acute coronary syndrome for student

急性冠心症和心臟衰竭診斷與治療急性冠心症和心臟衰竭診斷與治療

高雄長庚醫院胸腔內科王逸熙高雄長庚醫院胸腔內科王逸熙

急性心肌梗塞的診斷急性心肌梗塞的診斷持續胸痛持續胸痛心電圖上有心電圖上有 ST ST 波段的位移波段的位移心肌酵素上昇心肌酵素上昇

Chronic Stable Angina Acute Coronary Syndrome

ER Patient CareER Patient Care

Initial assessment (< 10 Initial assessment (< 10 min)min)

Measure vital signs Measure vital signs

Measure SMeasure SppO2O2

Obtain IV accessObtain IV access

Obtain 12-lead ECGObtain 12-lead ECG

Perform brief, targeted Perform brief, targeted history and PE)history and PE)

Obtain initial cardiac Obtain initial cardiac marker levelsmarker levels

Evaluate initial Evaluate initial electrolyte and electrolyte and coagulation studiescoagulation studies

Request, review Request, review portable chest x-ray portable chest x-ray (<30 min)(<30 min)

ER patient careER patient care

Initial general treatment (memory aid: Initial general treatment (memory aid: ““MONAMONA” greets all patients” greets all patients– Morphine, 2-4 mg repeated q 5-10 minMorphine, 2-4 mg repeated q 5-10 min

– Oxygen, 4 L/min; continue if SOxygen, 4 L/min; continue if SaaO2 < 90%O2 < 90%

– NTG, SL or spray, followed by IV for NTG, SL or spray, followed by IV for persistent or recurrent discomfortpersistent or recurrent discomfort

– Aspirin, 160 to 325 mg (chew and swallow)Aspirin, 160 to 325 mg (chew and swallow)

Triage by ECGTriage by ECG

ST elevation or new LBBBST elevation or new LBBB– ST elevation 1 mm in 2 or more contiguous leads≧ST elevation 1 mm in 2 or more contiguous leads≧

ST depression or dynamic T-wave inversionST depression or dynamic T-wave inversion– ST depression > 1 mmST depression > 1 mm– Marked symmetrical T-wave inversion in multiple Marked symmetrical T-wave inversion in multiple

precordial leadsprecordial leads– Dynamic ST-T changes with painDynamic ST-T changes with pain

Non-diagnostic ECG or normal ECGNon-diagnostic ECG or normal ECG

Suspicious Chest PainsSuspicious Chest Pains

Classic anginaClassic angina - dull, pressure, - dull, pressure, substernal; arm or neck radiation; SOB, substernal; arm or neck radiation; SOB, palpitations, sweating, nausea or vomitingpalpitations, sweating, nausea or vomitingAngina EquivalentAngina Equivalent - no pain but sudden - no pain but sudden ventricular failure or ventricular ventricular failure or ventricular dysrhythmiasdysrhythmiasAtypical chest painAtypical chest pain - precordial area but - precordial area but with musculoskeletal, positional, or with musculoskeletal, positional, or pleuritic featurespleuritic features

Typical Chest PainTypical Chest Pain

SAVEN SAVEN 鑑別口訣鑑別口訣 S: Substernal areaS: Substernal area

A: Abrupt onset A: Abrupt onset

V: Vagus distributionV: Vagus distribution

E: Exertion-relatedE: Exertion-related

N: NTG or Rest relieve it! N: NTG or Rest relieve it!

常見胸痛的輻射位置

Cardiac MarkersCardiac Markers

MyoglobinMyoglobin– NonspecificNonspecific– Rapid-release kineticsRapid-release kinetics– Useful for its negative Useful for its negative

predictive accuracy in predictive accuracy in the early hours after the early hours after symptom onsetsymptom onset

– Useful marker for Useful marker for reperfusionreperfusion

Inflammatory MarkersInflammatory Markers– Can indicate plaque or Can indicate plaque or

systemic inflammation systemic inflammation associated with ACSassociated with ACS

– CRP identifies a CRP identifies a subgroup of patients subgroup of patients with unstable angina at with unstable angina at high risk for adverse high risk for adverse cardiac eventscardiac events

Cardiac MarkersCardiac Markers

CK-MB IsoformsCK-MB Isoforms– Improved sensitivity Improved sensitivity

compared with CK-MBcompared with CK-MB– Only one form in the Only one form in the

myocardiummyocardium

– CK-MBCK-MB22 > 1U/L or CK- > 1U/L or CK-

MBMB22/CK-MB/CK-MB11 > 2.5% > 2.5%

Troponins (cTnT or cTnI)Troponins (cTnT or cTnI)– Troponin I/Troponin T Troponin I/Troponin T – Increased sensitivity Increased sensitivity

compared with CK-MBcompared with CK-MB– Detect minimal myocardial Detect minimal myocardial

damagedamage– Useful in risk stratificationUseful in risk stratification– < 0.04 ng/ml (normal)< 0.04 ng/ml (normal)– > 0.5 ng/ml (cut off value of > 0.5 ng/ml (cut off value of

MI)MI)

ST , LBBB

12 symptomsnon ST ACS,

mod-to-high risk

pain-free, low-to-mod risk, neg or nonspecific ECG, neg CK-MB, TnT/I

chest pain unit

TT“ineligible,”

shock

TT “eligible”

consider primary

PTCA, IABP

symptoms of acute ischemiasymptoms of acute ischemia

ASA 325 mg initial dose; 160 mg qd

<12 h symptoms

reperfusion therapy NSSTT s,– cardiac markers

dynamic ST shifts, + cardiac markers

antithrombotic therapy

enoxaparin UFH

cath in 12 h

no cath in 12 h

heparin therapy

eptifibatide or tirofiban +

heparin (consider

enoxaparin)

early cath

direct PCI (TTB<90 min)

UFH enoxaparin

Cr <2.5 mg/dLclopidogrel (reasonable certainty patient will not have early CABG)

Cr >2.5 mg/dL

ACS algorithmACS algorithm consider clinical trialsconsider clinical trials

TTTNK

ST Elevation Myocardial ST Elevation Myocardial Infarction (STEMI)Infarction (STEMI)

Coronary Artery Anatomy

Acute Myocardial Infarction (STEMI, inferior wall)

Ventricular Tachyarrhythmia

R

R

R

R

R

RV Involvement ? Right Precordial Leads

Heart Block and Bradycardia

Complete heart block

Anterior wall STEMI

Left bundle branch block

Post MI Mechanical Complications Post MI Mechanical Complications

VSD VSD 心室中隔缺損心室中隔缺損 Acute MR Acute MR 急性二尖瓣閉鎖不全急性二尖瓣閉鎖不全 Free wall rupture Free wall rupture 心臟破裂心臟破裂 Cardiac tamponade Cardiac tamponade 心包填塞心包填塞 Dressler’s syndrome Dressler’s syndrome 心包膜炎心包膜炎 Cardiogenic shock / pumping failure Cardiogenic shock / pumping failure 心因性休克心因性休克 Malignant cardiac arrhythmia Malignant cardiac arrhythmia 惡性心律不整惡性心律不整

IABP 主動脈內氣球幫浦

General Medical Indication:

1. Left ventricular power failure

2. Cardiogenic shock

3. Pre-shock syndrome

4. Myocardial ischemia

5. Acute MR or VSD

6. Drug refractory - Malignant Ventricular arrhythmia recurrence due to Myocardial ischemia

placement of the IAB in the placement of the IAB in the descending aortadescending aorta with it’s tip at the with it’s tip at the distal aortic arch (below the origin of distal aortic arch (below the origin of the left subclavian artery)the left subclavian artery)

helium -- lower density and a better helium -- lower density and a better rapid diffusion coefficientrapid diffusion coefficient

carbon dioxide -- increased carbon dioxide -- increased solubility in blood and reduces the solubility in blood and reduces the potential consequences of gas potential consequences of gas embolization following a balloon embolization following a balloon rupturerupture

the balloon is connected to a drive the balloon is connected to a drive console (consists of a pressurized console (consists of a pressurized gas reservoir, a monitor for ECG and gas reservoir, a monitor for ECG and pressure wave recording, pressure wave recording, adjustments for inflation/deflation adjustments for inflation/deflation timing, triggering selection switches timing, triggering selection switches and battery back-up power sources)and battery back-up power sources)

a pressurized gas reservoir, adjustments for inflation/ deflation timing, triggering selection switches and battery back-up power sources

Monitor for a ECG and pressure wave recording

Intra-aortic balloon pump in Cardiogenic Shock

Reperfusion Strategy for Reperfusion Strategy for STEMISTEMI

1.1. Thrombolytic (Fibrinolytic) TherapyThrombolytic (Fibrinolytic) Therapy

2.2. Primary PTCAPrimary PTCA

3.3. Emergency CABGEmergency CABG

ST elevation or new LBBBST elevation or new LBBB

Start adjunctive treatmentStart adjunctive treatment

If time < 12 hrIf time < 12 hr– Select a reperfusion strategy based on local Select a reperfusion strategy based on local

resourcesresources

If time > 12 hrIf time > 12 hr– Assess clinical status, either high-risk or Assess clinical status, either high-risk or

clinically stableclinically stable

ST elevation or new LBBBST elevation or new LBBB

Adjunctive treatmentsAdjunctive treatments– β-blockersβ-blockers– NTG IVNTG IV– Heparin IVHeparin IV– ACE inhibitors (after 6 hours or when stable)ACE inhibitors (after 6 hours or when stable)

ST elevation or new LBBB, time < 12 hrST elevation or new LBBB, time < 12 hr

Reperfusion strategy based on local Reperfusion strategy based on local resourcesresources– Thrombolytics (< 30 min)Thrombolytics (< 30 min)

TPA 15 mg bolus + 0.75 mg/Kg over 30 min + 0.5 TPA 15 mg bolus + 0.75 mg/Kg over 30 min + 0.5 mg/Kg over 60 min ormg/Kg over 60 min or

SK 1.5 million IU over 1 hSK 1.5 million IU over 1 h

– Primary percutaneous coronary intervention Primary percutaneous coronary intervention (PCI, angioplasty ± stent) (PCI, angioplasty ± stent) (90 (90 30 min) 30 min)

– Cardiothoracic surgery backupCardiothoracic surgery backup

ST elevation or new LBBB, time > 12 hrST elevation or new LBBB, time > 12 hr

Perform cardiac Perform cardiac catheterization for catheterization for high-risk patientshigh-risk patients– Persistent symptomsPersistent symptoms– Depressed LV functionDepressed LV function– Widespread ECG Widespread ECG

changeschanges– Prior AMI, PCI, CABGPrior AMI, PCI, CABG

Admit to CCU/ Admit to CCU/ monitored bed if monitored bed if clinically stableclinically stable– Continue or start Continue or start

adjunctive treatmentsadjunctive treatments– Serial serum markersSerial serum markers– Serial ECGSerial ECG– Consider imaging Consider imaging

study (2D study (2D echocardiography or echocardiography or radionuclide)radionuclide)

血栓溶解劑的臨床好處血栓溶解劑的臨床好處Benefit of ThrombolyticsBenefit of Thrombolytics

Time Lives saved/1000 < 1h 65 1-2 h 37 2-3 h 29 3-6 h 26 6-12 18

12-24 9

Contraindications to ThrombolyticsContraindications to Thrombolytics

AbsoluteAbsolute ：：–Previous hemorrhagic strokePrevious hemorrhagic stroke

–CVA within past 1 yearCVA within past 1 year

–Brain neoplasmBrain neoplasm

–Active internal bleedingActive internal bleeding

–Suspected aortic dissectionSuspected aortic dissection

血栓溶解劑的禁忌症血栓溶解劑的禁忌症 Contraindications to ThrombolyticsContraindications to Thrombolytics

Relative:Relative:– BP > 180/110 or BP > 180/110 or

chronic severe chronic severe hypertensionhypertension

– On anticoagulantsOn anticoagulants– Trauma or internal Trauma or internal

bleeding < 2-4 wksbleeding < 2-4 wks

– Traumatic CPR (>10 min)Traumatic CPR (>10 min)– Major surgery < 3 wksMajor surgery < 3 wks– Previous SKPrevious SK– Active ulcerActive ulcer– Pregnancy Pregnancy – Hidden punctureHidden puncture

Reperfusion EvidenceReperfusion Evidence

ST Elevation Subsides (> 50 %)ST Elevation Subsides (> 50 %)

Symptom of Angina RelievedSymptom of Angina Relieved

Reperfusion rhythm (AIVR)Reperfusion rhythm (AIVR)

Cardiac Enzyme early peak (12-20 hourCardiac Enzyme early peak (12-20 hour after onset of chest pain) after onset of chest pain)

AIVR (Accelerated Idio-Ventricular Rhythm) or Slow VT

介入性心導管術介入性心導管術

PTCA (Balloon Angioplasty)PTCA (Balloon Angioplasty)

Stent Implant Stent Implant

Primary PTCA with StentPrimary PTCA with Stent

冠狀動脈氣球擴張術前

狹窄處

氣球擴張術中

術後

冠狀動脈氣球擴張術後

Multivessel DiseaseCABG is Recommended

冠狀動脈繞道手

術

Unstable AnginaUnstable AnginaNSTEMINSTEMI

Definition of Unstable AnginaDefinition of Unstable Angina

Recurrent ischemic symptoms while on therapy Recurrent ischemic symptoms while on therapy High risk findings on stress test (see stress test section) High risk findings on stress test (see stress test section) Reduced LV function, with ejection fraction LVEF < 40% Reduced LV function, with ejection fraction LVEF < 40% Clinical evidence of CHF during chest pain Clinical evidence of CHF during chest pain Hemodynamic instability Hemodynamic instability Sustained ventricular tachycardia Sustained ventricular tachycardia Percutaneous intervention within the past 6 months Percutaneous intervention within the past 6 months Prior CABG surgery Prior CABG surgery Elevated troponin or other markers of necrosis Elevated troponin or other markers of necrosis Dynamic ECG changes at presentation Dynamic ECG changes at presentation

Unstable Angina & NSTEMIUnstable Angina & NSTEMI

ST depression or dynamic T-wave inversionST depression or dynamic T-wave inversion

Thrombolytics contraindicatedThrombolytics contraindicatedAdjunctive therapy:Adjunctive therapy:– Heparin (UFH/LMWH)Heparin (UFH/LMWH)– Aspirin 160-325 mg qdAspirin 160-325 mg qd– Glycoprotein IIb/IIIa receptor inhibitorsGlycoprotein IIb/IIIa receptor inhibitors– Clopidogrel (Plavix)Clopidogrel (Plavix)– NTG IV NTG IV -blockers-blockers

Cardiac catheterization for high-risk patients or Cardiac catheterization for high-risk patients or monitoring for clinically stable patientsmonitoring for clinically stable patients

Lower dose of heparinLower dose of heparin

To reduce the incidence of ICHTo reduce the incidence of ICHBolus dose: 60 U/kg (maximum 4000U)Bolus dose: 60 U/kg (maximum 4000U)

Maintenance dose: 12 U/kg/hr (maximum Maintenance dose: 12 U/kg/hr (maximum 1000 U/hr for patients weighing < 70 kg)1000 U/hr for patients weighing < 70 kg)

Optimal aPTT: 50-70 secOptimal aPTT: 50-70 sec

Clopidogrel (Plavix)Clopidogrel (Plavix)

blocks the platelet ADP receptorblocks the platelet ADP receptor

emerging as an important agent both in emerging as an important agent both in the acute and in the chronic phases of the acute and in the chronic phases of acute coronary syndromes. acute coronary syndromes.

nearly universally used in conjunction with nearly universally used in conjunction with coronary stenting. coronary stenting.

Platelet Aggregation

GGlycoprotein IIb/IIIa receptor inhibitorslycoprotein IIb/IIIa receptor inhibitors

Inhibits the GP IIb/IIIa receptor in the Inhibits the GP IIb/IIIa receptor in the membrane of plateletsmembrane of plateletsInhibits final common pathway activation Inhibits final common pathway activation of platelet aggregationof platelet aggregationAvailable approved agentsAvailable approved agents– Abciximab (ReoPro)Abciximab (ReoPro)– Eptifibitide (Integrilin)Eptifibitide (Integrilin)– Tirofiban (Aggrastat)Tirofiban (Aggrastat)

Benefit of clopidogrel & glycoprotein IIb/IIIa inhibitors stratified by cardiac markers

ST , LBBB

12 symptomsnon-ST ACS,

mod-to-high risk

pain-free, low-to-mod risk, neg or nonspecific ECG, neg CK-MB, TnT/I

chest pain unit

emergent cath, PCI, IABP for

shock

symptoms of acute ischemiasymptoms of acute ischemia

ASA 325 mg initial dose; 160 mg qd

<12 h symptoms

reperfusion therapyNSSTT s,

– cardiac markersdynamic ST shifts, + cardiac markers

antithrombotic therapy

enoxaparin UFH

cath in 12 h

no cath in 12 h

heparin therapy

eptifibatide or tirofiban +

heparin (consider

enoxaparin)

early cath

primary PCI (if time to balloon <90 min)

UFH enoxaparin

Cr <2.5 mg/dLclopidogrel (reasonable certainty patient will not have early CABG)

Cr >2.5 mg/dL

ACS acute care algorithmACS acute care algorithmfor centers with a cath lab and primary PCI capabilityfor centers with a cath lab and primary PCI capability

thrombolysis(with TNK, consider

enoxaparin)

TT“ineligible,”

shockTT

“eligible”

什麼是心衰竭什麼是心衰竭 ????

心臟衰竭就是心臟功能發生問題，心臟衰竭就是心臟功能發生問題，最常見的是無法輸出足夠的血量，最常見的是無法輸出足夠的血量，供應身體各部份組織器官的需要供應身體各部份組織器官的需要

NYHA classification for CHF

心衰竭有什麼症狀 ??喘喘

1. 呼吸困難：病人運動或工作時，就會呼吸困難，嚴重時，甚至於躺在床上或休息時，也會感覺呼吸困難。

2. 端坐呼吸：嚴重的心臟衰竭，病人平躺時會感到呼吸困難；需藉著坐起來或墊高枕頭才得以緩解。

3. 陣發性夜間呼吸困難：病人易從睡夢中驚醒，呼吸較費力且有喘鳴聲，需藉著坐起來或打開窗戶呼吸新鮮空氣來緩解。

4. 肺水腫 ; 咳嗽

腫腫1.1. 下肢水腫：開始出現在身體下端下肢水腫：開始出現在身體下端

部份，典型是發生在下肢踝部。部份，典型是發生在下肢踝部。 2.2. 可能導致肝腫大，易出現腹水及可能導致肝腫大，易出現腹水及

黃疸等肝臟受損的症狀。黃疸等肝臟受損的症狀。3.3. 可能導致頸靜脈怒張。可能導致頸靜脈怒張。

心臟方面的症狀心臟方面的症狀 a.a. 心臟跳動加快出現奔馬律。心臟跳動加快出現奔馬律。 b.b. 大部份的病人會出現心臟擴大的情大部份的病人會出現心臟擴大的情

形。形。c.c. 心臟跳動有雜音或跳動不規則。心臟跳動有雜音或跳動不規則。

New Approach to the ClassificationNew Approach to the Classification

Marked symptoms at rest despite maximal medical therapy (eg, those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions)

Refractory end-stage CHFD

Overt CHFSymptoms may be current or prior

Symptomatic CHFC

Known structural heart diseaseCardiomegaly, Previous MI, valvular

disease, LV systolic dysfunction

Asymptomatic CHFB

HypertensionCAD, cardiotoxin exposure Diabetes mellitusFamily history of cardiomyopathy

High risk for developing CHFA

Patient DescriptionStage

Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

但是很不幸的但是很不幸的 ,, 有超過一半以上的末期有超過一半以上的末期CHFCHF 病人病人 ,, 在等待在等待 heart heart transplantationtransplantation 的過程當中的過程當中 ,, 因為因為CHFCHF 引起的併發症引起的併發症 ,, 如如 AMIAMI 或是或是 VTVT 而死而死亡。亡。在部份嚴重在部份嚴重 congestive heart congestive heart failurefailure 的病人的病人 ,, 在用藥物之後在用藥物之後 ,, 仍然無仍然無法維持生命情形之下法維持生命情形之下 ,, 所以使用所以使用 non-non-pharmacologic therapiespharmacologic therapies 是一另外是一另外的選擇。的選擇。

Non-pharmacologic therapiesNon-pharmacologic therapies of CHF of CHF

(1) (1) Automatic implantable Automatic implantable

cardioverter defibrillatorcardioverter defibrillator (AICD) (AICD)

(2) (2) Left Ventricular Assist DeviceLeft Ventricular Assist Device (LVAD) (LVAD)

(3) (3) Intra Aortihc Balloon PumpIntra Aortihc Balloon Pump (IABP) (IABP)

(4) (4) Extracorporeal membrane oxygenator Extracorporeal membrane oxygenator (ECMO)(ECMO)

(5)(5) Coronary revascularizationCoronary revascularization

( hibernating and stunned myocardium)( hibernating and stunned myocardium)

(6)(6) Reconstructive cardiac surgeryReconstructive cardiac surgery

(been largely abandoned)(been largely abandoned)

(7)(7) Mitral valve repair in dilated cardiomyopathyMitral valve repair in dilated cardiomyopathy

(8)(8) LV aneurysmectomy in symptomatic patientsLV aneurysmectomy in symptomatic patients

Left Ventricular Assist DeviceLeft Ventricular Assist Device

正常情形下正常情形下 ,, 血液先經由血液先經由LV apexLV apex 的入口的入口 , , 經由經由人工血管人工血管 (inflow (inflow graft)graft) 流入血液幫浦的流入血液幫浦的血液室中血液室中 ,, 經經 pumppump 壓縮壓縮之後之後 ,, 再經由人工血管再經由人工血管(outflow graft)(outflow graft) 流流出出 ,, 將血液送至將血液送至ascending aorta,ascending aorta, 以以供應身體所需。供應身體所需。而而 pumppump 之出入口中之出入口中 ,, 各各有一個有一個豬瓣膜豬瓣膜 ,, 以維持血以維持血液的單向流動。液的單向流動。


LVADLVAD 在在 19851985 年正式獲得美國的通過年正式獲得美國的通過 ,, 准許可應准許可應用於臨床上嚴重心衰竭的病人用於臨床上嚴重心衰竭的病人 ,, 做為一個等待心做為一個等待心臟移植的橋樑。並於臟移植的橋樑。並於 19861986 年有了全世界首例的年有了全世界首例的使用。使用。在一開始研發之時在一開始研發之時 ,, 目的就是在建立一個目的就是在建立一個長期的長期的左心室輔助系統左心室輔助系統 ,, 希望病人能夠在等待心臟移植希望病人能夠在等待心臟移植的漫漫長路之中的漫漫長路之中 ,, 有一個安全穩定的依靠。有一個安全穩定的依靠。由於等待心臟移植的病人日益增加由於等待心臟移植的病人日益增加 ,, 而捐心者並而捐心者並沒有成比例增加的情況之下沒有成比例增加的情況之下 ,, 可以預期的是可以預期的是每一每一位等待換心的病人位等待換心的病人 ,, 他的等待換心期間將會愈來他的等待換心期間將會愈來愈長愈長。而此種長期性的。而此種長期性的 LVADLVAD 在臨床上所扮演的在臨床上所扮演的角色將會愈來愈重要。角色將會愈來愈重要。


LVADLVAD 主要是針對慢性心衰竭病患在等待換心主要是針對慢性心衰竭病患在等待換心期，產生嚴重心衰竭時輔以高劑量強心劑，或期，產生嚴重心衰竭時輔以高劑量強心劑，或IABPIABP 仍無法維持足夠之心輸出量情況下，所仍無法維持足夠之心輸出量情況下，所需考慮的治療方式。需考慮的治療方式。病患的血液動力學狀況必需符合下列標準，才病患的血液動力學狀況必需符合下列標準，才考慮進行考慮進行 LVADLVAD 的植入手術的植入手術 ::

(1) (1) Pulmonary capillary wedge pressurePulmonary capillary wedge pressure > 20mmHg> 20mmHg

(2) (2) SBP<80mmHgSBP<80mmHg 或是或是 cardiac index < 2.0 cardiac index < 2.0 L/min/M2L/min/M2


LVAD LVAD 在美國而言，已經是通過在美國而言，已經是通過 FDAFDA 核准，核准，在臨床上使用的醫療項目，而且醫療保險在臨床上使用的醫療項目，而且醫療保險公司也將此醫療支出納入給付項目之一。公司也將此醫療支出納入給付項目之一。可是在國內而言，依然目前法律規可是在國內而言，依然目前法律規定，定， HeartMate LVADHeartMate LVAD 及及 Novacor Novacor LVADLVAD 的治療尚屬於人體臨床試驗的項目，的治療尚屬於人體臨床試驗的項目，健保不給付，而必需由實驗經費來負擔，健保不給付，而必需由實驗經費來負擔，龐大的醫療經費支出，造成推廣的困難。龐大的醫療經費支出，造成推廣的困難。


據大規模的資料統計據大規模的資料統計 ,, 接受接受 LVADLVAD 植入的病人植入的病人 , , 比起對照組病人而言比起對照組病人而言 ,LVAD,LVAD 可以有意義的改善可以有意義的改善 : :

(1) (1) 病人的病人的 survival rate and lengthsurvival rate and length (2) (2) 病人病人 CHFCHF 的症狀的症狀 : : 接受接受 LVADLVAD 的病人的病人 , , 術前皆為術前皆為 NYHA Fc IV,NYHA Fc IV, 而接受完手術而接受完手術之後之後

,, 心臟功能幾乎都轉變為心臟功能幾乎都轉變為 NYHA Fc INYHA Fc I (3) (3) 因為因為 cardiac outputcardiac output 的大幅增加的大幅增加 ,, 使使得得

原本因原本因 low cardiac outputlow cardiac output 而引起的而引起的 multiple organ failuremultiple organ failure 得以改善得以改善 ,, 如腎功能改善與肝功能改善如腎功能改善與肝功能改善


嚴重心臟衰竭只用嚴重心臟衰竭只用 LVADLVAD 病人約有病人約有 20%20% 持續右心持續右心衰竭，所以右心房壓力太高衰竭，所以右心房壓力太高 (( 如如 > 20mmHg)> 20mmHg) 或或肺動脈阻力太大肺動脈阻力太大 (( 如如 > 5 Wood Units)> 5 Wood Units) 或右或右心收縮力太差心收縮力太差 (( 如如 RVEF < 10%)RVEF < 10%) 者，不要單獨者，不要單獨使用使用 LVADLVAD ，因嚴重右心衰竭會使，因嚴重右心衰竭會使 LVADLVAD 無法有無法有效運作，需要趕快再裝上右心室輔助器效運作，需要趕快再裝上右心室輔助器 (RVAD)(RVAD) 。。在使用雙心輔助器在使用雙心輔助器 (BVAD)(BVAD) 時，為避免時，為避免pulmonary edemapulmonary edema ，通常將，通常將 RVADRVAD 的流量調得的流量調得較較 LVADLVAD 流量稍低。流量稍低。

Implantable cardioverter defibrillatorImplantable cardioverter defibrillator

Sudden deathSudden death is a major cause of mortality is a major cause of mortality in patients with ventricular dysfunction. in patients with ventricular dysfunction.

Current methods of risk stratification are Current methods of risk stratification are inadequate, and a rational therapy for inadequate, and a rational therapy for prevention of sudden death is not available. prevention of sudden death is not available.

The implantable cardioverter-defibrillator The implantable cardioverter-defibrillator (ICD) has proven to be (ICD) has proven to be more effective more effective than drugsthan drugs in reducing sudden-death risk in reducing sudden-death risk in some subsets of patients. in some subsets of patients.

Mechanism of IABP

Mechanism of IABPMechanism of IABP

Improvement in coronary blood flow occurs Improvement in coronary blood flow occurs without an increase in myocardial work and without an increase in myocardial work and results in a 10-20% reduction in oxygen results in a 10-20% reduction in oxygen consumption. consumption.

Thus, the net effect of IABP in cardiogenic Thus, the net effect of IABP in cardiogenic shock is to increase coronary blood flow and shock is to increase coronary blood flow and myocardial oxygen supply while reducing myocardial oxygen supply while reducing myocardial work and oxygen consumption. myocardial work and oxygen consumption.

Cardiac output may increase by as much Cardiac output may increase by as much as 50%.as 50%.

Thanks for your attention!Thanks for your attention!

acute coronary syndrome for student

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