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1 ACS Circulation Journal Vol. 72, Suppl. IV,

2 PCI CCU CCU STEMI CABG ST ST 1 EBM ST ST ST ST EBMEvidence-Based Medicine 1348 Circulation Journal Vol. 72, Suppl. IV, 2008

3 ACS ST T ST CLBBB ST ACS ST ACS 12 CPK 24 ST ST Q Q ST ST ST ST ST ST STST ST CCU a a b A B Circulation Journal Vol. 72, Suppl. IV,

4 C ACSacute coronary syndrome STEMIST-elevation myocardial infarction ST PCIpercutaneous coronary intervention CABGcoronary artery bypass grafting CCUcoronary care unit T vulnerable plaque Davies Fuster ACS 23positive remodeling T DeWood 1350 Circulation Journal Vol. 72, Suppl. IV, 2008

5 T 2 Vulnerable Patient CRP ACS Erosive Thrombosis.. //.. CCU... MONICA // hypokinesis akinesisdyskinesis dp/dt Frank-Starling Circulation Journal Vol. 72, Suppl. IV,

6 STEMI autopsy HurlerFabry CO DIC STEMI STEMI B B STEMICCU ACC/AHA A chain of survival C chain of survival B STEMICCU STEMI STEMI ventricular fibrillationvf VF automated external defibrillator AED AED 1352 Circulation Journal Vol. 72, Suppl. IV, 2008

7 AED AED AED cardiopulmonary resuscitation CPR AHACPR CPR CPR CPR AED 34 CPRAED A C A STEMI AED mg/ 119 AED / AED AED Circulation Journal Vol. 72, Suppl. IV,

8 B STEMIMONA B STEMI FAXC a B 1 STEMI..C.I. -. ACC/AHA TIMI flow facilitated PCI TIMI flow primary PCI TIMI flowprimary PCI Step ST Step mmHg 15mmHg 110mmHg 3 6 CPR10 Step 3. 1PCI 100/ < 100mmHg Killip Step Circulation Journal Vol. 72, Suppl. IV, 2008

9 facilitated PCI a STEMI PCI CABG A STEMI PCI B STEMI C a 1Step PCI B STEMI PCICABG STEMI TIMI PCI B STEMI STEMI X 3 Door-to-needle time : 30 Door-to-balloon time : 90 1V4R 2 3 Door-to-needle time Door-to-balloon time Circulation Journal Vol. 72, Suppl. IV,

10 2 C STEMI 12THyperacute TT RST / Q V 4 R : CKCK-MBH-FABP intimal flap X 1356 Circulation Journal Vol. 72, Suppl. IV, 2008

11 C Bezold-Jarisch mmhg Killip 3 thrill Killip STEMIStanford A 50% 50% 90mmHg Circulation Journal Vol. 72, Suppl. IV,

12 ACS C ACS C V R B ST.mVST STEMI STEMI Thyperacute T Hyperacute TR STQSTEMI ACS V R V RmmST ST ST STEMI ST ST STV - V ST V -V ST STT ST V -V STQS ST ST avr STPR avrst PR WPWST-T QRS mm ST V -V mmstqrs mmststemi QRS V V V qr STQRS V rrr Yamaji avr STV ST C STEMI 1358 Circulation Journal Vol. 72, Suppl. IV, 2008

13 CKMBCK-MB H-FABP TI T STEMI I CK STEMI CK CK.ng/ml CK ESC/ACC STACS H-FABP H-FABPT 4 X C C X X X XX <2h 2 4h 4 6h 6 12h 1224h 2472h >72h * H-FABP* * CK-MB CK * Circulation Journal Vol. 72, Suppl. IV,

14 C C C C C C a C b C echo free space diastolic collapse intimal flap C STEMI Killip3 Killip mmhgmmhg SHOCK registry TIMI / simple risk index CADILAC Killip TIMI STEMI 1360 Circulation Journal Vol. 72, Suppl. IV, 2008

15 B a C l/ C C mmhg mmhgbpm bpm C B mmhg mmhg bpmbpm C mg mg Circulation Journal Vol. 72, Suppl. IV,

16 ..mg. mg AmgC mg mg STEMI mg mg mg PCI ACT C a tpapro-ukmutant tpa aptt C C PCI ACTactivated clotting time TIMI tpa tpa aapttactivated partial thromboplastin time STEMI A C mmhgc / C C C C PCI 1362 Circulation Journal Vol. 72, Suppl. IV, 2008

17 STEMIPCI TIMI doorto-needle time PCI door-to-balloon time6 AHA ILCORPCI PCI PCI TIMI PCI STEMI PCI PCI TIMI PCI PCI 7 STEMI ST 1mm PCI facilitated PCI facilitated PCI PCI 90 CABG PCI Circulation Journal Vol. 72, Suppl. IV,

18 STEMI ST 1mm PCI 24 PCI PCI PCI *STT STEMI STEMI PCI.. CCU direct PCI STEMIPCI.mVST A A a C ST B C STACS A A B 1364 Circulation Journal Vol. 72, Suppl. IV, 2008

19 / mmhg ST PCI PCI PCI PCI 67 primary PCI A primary PCI B a PCI primary PCIB B bprimary PCI B ckillip primary PCIB a ac bc cc primary PCI C primary PCIC PCI primary PCI STEMIprimary PCI primary PCI STEMI PCI PCI PCI PCI Circulation Journal Vol. 72, Suppl. IV,

20 PCI rescue PCI STEMI primary PCIC b primary PCI B primary PCI C a PCI B facilitated PCI PCI facilitated PCI PCI facilitated PCI B a B ac bc rescue PCI PCI A a PCI B STEMI PCI C 1366 Circulation Journal Vol. 72, Suppl. IV, 2008

21 PCI B PCI B a C C b C a STEMIPCI B STEMIPCI no reflow TIMI PCI B PCI B B STEMI ST A B a STEMI PCI B CABG B CABGC CABG C STEMICABG CABG PCI STEMICABG PCI PCI PCI ST rescue PCI TIMIblushTIMI Circulation Journal Vol. 72, Suppl. IV,

22 blush ST STEMI C PCI ac tpapro-ukmutant tpa STEMIPCI PCI ACC/AHA U/kg UaPTT.. U/hr ACTaPTT STEMI bb HIT ACS PCI HIT.mg/kg/ / PCI.mg/kg g/kg/actaptt.g/kg/ ACTaPTT A STEMI B STEMI mg/mg/ 1368 Circulation Journal Vol. 72, Suppl. IV, 2008

23 b/a PCI ab ab STEMIPCI.g/kg/ STEMI J-WIND A STEMIPCI PCI no reflow mg PCI B b PCI B. mg/dl.mg Cigarroa ml kg mm/ mg/dl PCI STEMICCU CCU Day Kansas Bethany Philadelphia Presbyterian Toronto CCU Cardiac Care Unit Circulatory Care Unit Chest Pain Center Circulation Journal Vol. 72, Suppl. IV,

24 CCU CCU PCI CABG CCU ACC/AHA B C C C ac PCI PCI CCU L/ ac CCU BSwan-Ganz B BCCU PCI CCU C bc Swan-Ganz CPK -CCU CPK ac PCI Kcal/ g/ CCU b C a C 1370 Circulation Journal Vol. 72, Suppl. IV, 2008

25 CCU bc Foley C C A CCU CCU ACC/AHA PCI CCU no reflow A Ab a STEMI. ac C DVTbC DVT C heparin-induced thrombocytopenia HIT C ac bc stunned myocardium Circulation Journal Vol. 72, Suppl. IV,

26 no reflow bc J-WIND STEMI a B IABP PAMI- IABP LMT PCI PCI IABP LMTPCI CABG PCI ac expansion expansion expansion expansion ACE ARB A J J J-JJ B a mg B.mEq/L.mg/dLC meq/ g a.-.mg/kg C b mg/ C STEMI B 8 STEMI > primary VF 1372 Circulation Journal Vol. 72, Suppl. IV, 2008

27 1 / 150J200J 360J K>4.0mEq/LMg>2.0mg/dL 1 125mg mg/kg 3 20mg/ 2 200J 1 125mg 2 IABP PCl 3K>4.0mEq/LMg>2.0mg/dL mg/kg 1 <90mmHg 100J 2 >90mmHg a. 125mg 10 b. 50J 3 / J 50J mg 4 12mg 1 210mg 0.125mg/kg 0.1ml/kg1mg/kg mg secondary VF AHA J J ACC/AHA ab mg mg/kg mg mg/kg mg Circulation Journal Vol. 72, Suppl. IV,

28 K primary VF STEMI B J J J-JJ <mmhg B J <mmhg B J a mg B IABP PCl B.mEq/L.mg/dL CmEq/ g /minqtc C a..mg/kg B b mmhg mg/c B bpm J mg mg mg mg mg 1374 Circulation Journal Vol. 72, Suppl. IV, 2008

29 mg/ ACC/AHA mmhg B..mg/kg.mg/ kg/hrtorsades de Pointes..mg/kg..mg/kg/hr mg/mg/kg STEMI electrical storm IABP PCl a >.meq/l >.mg/dl CmEq/ g A KMg ph CAST Na STEMI Na C C STEMI implantable cardioverter-defibrillatoricd ICD ICD STEMI> STEMI Circulation Journal Vol. 72, Suppl. IV,

30 ICD ACC/AHA MADIT- ICD a NYHA ac JJ J b..mgmg C ac mg..mg/kg.ml/ kgmg/kg bc.-mg mg mg cstemi C dc ac batpc mg mg mg c C C STEMI J mgmg..mg/kg..mg/kg/min.ml/kgmg/kg mmhg bpm K 1376 Circulation Journal Vol. 72, Suppl. IV, 2008

31 B pulseless electrical activity STEMI bpm C STEMI C STEMI STEMI bpm.mg. mg/kg mg / kg STEMI Mobitz a.mobitz. QTc b STEMI STEMI Mobitz STEMI amobitz STEMI Mobitz I STEMI Circulation Journal Vol. 72, Suppl. IV,

32 STEMI STEMIHis-Purkinje His-Purkinje B B C b B B B B B His-Purkinje STEMI STEMI DDD VVI DAVID ICD VVI bpmddd bpm MOST DDDR STEMI ICD Cardiac Resynchronization TherapyCRT CRT-D QRS CRTCRT-D CRT NYHA QRS msec C 1378 Circulation Journal Vol. 72, Suppl. IV, 2008

33 C a C C C C C C mmhgc C C a C b C C Swan-Ganz Forrester pulmonary capillary wedge pressurepcwpcardiac indexci hemodynamic subset9 subset PCWP mmhgci.// ACE subset PCWP>mmHgCI.// /min / m2 2.2 mmhg subset PCWP mmhgci.// subset PCWP mmhgci.// intra-aortic balloon pumpingiabp percutaneous cardiopulmonary support systempcps X Swan-Ganz Nohria Forrester Circulation Journal Vol. 72, Suppl. IV,

34 Swan-Ganz warm and dry Forrester cold and dry Forrester warm and wet Forrester cold and wet Forrester C C IABP B C C PCI IABP C B IABP B PCI CABG B B B g/kg/ IABP PCI CABG C C mmhg mmhg IABP C C ACE A C LVEF ACE A 1380 Circulation Journal Vol. 72, Suppl. IV, 2008

35 C b IABP C B STEMI extension Killip5 STEMI IABP primary PCI positive end expiratory pressurepeep noninvasive positive pressure ventilationnppv mg mmhg mg Killip Killip primarypci % 6% 5% % 1921% :50% 17% 21% 7 16% 1921% :50% 38% 35% 1924% 2 3% 81% 67% 61% Circulation Journal Vol. 72, Suppl. IV,

36 NaKMg B BNPnesiritide AANP ACE SAVE TRACE AIRE ARB STEMIARB ACE OPTIMAAL VALIANT IABP B C PCI CABG A PCI CABG B C a Swan-Ganz C PCI CABG B mmhgmmhg ml/ STEMI X Swan-Ganz g/kg/ g/kg/ <g/kg/ >g/kg/ g/kg/ g/kg/ PDE - IABP STEMI PCI CABG SHOCK. vs Circulation Journal Vol. 72, Suppl. IV, 2008

37 . vs..p<. ACE STEMI 11 V R B C C C IABP C C a CABG C STEMI V R mmst Kussmaul 6 / CPAP/ NPPV 35mg IABP >100mmHg 70100mmHg < 70mmHg NTG g/kg/ ISDN0.22.0g/kg/ g/kg/ 13g/kg/ 0.520g/kg/ 0.520g/kg/ g/kg/ ACE ARB PCICABG CPAP NTG NPPV ISDN IABP ACE PCI ARB CABG Circulation Journal Vol. 72, Suppl. IV,

38 A B 1 V 4 RST0.1mv 2akinesis dyskinesis 3 10mmHg 5mmHg 4 noncompliant 5 C mmHg 4Kussmaul 5 99m Tc PCWP mmhg PCWP mmhg ml IABP CABG Swan-Ganz mmhg PCWP mmhg ynoncompliant STEMI 7 Swan-Ganz 1% 13% % > % 3.9% primary PCI : :1 14 :2435 :1 14 :2435 :1 14 thrill - v thrill+ - 29%47% Pulseless Electrical Activity 5mm 1384 Circulation Journal Vol. 72, Suppl. IV, 2008

39 IABP B CABG B STEMI SHOCK registry B CABG B STEMI GUSTO-I GUSTO-I SHOCK registry IABP CABG SHOCK registry GUSTO-I B CABG C STEMI ST-T PEApulseless electrical activity Q NSAIDs CABG Circulation Journal Vol. 72, Suppl. IV,

40 a CABG B STEMI. vs. STEMI.. NYHA IABP STEMIIABP PCPSpercutaneous cardiopulmonary support LVADleft ventricular assist devicepcps STEMI B IABP C PCI CABG B primary PCI C a PCI ST C CK-MB H-FABPST ST T pseudonormalization 1386 Circulation Journal Vol. 72, Suppl. IV, 2008

41 ST CK-MB PCI. primary PCI primary PCI primary PCI PCI CABG B C a C b C B B STEMI STEMI STPR J STEMI Q oozing rupture STEMI T T T CK-MB Circulation Journal Vol. 72, Suppl. IV,

42 mg C XCT/MRIMRA C A B a A b C STEMI.. STEMI STEMI STEMI SAVE Killip STEMI STEMI MRIMRA X CT STEMI PCI mg/ mg/ INR STEMI distal protection device 1388 Circulation Journal Vol. 72, Suppl. IV, 2008

43 . vs..p=. vs..p<.tia PT-INR A A PT-INR STEMI STEMI STEMI PCI STEMI viability STEMI B V R B a V V B avrstv Circulation Journal Vol. 72, Suppl. IV,

44 avrst.mmv STV ST V V septal Q Seg. V V septal Q avlq avlst mmst avlst ST V V mm ST ST IaVL ST ST V V ST avlst Seg.AV V R-V RV -V V Rmm ST V V V V STQ QSTT mmsttq Q Q MR Q T T QT QT Q QR R CK CK-MB B a B CK CK-MB I T CK CK-MB IT ESC/ACC CK CK-MB g T T.ng/ml PCI TIMI no reflow IT 1390 Circulation Journal Vol. 72, Suppl. IV, 2008

45 B 8 WPW ASE AHA normokinesis hypokinesisakinesis dyskinesisaneurysm CPK STEMI stunned myocardium B B a I-BMIPP C a b STEMI Tl m Tc- MIBI m Tc-tetrofosmin m Tc Berman uptake uptake m Tc-MIBI Circulation Journal Vol. 72, Suppl. IV,

46 Tl m Tc Quantitative Gated SPECTQGS QGS I-BMIPP SPECT Tl I-BMIPP m Tc-pyrophosphate peak CK a MRI C MRI C MRI MRI STEMI MRI / thickening radial shortening Late Gadolinium Enhanced LGEMRI LGE LGE-MRI SPECTLGE-MRI / no reflow microvascular obstructionmo MO STEMI MR LGE MO LGE-MRISTEMI Choi LGE. Tl-SPECT LGE-MRISTEMI KitagawaSTEMI LGE-MRI Tl-SPECT LGE-MRI Tl-SPECT a B B 1392 Circulation Journal Vol. 72, Suppl. IV, 2008

47 STEMICABG STEMICABG V-STEMI CABG Creswell CABG..... CABG STEMI CABG STEMI B PCI Hirose Hirotani STEMI PCI CABG B STEMI PCI CABG CABG CABG A A A B A STEMIPCI CABG CABG ACC/AHA CABG CABG Circulation Journal Vol. 72, Suppl. IV,

48 CABG CABGoff pump coronary artery bypassopcab STEMI CABG C CABG B CABG mg/ STEMI CABG STEMI STEMI A B a C STEMI ST mmst 1394 Circulation Journal Vol. 72, Suppl. IV, 2008

49 B C B a C C a A b B wall motion score index STEMI STEMI STEMI B B B a I-BMIPP C MRI C m Tc Tl Tl m Tc Tl SPECT ATP viability Tlup take stunned myocardium I-BMIPP STEMI BMIPP MRI Circulation Journal Vol. 72, Suppl. IV,

50 A a BNP B STEMI BBNP STEMI A B B C a C C STEMI CABG PCI STEMI a B b T B STEMI ICD ICD QRS Talternans ICD / C 1396 Circulation Journal Vol. 72, Suppl. IV, 2008

51 phasephase phase STEMI QOL Taylor p=.p= p=. ACC/AHA STEMI STEMI QOL STEMI PCI PCI 9 AHA STEMI ST TST STEMI C a C Circulation Journal Vol. 72, Suppl. IV,

52 12METs STEMI9ST * *STEMI. STEMI C STEMI STEMI STEMI /B B 1398 Circulation Journal Vol. 72, Suppl. IV, 2008

53 PCI STEMI STEMI 78 S T E M I m : 200m : m 1600Kcal6g 1600Kcal6g : : 200m : : : : : : KillipCK U/LCK <U/L 1 : 2:120/ 40/ 3 : 4ST : 1mm ST ST. 5 : 20mmHg 30mmHg 2 STEMI STEMI 12 a Circulation Journal Vol. 72, Suppl. IV,

54 C 3I m 0 0 m2 KillipCK U/L m P 3 STEMI STEMI ACC/AHA 12 STEMI 1400 Circulation Journal Vol. 72, Suppl. IV, 2008

55 C ACE LVEF ICD METs / STEMI.../././. vs.. vs. STEMI STEMIACC/AHA METs 12 METs..METs.METs 13..METs.METs METs Circulation Journal Vol. 72, Suppl. IV,

56 NYHA NYHA NYHA : ST :5METs ST :5METs ST 10METs* :5 10METs* :<5METs* LVEF 60% LVEF:40 60% LVEF: 40% CTR 55% BNP100pg/ml BNP100pg/ml LMT50%75% *. METs <3METs METs 6.1METs * 5METs * * * * * * %, *% *.METs AED - METs 1402 Circulation Journal Vol. 72, Suppl. IV, 2008

57 Q PCI PAMI-II LVEF PCI STEMI QOL STEMI STEMI STEMI social isolation STEMI STEMI B C BLSAED C C 14 STEMI QOL Circulation Journal Vol. 72, Suppl. IV,

58 / 16g 1 30ml LDL100mg/dL BMI 22kg/m 2 BMI HbA1c6.5% mg/ 112 LDL100mg/dL LDL ACE LVEF40% ACE ACEARB a 20mg/a A STEMI B HDL ACS JPHC.. NIPPON DATA.. STEMI STEMIOACIS 1404 Circulation Journal Vol. 72, Suppl. IV, 2008

59 HDL LDL... ga ml A BMI.. A A /mmhg /mmhg B /mmhg B STEMI JSH C A LDLmg/dl B LDL B STEMI LDLSTEMI 14 LDL MUSASHI-AMI STEMI LDL LDL LDL LDL LDL mg/dl HDL HDL HDL B A Circulation Journal Vol. 72, Suppl. IV,

60 a A C HbA C.B STEMI B ACS Japan Diabetes Complications StudyJDCS /,.... STEMI UKPDS HbA C HbA C HbA C. BMI B BMI.-.BMI A C B B / C mg/ A mg/ mg/ C mg/ mg/ B a mg/ 1406 Circulation Journal Vol. 72, Suppl. IV, 2008

61 B mg/ mg/mg/ mg/ B B C C GPb/a ISIS- STEMI mg/ Antithrombotic Trialists CollaborationATC STEMI mg JAMIS STEMImg/ mg/ JMIC-M STEMI ACC/AHA/SCAI FDA * A * B a *STEMI A C STEMI STEMI STEMI ACE Circulation Journal Vol. 72, Suppl. IV,

62 JBCMI STEMI MUCHA CAPRICORN LVEF a B B A STEMI STEMI Q STEMI a B JCAD J-WIND mgiona ACE A 1408 Circulation Journal Vol. 72, Suppl. IV, 2008

63 ACELVEF A LVEF X ACE ARB B a LVEF X ACE ARB B b LVEF ACEARB B ACE STEMIACE ACE LVEF LVEF JAMP ACE ARBACE STEMILVEF ARB ACE ACEARB ACE ACE ARB ACE ARB STEMI ACE LVEFACE RALES mg LVEF STEMIEPHESUS K ACEARB A C a A b C STEMI Circulation Journal Vol. 72, Suppl. IV,

64 PT-INR PCI STEMI A KLIS LISK PATE MEGA JELIS 1410 Circulation Journal Vol. 72, Suppl. IV, 2008

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