허혈성심질환의 일차진료 권현철성균관의대삼성서울병원심장혈관센터순환기내과
목차 허혈성심질환의진단 흉통의병력청취 비침습성검사 허혈성심질환환자의의뢰 의뢰대상 의뢰방법 되의뢰된허혈성심질환환자진료 항혈소판제제 기타약물치료
Causes of Chest Pain Myocardial ischemia and injury (31%) Angina pectoris, AMI Other cardiac cause Pericarditis Valvular heart disease MVP, AS, AR hypertrophic cardiomyopathy Disease of aorta Aortic dissection, Rupture of aneurysm Pulmonary disease (6%) Pulmonary embolism Pneumothorax Gastrointestinal disease (42%) Esophageal reflux Peptic ulcer Gallbladder disease Musculoskeletal disease (28%) Psychogenic cause Modified from Fruergaard P, Eur Heart J 1996
흉통의감별진단 My Algorithm Chest pain Really a pain? DDx of palpitation or dyspnea Typical location? Chest wall pain, non-angina pain Exertional? Probably angina DDx: aortic valve disease, anemia, LV hypertrophy Morning only? R/O Variant angina DDx for resting angina Unstable angina / AMI, aortic dissection, pulmonary embolism, GE reflux, neurosis, pericarditis, aortic valve disease
증례 1 F/45, 숨이차다. 질문 : 숨을들이쉴때다들이쉬어지지않나요? 답변 : 그렇습니다. 질문 : 운동을할때숨이더찬가요? 답변 : 그렇지는않습니다. 질문 : 한숨을많이쉬나요? 답변 : 그렇습니다. 질문 : 숨이안쉬어져서죽을것같은기분이드나요? 답변 : 그렇습니다. -------------------------------------------------------- 가능성 : 과호흡증후군
과호흡증후군 정의 이산화탄소의과도배출에의한호흡장애 원인 신체적인원인 : 폐렴, 폐색전증, 천식, 갑상선기능항진증 정신적원인 : 불안, 우울증 증상 호흡중추억제 : 숨을들이쉬어도다들이쉬지못하는것같다. 알칼리화에의한증상 : 어지러움, 감각이상, 손발경련, 근육의힘이없어지는증상, 가슴통증, 부정맥, 실신 치료 비닐봉지로숨쉬기 정신적요인에대한설명및약물치료
증례 2 M/45, 좌측흉부통증질문 : 어디가아프지요? 답변 : 여기요. ( 왼쪽늑연골관절을손가락으로가리키며 ) 질문 : 어떤식으로아픈가요? 답변 : 타는듯이아픕니다. 질문 : 얼마나오래지속되지요? 답변 : 10분정도지속됩니다. 질문 : 운동을하면심해지나요? 답변 : 아닙니다. 질문 : 자세에따라통증이달라지나요? 답변 : 그렇습니다. ----------------------------------------------------------------- 가능성 : 늑연골관절염
늑연골관절염 뻐근하거나타는듯한통증이 10분또는수시간, 길면며칠간지속국소적관절을움직이는일에통증 : 몸통을움직임, 한쪽으로눕기. 기침, 무거운것들기저절로, 또는부딪치거나운동후발생 DDx.: 늑간신경통
증례 3 M/50, 안정시흉통질문 : 어디가아프지요? 답변 : 여기요. ( 가슴가운데를손바닥으로가리키며 ) 질문 : 운동을하면통증이심해지나요? 답변 : 아닙니다. 질문 : 아침에주로아프나요? 오후에는아프지않나요? 답변 : 그렇습니다. 질문 : 술마신다음날심해지나요? 답변 : 그렇습니다. -------------------------------------------------------- 가능성 : 변이형협심증
변이형협심증 흉통악화요인 : 아침, 추위, 술마신다음날 감별진단 : peptic ulcer, GE reflux
허혈성심질환의검사 심전도 급성심근경색증이외에는도움이많이되지않음 운동부하검사 가장중요한인자 : 운동시간, Duke score False positive: Baseline EKG 에서 ST change 가있는환자 심근스캔 병원의정도관리에따라신뢰도가다양하다. 관상동맥 CT 음성예측도 (negative predictability) 가높다.
EKG is Non-diagnostic in Most of Cases The resting EKG is normal in 50% of stable angina, and in 38% of unstable angina. Serial follow-up is most important Non-specific ST-T change
Test Characteristics for Investigations Used in the Diagnosis of Stable Angina Diagnosis of Coronary Artery Disease Sensitivity (%) Specificity (%) Exercise ECG 68 77 Exercise echo 80 85 84 86 Exercise myocardial perfusion 85 90 70 75 Dobutamine stress echo 40 100 62 100 Vasodilator stress echo 56 92 87 100 Vasodilator stress myocardial perfusion 83 94 64 90 Fox K, ESC Guideline. Eur Heart J 2006
장점 관상동맥 MD CT Negative predictability가높다. 촬영시간이짧다. 단점 * MD = multi-detector 신장기능이나쁜경우에는합병증이있다. 협착이과장되는경향이있다.: 특히석회화, 스텐트내부
MD CT Exaggerates CT Resolution: 0.5~0.6 mm Blooming effect of calcium
MD CT Exaggerates Reading: LAD 50%, PDA 50% Exercise duration 10 min. Negative test 항상증세와 functional test 와함께평가하여야함.
Coronary Calcium Score 의미 : 관상동맥동맥경화가있고추후허혈성심질환의발생가능성이높다. 현재의미있는허혈성심질환이있다는뜻은아님.
응급실에서의통증감별 중증통증 급성심근경색증 심전도이상동반 대동맥박리 시작시최대통증, 흉부사진 폐동맥색전 진단방법 심전도 : serial follow-up Troponin Triple rule out CT SaO 2 저하동반, 심초음파 2
SMC QI Program for AMI Chest pain center Fast track at ER for acute chest pain EMR-based critical pathway One-call system Primary physician at ER activates PCI team Only based on patient s symptom and ECG findings Call center (#3777): call to recruit intervention team Quality improvement (QI) program for AMI
Door-to-Balloon Time SMC AMI QI Report AMI 입원중사망률심평원자료 123 100 74 115 95 76 AMI QI 84 75 58 83 61 47 Year SMC 국내평균 2003 5.4% 10.8% 2007 2.9% 8.9% 2008 3.2% NA 2008 년심근경색적정성평가 1 등급 *Guideline recommends less than 90 minutes, which has been achieved in about 50% of cases in America.
Complex Lesion Chronic Total Occlusion
Lesions Not To Treat Insignificant stenosis Small area of myocardium Low success rate
Transradial PCI (TRI) 1200 1000 SMC PCI Numbers Transradial Total Transfemoral 800 600 400 Transradial 200 0 2001 2002 2003 2004 2005 2006 2007 2008
Transradial intracoronary Spasm Test Lee KJ, Gwon HC, Catheter Cardiovasc Interv 2005
SMC experience Miniaturized PCI 5-French Transradial PCI Prospective randomized study N = 200 patients (246 lesions) 5 French vs. 6 French Sheath: Cook 28 cm Subjects Inclusion All transradial PCI Exclusion Primary PCI Left main disease Bifurcation lesion Cutting balloon Gwon HC, J Invasiv Cardiol 2006
One-day Admission CAG/PCI Program Since 2001
입원일수및입원진료비 - 심평원자료 - 7 6 5 4 3 2 1 3.8 * 6.2 6.4 5.9 5.8 5.8 5.7 4.9 5.0 4.5 SMC AMC SNUH YUMC 3차기관평균 0 입원일수 ( 일 ) 입원진료비 ( 백만원 ) * 전국 1 위 건강보험심사평가원자료 ( 세계일보 2009.1.5.)
당일입퇴원시술수탁프로그램 예약 : 진료의뢰센터시술당일 : 입실후간단한혈액검사후시술동의서시술 : CAG 및 PCI를당일오전중에시행퇴원 : 특별한일이없는한환자는당일퇴원시술결과확인 당일전화또는소견서 관상동맥조영술 CD-ROM을환자편에보내드립니다시술후 환자는원칙적으로바로되의뢰 고위험군환자는일단본원에서외래통원
당일입퇴원시술수탁프로그램
Cardiology Refer System 진료의뢰센터 (3410-0800) Chest pain center at ER CAD team coordinator (3410-2119) 의뢰의사와직접연락 외래및입원 arrange
Very Late Stent Thrombosis 스텐트를시술하고 1 년이후갑자기혈전으로막히는현상사망률 30-50% Baseline Final CAG DES 에서많이보고 됨 6-mo FU 20-mo FU * DES = drug-eluting stent ( 약물용출 ( 코팅 ) 스텐트 )
Cypher Taxus Endeavor Endeavor Resolute Xience/Promus Pico Elite Coroflex Please Cordis Boston Scientific Medtronic Medtronic Abbott / Boston Scientific AMG Biotronic Cypher Taxus Endeavor Xience Pico elite Coroflex Please
Firestorm from WCC 2006 Edoardo Camenzind (University Hospital Geneva, Switzerland) Meta-analysis by pooling published or presented data 10 BMS DES 8 6 4 2 0 6.3 3.9 2.3 2.6 N=870 N=878 N=1675 N=1685 Cypher Taxus * BMS = bare metal stent, DES = drug-eluting stent
Kastrati A. Meta-analysis of 14 trials comparing DES vs. BMS Similar Death/MI, but increased stent thrombosis After 1 year, DES 0.6%, BMS 0.05% p=0.02 Kastrati A, NEJM 2007
Clopidogrel 의처방기간이문제 Duke database: BMS 3165, DES 1501 patients 8 24-month Death/MI No Clopidogrel Clopidogrel 6 4 3.6 P=0.44 4.7 P<0.001 4.5 2 Eisenstein EL, JAMA 2007 0 BMS DES 0.0
2009 AHA/ACC Focused Updated Guideline For the Use of Clopidogrel Class I BMS: at least 1 month DES: at least 12 months Acute coronary syndrome: at least 12 months Class IIb Continuation beyond 15 months may be considered in DES group. Circulation 2005
Need for Minor or Major Surgery The patients are usually elderly, susceptible to various kinds of minor or major surgery. Most frequently encountered surgery Endoscopic biopsy and polypectomy Cataract operation Vascular surgery Cancer surgery
AHA/ACC/SCAI/ACS/ADA Guideline
Current Recommendations for Antiplatelet before the Surgery High risk of bleeding: stop antiplatelets Major surgery: orthopedic surgery, neuro-surgery Polypectomy, sphincterotomy Low risk of bleeding: continue antiplatelets Dental extraction, cataract or dermatology surgery Endoscopy ± biopsy Delay the surgery with high risk of bleeding BMS: at least 2 weeks, ideally 4 weeks DES: at least 6 months, ideally 12 months Balance the risk and benefit Try to continue at least aspirin, if possible Grines C, Circulation 2007
Guidelines for Endoscopic Procedure When to stop aspirin before colonoscopy Primary prevention: 5-7 days Secondary prevention: 3-4 days When to restart aspirin after polypectomy Primary prevention: 2 weeks Secondary prevention: < 1 week Clopidogrel Limited data Stop 5 days before colonoscopy Kimchi NA, Digestion 2007
관상동맥중재술받은환자의퇴원처방 - 저의처방 - Aspirin 100 mg QD Clopidogrel 75 mg QD after PCI Statin Post-MI or LV dysfunction Carvedilol or bisoprolol Angiotensin receptor blocker (class effect) Angina control Bisoprolol Rarely nitrate, nicorandil, trimetazidine BP control ARB (± thiazide) ± calcium channel blocker
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