【文章內容簡介】 rt ?anginal symdrome may be present at rest. Stable angina pectoris 第四十九頁，共一百一十五頁。 1. General consideration： ? rest， avoid provocative factors , risk factors control 2. Drug therapy: ? prevent MI and death ? symptom relief and quality of life improvment 3. Coronary revascularization: ? percutaneous coronary intervention (PCI) ? Coronary artery bypass surgery (CABG) SVG, LIMA Prevention and treatment Stable angina pectoris 第五十頁，共一百一十五頁。 antianginal and antiischemic therapy Drug therapy Oxygen supply Oxygen demand blockers antagonists improving metabolism Stable angina pectoris 第五十一頁，共一百一十五頁。 Drug therapy ?lower oxygen demand: decrease arteriolar and venous tone, reduce preload and afterload ?increase coronary supply: Coronary dilatation ?Nitroglycerin ?Isosorbide dinitrate ?isosorbide 5mononitrate (longacting nitrates) Stable angina pectoris 第五十二頁，共一百一十五頁。 b. 223。－ blockers: ?reduce myocardial oxygen: reduce HR, myocardial contractility, BP,the LV wall stress Abslute contraindications： sever bradycardia: highdegree AV block, SSS, severe unstable LV failure Relative contraindications: asthma and bronchospastic disease peripheral vascular disease 223。1selective： metoprolol, atenolol, bisoprolol Drug therapy Stable angina pectoris 第五十三頁，共一百一十五頁。 antagonists： ?Increase oxygen supply: dilate resistance vessels, release spasm, improve microvascular function ?Decrease oxygen demand: negative inotropic effect, decrease BP ?Antiplatelet effect d. Drugs improving metabolism： trimethazine〔 vasorel〕， selectively inhibit 3KAT〔 3酮酰輔酶 A硫解酶〕， partly inhibit FA oxidation Drug therapy Stable angina pectoris 第五十四頁，共一百一十五頁。 prevent MI and death therapy angents： ?ASA， 75325mg/d ?clopidogrel。 ticlopidine: ADP receptor antagonists: ?Cilostazol: phosphodiesterase inhititor,50100mg bid b. Lipidlowering angents: statins c. Angiotesinconverting enzyme inhibitor (ACEI) Drug therapy Stable angina pectoris 第五十五頁，共一百一十五頁。 stenting Stable angina pectoris 第五十六頁，共一百一十五頁。 Unstable angina(UAP) and nonSTEMI 第五十七頁，共一百一十五頁。 Resting ischemia NonST elevation STelevation Unstable angina NonQ wave AMI Q wave AMI *positive serum cardiac markers * * * * occasionally variant angina Acute Coronary Syndrome(ACS) 第五十八頁，共一百一十五頁。 ?Occuring at rest (or with mininal exertion): last 20 mins ?severe and of newonset: within 12 months, CCS III ?Occuring with a deteriorative pattern: at least CCS III ?variant angina pectoris (Prinzmetal angina): ?transient ST elevation, caused by the coronary spasm Definition UAP and nonSTEMI Angina pectoris or equivalent ischemic disfort with at least one of the three features 第六十頁，共一百一十五頁。 Braunwald classification of unstable angina Severity： ?Class I： ?Newonset, or accelerated severe angina ?no rest pain within 2 months ?Class II： ?Angina at rest, subacute angina at rest (within the preceding month but not within 48 h) ?Class III： ?Angina at rest, acute ( within the preceding 48 h) UAP and nonSTEMI 第六十一頁，共一百一十五頁。 Braunwald classification of unstable angina Clinical Circumstances ? Class A： Secondary UAP a clearly identified condition extrinsic to the coronary vascular bed that has intensified myocardial ischemia, . anemia, hypotension, tachyarrhythmia ?Class B： Primary unstable angina ?Class C： Postinfarction UAP (within 2 weeks of a documented MI) UAP and nonSTEMI 第六十二頁，共一百一十五頁。 mechanism： rupture and erosion, with nonocclusive thrombus obstruction: Vasoconstruction mechnial obstruction(rapidly advancing or ISR following stenting) UA Inflammation Thrombogenesis UAP and nonSTEMI 第六十三頁，共一百一十五頁。 ECG: NonSTEMI: ST depression last 12 hr Cardiac biomarkers of myocardium damage: cTnT, cTnI CKMB UAP and nonSTEMI ?Coronary angiography ?Angioscopy and IVUS ?Other laboratory tests 第六十四頁，共一百一十五頁。 Risk stratification： TIMI Risk Score ?Age =65yrs ?More than 3 coronary risk factors ?Prior angiographic coronary obstruction ?STsegment deviation ? mm ?More than 2 angina events within 24 hours ?Development of UA/NSTEMI while on aspirin ?Elevated cardiac markers Antaman, JAMA 2024。 284:83542 TIMI IIB, ESSENCE, PRISMPLUS,TACTICSTIMI18 UAP and nonSTEMI 第六十五頁，共一百一十五頁。 Treatment management: rest, oxygen, CCU 2. Drug therapy A. Antiischemic drug: intravenously, orally ?nitrates ??blocker ?Calcium antagnoist: first choice for variant angina ?Morphine UAP and nonSTEMI 第六十六頁，共一百一十五頁。 Treatment 2. Drug therapy: B. antithrombotic therapy a. Antiplatelet ?Aspirin: early, 300mg loading dose ?ADPreceptor antagonist: clopidogrel 300mg600mg loading dose, 75 mg/d ?GP IIb/IIIa receptor inhibitor: used in pts planned to PCI b. Anticoagulation therapy: ?Heparin ?Low molecular weight heparin(LMWH) ?Direct antithrombin drug: bivalirudin, hirudin UAP and nonSTEMI 第六十七頁，共一百一十五頁。 Treatment 2. Drug therapy: C. other medical therapy a. lipidlowering drugs: statins, early use(in first 24 hrs) LDLc target: 70 mg/dl b. ACEI: longterm secondary prevention UAP and nonSTEMI 第六十八頁，共一百一十五頁。 Treatment 3. Invasive versus conservative strategy early invasive strategy indicated for high risk patients: within 4872 hrs, Following by coronary revascularization(PCI or CABG) 4. Longterm management 223。blockers, Statin, ACEI,aspirin clopidegrel(12m) UAP and nonSTEMI 第六十九頁，共一百一十五頁。 SYMPTOMS SUGGESTIVE OF ACS Noncardiac Diagnosis Chronic Stable Angina