한국형안정형협심증권고안 (Stable Angina Guideline)
한국형안정형협심증권고안 (Stable Angina Guideline) Based on 2002 ACC/AHA Guideline and 2006 ESC Guideline
한국형안정형협심증권고안 (Stable Angina Guideline) 특징 - 현재 ACC/AHA, ESC guideline을근거하였으며한국에서만의다기관연구결과가미흡하여 expert opinion을통하여근거를도출함. - PCI 등의권고안은한국형 PCI 권고안과통일함.
권고수준 수준 (Level of Recommendation) 증거수준 수준 (Level of Evidence)
흉통의임상적분류 전형적흉통 (3 가지모두해당될때 ) 1) 특징적인양상및기간동안흉골하부의통증 2) 운동시나정신적스트레스에의해유발 3) 니트로글리세린에의해호전 비전형적흉통위사항중 2 가지에만족할때 심장외요인에의한흉통위사항중해당사항이없거나 1 가지에해당할때
Pretest probability of CAD by age, gender, symptoms Intermediate probability of CAD 1. Typical angina: males(30-39), females(< 60) 2. Atypical angina: males(all age), females( 40) 3. Non cardiac chest pain: males( 40), females( 60)
관상동맥질환진단을위해초기에운동부하심전도 (TMT) 의권고사항 Class I 나이, 성별, 증상을고려한관상동맥질환의중등도위험군에서운동부하심전도의시행 ( 완전우각차단이나 1 mm 이하의 ST 분절하강의경우는해당되나 class II나 III에기술된경우는제외 ) (Level of evidence: B) Class IIa 관상동맥연축이의심되는환자에서운동부하심전도의시행 (Level of evidence: C) Class IIb 1. 나이, 성별, 증상을고려한고위험군에서운동부하검사의시행 (Level of evidence: B) 2. 나이, 성별, 증상을고려한저위험군에서운동부하검사의시행 (Level of evidence: B) 3. 디곡신복용중인환자에서 1 mm 이하의 ST 분절하강소견을보인경우운동부하검사의시행 (Level of evidence: B) 4. 좌심실비대에해당하는심전도소견에서 1 mm 이하의 ST 분절하강소견을보인경우운동부하검사의시행 (Level of evidence: B) Class III 1. 아래와같은심전도소견을보이는환자에서운동부하검사의시행 심실조기흥분증후군 (WPW 증후군 ) (Level of evidence B) 심박동기조율 (Level of evidence B) 안정시심전도상 1 mm 이상의 ST 분절하강소견 (Level of evidence B) 완전좌각차단 (Level of Evidence B)
만성안정형협심증이의심되는환자에서흉통진단을위한심초음파의권고사항 Class I 1. 대동맥협착증이나비후성심질환이의심되는수축기심잡음이있은환자에서심초음파의시행 (Level of evidence: B) 2. 임상적으로심부전이의심되는환자에서심초음파의시행 (Level of evidence: B) 3. 이전에심근경색이있었던환자에서심초음파의시행 (Level of evidence: B) 4. 좌각차단, Q파, 좌전다발차단이심전도에서관찰되는경우 (Level of evidence: C) Class IIb 승모판탈출증을진단하기위해심잡음 (murmur or click) 이있는환자에서심초음파의시행 (Level of evidence: C)
운동이가능한만성안정형협심증환자의진단에있어초기검사로부하영상진단에대한권고사항 Class I 1. 다음 2 가지사항중하나에해당하고중등도관상동맥질환위험군에서운동부하심근조영이나심초음파를하는경우 심실조기흥분증후군 (WPW 증후군 ) (Level of evidence: B) 안정시심전도에서 1 mm 이상 ST 분절하강이있는경우 (Level of evidence: B) 2. 이전에재관류술 ( 관동맥성형술또는관동맥우회술 ) 을시행받은경우에운동부하심근조영또는심초음파의시행 (Level of evidence: B) 3. 다음 2 가지사항중하나에해당하고관상동맥질환중등도위험군에서 adenosine 혹은 dipyridamole 부하심근조영이나심초음파를하는경우 심박동기율동 (Level of evidence: B) 좌각차단 (Level of evidence: B)
운동이불가능한만성안정형협심증환자의진단에있어초기검사로부하영상진단에대한권고사항 Class I 1. 나이, 성별과증상으로보아중등도관상동맥질환위험군에서 adenosine 혹은 dipyridamole 부하심근조영이나 dobutamine 부하심초음파를하는경우 (Level of evidence: B) 2. 이전에재관류술 ( 관동맥성형술또는관동맥우회술 ) 를시행받은경우에 adenosine 혹은 dipyridamole 부하심근조영이나 dobutamine 부하심초음파를하는경우 (Level of evidence: B)
Class I 관동맥조영술의권고사항 1. 심장돌연사로부터생존한협심증환자혹은의심되는환자 (Level of evidence: B) Class IIa 1. 관상동맥조영술의위험이나비용에비해정확한진단이보다이득이되는환자군에서비침습적검사결과모호한경우 (Level of evidence: C) 2. 장애, 질환, 심각한비만으로비침습적검사를시행할수없는경우 (Level of evidence: C) 3. 직업때문에정확한진단이필요한경우 (Level of evidence: C) 4. 젊은나이에증상, 비침습적검사나다른임상적소견으로인해동맥경화외다른원인으로인한심근허혈유발이의심되는환자 (Level of evidence: C) 5. 관상동맥연축이의심되는상태에서유발검사가필요한경우 (Level of evidence: C) 6. 좌주간지나삼혈관질환이강력히의심되는환자 (Level of evidence: C) Class IIb 1. 반복적인흉통으로인한입원으로정확한진단이필요한경우 (Level of evidence: C) 2. 관상동맥질환저위험군에서정확한진단을원하는환자 (Level of evidence: C) Class III 1. 심각한동반질환으로시술로인한이득보다위험이더큰환자 (Level of evidence: C) 2. 관상동맥질환저위험군에서가능성은낮고이득이없을것으로판단되는상황에서환자가정확한진단을원하는경우 (Level of evidence: C)
Class I 안정형협심증에서위험도계층화를위한관동맥조영술의권고사항 1. 약물치료에도불구하고 CCS III 이나 IV 의증상을보이는만성안정형헙심증환자 (Level of evidence: B) 2. 흉통의정도와무관하게비침습적인검사에서고위험군기준에해당되는환자 (Level of evidence: B) 3. 심장돌연사로부터생존했거나중증심실빈맥을보이는협심증환자 (Level of evidence: B) 4. 울혈성심부전증의증상및징후를보이는협심증환자 (Level of evidence: C) 5. 중증의관상동맥질환을강력히시사하는임상적인특징을보이는환자 (Level of evidence: C) Class IIa 1. 비침습적인검사에서는고위험군에비해서는낮지만 CCS I 이나 II의협심증, 좌심실구혈율 45% 이하의좌심실기능장애를보이는환자 (Level of evidence: C) 2. 비침습적검사에서예후에대한평가가불충분하게된환자 (Level of evidence: C) Class IIb 1. CCS I 이나 II의협심증, 좌심실구혈율 45% 이상을보이는경우, 비침습적검사상고위험군에해당되지않는환자 (Level of evidence: C) 2. CCS III나 IV의협심증환자가약물치료후 I 이나 II로호전된경우 (Level of evidence: C) 3. 적절한내과적치료약물에견디지못하는 CCS I 이나 II의협심증환자 (Level of evidence: C) Class III 1. CCS I 이나 II의협심증이약물에잘반응하고비침습적인검사에서허혈증거가없는환자 (Level of evidence: C) 2. 재개통술을원하지않는환자 (Level of evidence: C)
심근경색과사망을예방하고증상을호전시키기위한약물치료의지침 Class I 1. 금기증이없는경우아스피린의사용 (Level of evidence: A) 2. 심근경색병력이있는경우 (Level of evidence A) 나병력이없는경우 (Level of evidence B) 에금기증이없을때베타차단제의사용 3. 당뇨그리고 / 혹은좌심실기능부전이있는관상동맥질환환자에서안지오텐신효소억제제의사용 (Level of evidence: A) 4. 관상동맥질환이진단된모든환자에서스타틴의사용 (Level of evidence: A) 5. 협심증의신속한경감을위한설하니트로글리세린이나스프레이를사용하는경우 (Level of evidence: B) 6. 베타차단제가금기인경우증상호전을위하여칼슘길항제나지속성질산염제를사용하는경우 (Level of evidence: B) 7. 베타차단제가초치료로서성공적이지못할경우칼슘길항제나지속성질산염제를사용하는경우 (Level of evidence: B) 8. 베타차단제에심각한부작용을보이는경우에그대체제로칼슘길항제나지속성질산염제를사용하는경우 (Level of evidence: C)
Class IIa 심근경색과사망을예방하고증상을호전시키기위한약물치료의지침 1. 아스피린이금기인경우 clopidogrel 사용 (Level of evidence: B) 2. 초치료로서베타차단제를대신하여지속성비dihydropyridine 계열의칼슘길항제의사용 (Level of evidence: B) 3. 관상동맥질환이확인되는경우혹은의증이면서저밀도지단백농도가 100~129 mg/dl로측정되는경우에서아래의치료시행 (Level of evidence: B) 저밀도지단백콜레스테롤저하 (100 mg/dl) 를위한생활습관조절및약물 대사증후군인환자에서체중감소및신체운동의증진 상승된중성지방이나감소된고밀도지단백의치료를위한니코틴산이나피브레이트치료 4. 다음에해당하는최고위험군에서는저밀도지단백콜레스테롤수치를 70 mg/dl 로억제시키는것이도움이될수있다. (Level of evidence: A) 다중의주요위험인자들 ( 특히, 당뇨 ) 을가진경우 심각하거나조절되지않는위험인자들 ( 특히흡연 ) 을가진경우 대사성증후군에해당하는다중의위험인자를가진경우 5. 관상동맥질환이나기타혈관질환을가진환자에서안지오텐신전환효소억제제의사용 (Level of evidence: B) Class IIb 1. 아스피린에더하여와파린으로시행하는저강도의항응고치료요법 (Level of evidence: B) Class III 1. Dipyridamole 사용 (Level of evidence: B) 2. Chelation 치료 (Level of evidence: B)
ISSUE in Stable Angina 1. Lipid lowering therapy시 target goal 2. CT angiography의 role 및지침 3. Nicorandil, Molsidomine, Trimetazidine 등현재우리나라에서널리사용되지만이점에대한증거가불충분한약제에대한지침
Lipid Lowering Therapy: Target Goal
LDL-C C Lowering Therapy in Patients With CHD and CHD Risk Equivalents Baseline LDL-C 130 mg/dl Intensive lifestyle therapies Maximal control of other risk factors Consider starting LDL-C lowering drugs simultaneously with lifestyle therapies Baseline (or On-Treatment) LDL-C C 100 129 129 mg/dl LDL-C lowering therapy Initiate or intensify lifestyle therapies and/or LDL-C lowering drugs Treatment of metabolic syndrome Emphasise weight reduction and increased physical activity Drug therapy for other lipid risk factors Baseline LDL-C: <100 mg/dl Further LDL-C C lowering not required Therapeutic Lifestyle Changes (TLC) recommended Consider treatment of other lipid risk factors (raised TG, low HDL-C) ATP III. JAMA 2001;285:2486
The major recommendations for modifications to footnote the ATP III treatment algorithm : In high-risk persons, the recommended LDL-C goal is 100 mg/dl, but when risk is very high, an LDL-C goal of 70 mg/dl is a therapeutic option, ie, a reasonable clinical strategy, on the basis of available clinical trial evidence. This therapeutic option extends also to patients at very high risk who have a baseline LDL-C < 100 mg/dl. J Am Coll Cardiol 2004;44;720-32
NCEP report 2004 Very high risk group 1. Diabetes with established CVD 2. Severe and poorly controlled risk factors and established CVD (Continued smoking, HTN) 3. Multiple risk factors of metabolic syndrome and CVD 4. Patients with acute coronary syndrome Further LDL-C C lowering not required 2001 NCEP ATP III Lower LDL-C < 70mg/dL NCEP Report J Am Coll Cardiol 2004;44:720-32
Evidence in Stable Angina TNT Treating to New Target LaRosa JC et al. NEJM 2005:352
Evidence in Stable Angina
Evidence in Stable Angina Patients with major cardiovascular event (%) 20 18 16 14 12 10 8 6 4 2 0 Atorvastatin 10 mg Atorvastatin 80 mg HR = 1.35 (0.63-2.90) (n=432) HR = 0.82 (0.57-1.19) (n=1500) HR = 0.95 (0.72-1.24) (n=2485) HR = 0.69 (0.54-0.89) (n=2624) HR = 0.77 (0.60-1.00) (n=2038) 0 1 2 3 4 5 No. of metabolic syndrome components HR = 0.68 (0.48-0.96) (n=922) Deedwania P, et al. Lancet 2006;368
검색결과 Randomized controlled trial : 1 Observational study
검토요약 안정형협심증에서지질강하요법의지침은아직한국에서시행된 randomized controlled trial (RCT) 는없지만최근미국및유럽에서시행된 RCT 및 systemic review를근거와 expert opinion에의하여근거를마련함.
ACC/AHA & ESC Guideline ACC/AHA giudeline 고용량스타틴에대한언급이아직포함되지않음. ESC guideline 매년 2% 이상의심혈관계사망률을보일수있는고위험군에서고용량 statin 사용을권고 (Class II a)
심근경색을예방하는약물치료지침 추가사항 Class IIa 다음에해당하는최고위험군에서의저밀도지단백수치를 70 mg/dl 이하로억제시키는것이도움이될수있다. (Level of Evidence: A) - 다중의주요위험인자들 ( 특히, 당뇨 ) 을가진경우 - 심각하거나조절되지않는위험인자들 ( 특히흡연 ) 을가진경우 - 대사성증후군에해당하는다중의위험인자를가진경우
CT Angiography
EBCT 2002년 ACC/AHA guidline 에는 EBCT에대한지침에포함 우리나라에서는거의 MDCT로되는상황으로 EBCT의지침에대한부분은실정에맞지않음 EBCT에대한내용은삭제및 MDCT 내용추가
Major limitations MDCT Single-center experiences very specific subset of symptomatic middle- aged white men who had a high prevalence of CAD The opportunity to noninvasively exclude significant CAD provides a compelling rationale for using coronary CTA in a variety of clinical applications.
만성안정형협심증의진단을위한관상동맥컴퓨터단층촬영에대한지침 ESC Guideline Class IIb 관상동맥컴퓨터단층조영술 (Level of Evidence: C)
검색결과 Systemic review : 0 Randomized controlled trial : 0 Only Observational study
근거 : 2006 ESC guideline Patients with a low pre-test probability of disease, with a non-conclusive exercise ECG or stress imaging test (Level of evidence: C) MDCT or Multislice CT appears the most promising of the two techniques in terms of non-invasive imaging of the coronary arteries, with preliminary studies suggesting excellent definition, and the possibility of examining arterial wall and plaque characteristics.
만성안정형협심증의진단을위한관상동맥컴퓨터단층촬영에대한지침 추가사항 Class IIb 관상동맥컴퓨터단층조영술 (Level of Evidence: C)
Medication Nicorandil Trimetazidine Molsidomine
Nicorandil The Impact Of Nicorandil in Angina (IONA) 안정형협심증환자에서의 nicorandil의투여는주요심장사건의감소를가져왔다고보고하였다. 하지만이러한효과는 1.6 년을추적관찰상심인성사망이나심근경색의감소보다는흉통으로인한재입원의감소로나타난결과였다. 아직은치료효과에대해서는논란의여지가있다. 우리나라나일본등지에는널리사용되고있지만아직사용의근거는미흡한상태이다. 아직정확한근거는없는상태로 guideline 내용에만포함하고권고안에는포함시키지않음
Trimetazidine 대사성약물로지방산의대사보다는당대사의활성도를높여항협심증효과를보이는것으로알려져있다. 단독또는다른약물즉, 칼슘차단제나베타차단제와병용할수있다. 20mg 하루 3회경구투여한다. 하지만아직안정형협심증에서의약제사용에따른예후에관한연구는없는실정이다. 아직정확한근거는없는상태로 guideline 내용에만포함하고권고안에는포함시키지않음
Molsidomine Organic nitrate와유사한효과가있는약물로항허혈성, 항협심증치료효과는입증이되었으나아직안정형협심증에서의약제사용에따른예후에관한연구는없는실정이다. 아직정확한근거는없는상태로 guideline 내용에만포함하고권고안에는포함시키지않음