria 1개 + Minor criteria 2개이상 2001년 ESC guideline에따른진단기준은다음과같다. A) 안정시혹은운동시심부전증의증상이있어야한다. B) 안정시심장기능이상의객관적인증거가있어야한다. * 상기사항으로도진단이확실치않은경우에는심부전증으로치료시반응이있으면심부전증으로진단한다. B) 단계 (Stage) 에따른진단기준과거에사용되던 NYHA(New York Heart Association) 의기능에따른분류법과 2005년 ACC/AHA의구조적이상에따른분류법이양립하고있다. 심부전의임상증상및경과는환자에따라매우다양하게나타나므로단계적이고계획적인치료가필요하다. ACC/AHA guideline에의한분류법은다음과같다. Stage A : 심부전발생위험이높은환자로구조적인심장질환이나심부전증상을동반하지않은상태. 고혈압, 관동맥질환, 당뇨병, 심근증의가족력, 심장독성을가진약물사용이나알코올과다복용등심부전의발생과관련된위험인자를가진경우이다. Stage B : 구조적인심장질환을가지고있으나심부전의증상이나증후를나타낸바없는상태. 좌심실의비후, 섬유화, 확장이나수축력저하를동반하거나심근경색의 46
기왕력을가진경우이다. Stage C : 구조적인심장질환을가지고있으면서현재또는과거에심부전증상을동반한상태. 좌심실수축기능저하로인한호흡곤란, 피로감등의증상이있거나과거심부전증상으로치료하였으나현재는증상이없는경우이다. Stage D : 중증심장질환으로최대한의내과적치료에도불구하고안정시심부전증상을가지고있거나특별한치료법이필요한상태. 심부전으로자주입원하거나안전하게퇴원할수없거나, 심장이식을기다리는상태, 정맥주사치료가지속적으로필요하거나기계적순환보조장치에의존하는환자가해당된다. 5) 심부전의치료 A) 급성심부전의치료 (From 2008 ESC guidelines for heart failure) a) 급성심부전이의심되는상황시 b) 초기치료목표 c) 초기치료알고리즘 47
d) 약물치료 Morphine : 중증의급성심부전환자, 특히호흡곤란, 흉통, 불안감등이있는환자에있어사용한다. 초기용량으로 morphine 2.5~5 mg을정주하고필요시반복할수있다. 호흡저하가발생할수있고위장관계불편감을호소할수있으며기타저혈압, 서맥, 이산화탄소저류, 방실전도장애의악화를야기할수있음에주의한다. Loop diuretics : 폐울혈및체액과다에의한증상을호소하는환자에정주한다. Vasodilator : 급성심부전환자의초기에투여한다. 단증상이있는저혈압, SBP <90 mmhg, 중증의폐쇄성판막질환이있는환자에는투여하지않는다. 48
Inotropics : 울혈이나관류저하의증상및증후가있고, 혈압이낮거나 cardiac index의저하가확인된급성심부전환자에만사용한다. B) 만성심부전의치료 (From 2009 ACC/AHA guidelines for heart failure) 참고 )2009 ACC/AHA guideline에따른분류법및이에따른치료법 49
From 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults 3. Valvular Heart Disease 50
2008 ACC/AHA VHD Guidelines: Classification of the Severity of Valve Disease in Adults 1) Mitral Stenosis Specific auscultation of mitral stenosis S1 accentuation / opening snap / diastolic rumbling murmur / presystolic murmur Percutaneous balloon vavuloplasty (TOC) Symptomatic(NYHA II-IV) with isolated MS orfice<~1.0cm 2 /BSA or 1.5cm 2 In the absence of LA thrombi, mod to severe MR (in TEE evaluation) 51
2) Mitral Regurgitation Cause of MR Disorder of annulus : annulus dilatation, annulus calcification - HTN, AS, HCMP - DM, Marfan s synd, CRF, hypercalcemia Disorder of mitral leaflet - rheumatic heart disease(m/c), MVP - IE, SLE, trauma, LA myxoma Disorder of chordae tendinae - chordal rupture - Myxomatous degerneration, IE, AMI Disorder of papillary muscles - coronary artery disease 52
3) Aortic Stenosis Etiology : congenital > rheumatic > degenerative Percutanous balloon aortic valvuloplasty가선호되는경우 Children Young adult with congenital AS Young adult with noncalcification Elderly with noncalcification 53
4) Aortic Regurgitation Cause of acute AR IE Aortic dissection Trauma 55 rule of AR in OP indication LVESV >55mL/m2 EF < 55% LVESD >55mm 54
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5. 고혈압 (Hypertension) 1)HTN 진단기준 (office BP, Home BP, 24hr AMBP) 2)Secondary HTN evaluation -> 내분비파트참조 3)Hypertensive crisis : Severe hypertension(sbp>210 & DBP>130) with acute impairment of end organ system with the possibility of irreversible organ-damage reduce the pressure by no more than 25% (within minutes to 1 or 2 hours) and then toward a level of 160/100 mm Hg within 2-6 hours. Excessive reductions in pressure may precipitate coronary, cerebral, or renal ischemia 56
4)Treatment of hypertension Lifestyle modifications to manage hypertension Oral drugs used in treatment of hypertension 57
6.Acute Aortic syndrome : Aortic dissection management 1)Acute Aortic syndrome a)aortic rupture b)aortic dissection c)intramural hematoma d)penetrating atherosclerotic ulcer 2) Aortic dissection 의 classification Daily or Stanford classification Type A Type B Dissection involving the ascending aorta, regardless of the site of the primary tear Dissection of the descending aorta DeBakey classification Type 1 Type 2 Type 3 Dissection of the ascending and descending thoracic aorta Dissection of the ascending aorta Dissection of the descending aorta 58
3) 임상증상 a)diaphoresis를동반한 sudden onset의 very severe an tearing pain, syncope, dyspnea, and weakness b) 통증위치 : front or back of the chest, often the interscapular region, and typically migrates with propagation of the dissection 4) 진단 : Chest X-ray(PA,Lt.lateral), EKG, TEE, aortography, CT or MRI 5) 치료 a) 내과적치료 -hemodynamic monitoring을위해중환자실입원 -beta blocker(propranolol, metoprolol, short-acting esmolol) : HR 60회 /min 유지 -sodium nitroprusside : systolic BP 120 mmhg 이하유지 -labetalol -CCB(calcium channel antagonists verapamil and diltiazem): nitroprusside 또는 beta blocker를사용할수없을경우 b) 수술적응증 -type A : acute ascending aortic dissections and intramural hematomas -complicated type B: propagation, compromise of major aortic branches, impending rupture, or continued pain * 금기 Isolated use of direct vasodilators(diazoxide, hydralazine) 7.Pulmonary thromboembolism & Deep vein thrombosis * Virchow s triad : stasis, abnormalities of the vessel wall, alterations in the blood coagulation system 1)Risk factor a) 혈관손상 : 하지수술, 다리부상, 골절 b) 혈액순환의저류 : 수술이나부상으로인한보행장애, 수술골절후 cast, 심부전 c) 혈액응고성의증가 :cancer, 혈액인자이상 59
d)thrombophilia: anti-thrombin III, protein C, protein S 결핍, antiphospholipid antibody, homocysteinuria 2) 임상증상 : 무증상 (40-60%), Dyspnea, tachypnea, pleuritic chest pain, cough, hemoptysis, hypotension 3) 진단 : Chest X-ray, EKG, ABGA, D-dimer, Chest CT, Echo, V/Q scan, pulmonary angiography, thrombophilia w/u, malignancy w/u 참고 1) 참고 2) 60
참고3) High Clinical Likelihood of PE if the Point Score Exceeds 4 Clinical Variable score Signs and symptoms of DVT 3.0 Alternative diagnosis less likely than PE 3.0 Heart rate >100/min 1.5 Immobilization (3 days) or surgery in the previous four weeks 1.5 Prior PE or DVT 1.5 Hemoptysis 1.0 Cancer 1.0 61
4) 치료 A)Anticoagulation of VTE a)immediate Parenteral Anticoagulation -Unfractionated heparin, bolus and continuous infusion, to achieve aptt 2 3 times the upper limit of the laboratory normal, or -Enoxaparin 1 mg/kg twice daily with normal renal function, or -Tinzaparin 175 units/kg once daily with normal renal function, or -Fondaparinux weight based once daily; adjust for impaired renal function b)warfarin Anticoagulation -Usual start dose is 5 10 mg. -Titrate to INR, target 2.0 3.0. -Continue parenteral anticoagulation for a minimum of 5 days and until 2 sequential INR values, at least 1 day apart, return in the target range. B)Fibrinolysis a) 적응증 : Extensive DVT or massive PE causing hemodynamic compromise or in patients with RV dysfunction or limited cardiopulmonary reserve (For older patients (>70 yrs) with risk of intracranial hemorrhage, a "watch and wait" approach is suitable, with frequent serial evaluation of RV function by echocardiography; fibrinolysis should be considered in those with deterioration of RV function) b) 투여용량 : recombinant tpa 100mg over 2 hrs c)fibrinolysis의금기 : Intracranial disease, Recent surgery, Trauma : The overall major bleeding rate is about 10%, including a 1 3% risk of intracranial Hemorrhage 62
C)IVC filter 적응증 : Active bleeding that precludes anticoagulation : Recurrent venous thrombosis despite intensive anticoagulation D)Pulmonary embolectomy : 혈전용해제를사용할수없는심한폐색전증에시행 8. Atrial fibrillation 분류 Paroxysmal (ie, self-terminating) Af 이자연적으로 7 일이내소실 ( 주로 24 시간이내 ) Persistent AF 7 일이내자연소실하지못한경우. Episodes may eventually terminate spontaneously, or they can be terminated by cardioversion. A patient who has had an episode of persistent AF can have later episodes of AF that classify as paroxysmal Permanent AF Permanent AF is considered to be present if the arrhythmia lasts for more than one year and cardioversion either has not been attempted or has failed. Lone AF Lone AF describes paroxysmal, persistent, or permanent AF in individuals without structural heart disease. Lone AF has primarily been applied to patients 60 years of age but older patients also may be at low risk. EKG 63
P waves are replaced by fibrillatory waves and the ventricular response is completely irregular. Management rate control - acute RVR : IV 제제사용 - Amiodarone (I-ADRO) - loading : 150 mg (1@) mix to FNS100 for 15 min - maintanance :900mg mix to F5D5B 첫 6 시간은 33ml/hr 이후 17 cc/hr Herben (I-HRB) - 0.25mg/kg ( 약 5 분동안 ) 5-15mg /hr (BP, HR 보면서조절 ) Digoxin (I-DGX) 0.25mg q 6 hr for 4 times 이후 po medication 으로변경 - 이후아래있는표에따라항혈전제사용결정할것 64
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9. PSVT Heart rate : usually 160~240/min Rhythm : essentially regular Pacemaker site: A reentry mechanism in the AV junction involving the AV node alone 67
P wave : present or absent QRS complex : usually normal Treatment A. 환자가안정적이면서심박수 150/min 이상인경우 Perform vagal maneuvers. Adenosine 6mg IV bolus rapidly, if necessary, repeat adenosine 12mg rapidly Diltiazem 29mg IV over 2min B. 환자가불안정하면서심박수 150/min 이상인경우 Vagal maneuver 시행 Digoxin 0.5mg IV over 5min Amiodarone 150mg IV infusion over 10min 10 Pulmonary hypertension 정의 : Right heart catheterization 으로측정한폐동맥혈압이 25mmHg 이상으로증가된 상태 Evaluation (ESC guidelines) 68
Treatment of PAH (ESC guidelines) 69
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