1.

2.
3.
4.
5.

1
ST elevation
2
1

2 noninvasive stress test

3
2
3
4
5
6

1
2
3
3
3
3
4
4
6

9
14
15
18
20
23
24
25
25
26
27
28
29
30
34
35
35
36
36
37

Cardiac imaging

.
.

.
.
.
.

Cardiac imaging

(
)
(Ischemic heart disease, IHD) (Coronary artery
disease, CAD)

50
2 (Stable angina)
(Acute coronary syndrome)

 (stable angina) (chronic stable angina)

(chronic ischemic heart disease)
2
(Acute coronary syndrome, ACS)
(Rest angina) 20
2
1. ST elevation acute coronary syndrome
ST segment 2 leads LBBB
Acute ST elevation
myocardial infarction (STEMI or Acute transmural MI or Q-wave MI)
2. Non ST elevation acute coronary syndrome ST
segment elevation ST segment depression / T wave inversion
30 non-ST elevation MI ( NSTEMI, or Non-Q
wave MI ) (Unstable angina)

1.
randomized control trials metaanalysis inclusion criteria baseline

2.

-
-

-
-
-
-
-
-
-
- -

,
- /

,
-

-
-

- (IABP)
- general chemistry /
- general chemistry
- general chemistry
cardiac markers
- cardiac enzyme / cardiac - cardiac enzyme
troponin
- cardiac troponin
- -
- -

- - -
-

(CPR)
-
6

- -


-

-
ST
elevation
-

- -

-
ST elevation

- -

(IABP) temporary pace

maker

(silent myocardial ischemia or silent

myocardial infarction)

(Typical angina pectoris) 30

1.
2.
3.
4.
5.
1. (angina pectoris)


sternum 2
2-3 nitroglycerin

1.

( 50)
(exercise stress test)

2.
(aortic dissection)
(acute pulmonary embolism)


3. (acute coronary syndrome)
20

4.
troponin
troponin 2
4 1 9

5.

(coronary angiography) 50 1
(echocardiography)
(percutaneous coronary intervention)
(coronary artery bypass graft surgery)
2

2
1. (intensive care unit, ICU)
(coronary care unit, CCU) 2
1.1 non-ST elevation acute coronary syndrome non-ST elevation myocardial infarction
unstable angina
1) aspirin thienopyridine
thienopyridine aspirin clopidogrel
aspirin
2) unfractionated heparin low molecular weight heparin 3-5
(antianginal drugs) nitrates, beta-blockers short acting
dihydropyridine calcium channel blockers
3) narcotics analgesics
4)
(cardiogenic shock), ,

1.2 ST-elevation acute coronary syndrome (ST-elevation myocardial infarction)

1) 1.1
2) (thrombolytic agent)
(primary percutaneous transluminal coronary angioplasty, primary PTCA)

6
12 12
10

3) heparin ( 3
)
2.
1) oxygen demand supply
,
,
2)

3)

4)


1.

( 1 )
2.
1.
1)

2)
(risk stratification)

3)
revascularization
3.1

3.2
3.3

11

2. 2
2.1 non-ST elevation (non-ST elevation ACS)
1) ( .)

2)
revascularization
2.1

2.2
l
2.3
1)
2) ST depression
3) Ventricular tachycardia
4)
5)
6) < 40 %
7) noninvasive stress test
8) 6
9)
10)
revascularization 48
3) (risk stratification)
( )

3 5
2.2 ST segment elevation
1)
12

1.1 (
12 )
1.2
1.3 30 90

1.4
60

12

2)

reperfusion 90 ( ST
elevation)
3) /
(cardiogenic
shock)
4) revascularization
ruptured interventricular septum, ruptured
papillary muscle, pericardial effusion, intractable left ventricular failure, intractable
ventricular arrhythmia, post myocardial infarction angina, recurrent myocardial infarction
5)
/

13

2.
2
1 2
, ,
, ,

3
Ischemic cardiomyopathy, valvular heart disease,
congenital heart disease chronic obstructive pulmonary disease,
pulmonary hypertension, ,

1. /



2.

3.
3.1
(acute ischemia) (acute MI)
LBBB
(OLD MI), LV aneurysm
3.2

4.
(regional wall motion abnormality),

14

3.
3.1

1.

S3 gallop
Killips classification ( )
2.
(acute
ischemia infarction pattern)

3.

4. acute pulmonary
emboli, acute respiratory distress syndrome, acute pneumonia, acute asthmatic attack
rupture chordae tendinae, rupture
sinus of valsava, acute myocarditis
5. cardiac markers (cardiac enzyme, troponin)

6. rupture papillary muscle rupture
interventricular septum murmur

,
nitrate
1.

15

2. nitroglycerine 90


3. morphine
90
4.

5. (intra-aortic balloon pump, IABP)

6.
ruptured papillary muscle, rupture interventricular septum

3.2

1.

(mitral regurgitation)

2.
(Q wave myocardial infarction pattern)
non-ST elevation MI
3.
(pulmonary congestion)
4.



16

5. , chronic
pulmonary emboli, pulmonary arterial hypertension
cardiomyopathy, constrictive pericarditis

1. revascularization

2.

betablockers preload afterload
nitrate ACEI
3. betablockers betablocker



4.

revascularization

17

4.





(cardiogenic shock Killip class IV)

1.
(shock)

2.
, cardiac enzyme troponin

3.

cardiac arrhythmia, complete AV block,
rupture papillary muscle, rupture IVS, rupture free wall
4. central venous
pressure, arterial line, Swan Ganz cardiac output

1.

2. 250-500 .

3. dopamine 5-20
/ dubutamine 10-40

4.

18

5. revascularization

6.

7. ruptured
papillary muscle, ruptured interventricular septum

19

5.

(syncope)

1.
(cardiac arrest)
ventricular standstill ventricular fibrillation

2. 12 lead
(ischemic pattern)

3.

4. (syncope)

24
(Holters monitoring) (tilt table test)
(cardiac electrophysiologic study)

1. (cardiac massage)
(ventricular standstill) adrenaline (1:1,000)
1 . 5-10 .
(endotracheal tube) calcium chloride calcium gluconate

2.
Ventricular tachycardia ventricular fibrillation
20

3. (temporary pacemaker) 3
(3rd degree AV block)

4.

5.

21

22

- 1 20
-

, aspirin 160 325 .
Nitroglycerin
EKG 12 lead
1,2

(<10 min)


ECG 12 lead

cardiac marker, electrolyte

4 ; O2 sat > 90%

Aspirin 160 320 mg ()
Nitroglycerin
Morphine
Nitroglycerin

EKG 12-lead

ST elevation

(Non ST elevation ACS)

ST elevation LBBB
5

(ST-Elevation ACS)

-Adrenergic receptor blockers

Thienopyridine
Heparin (UFH or LMWH)

Nitroglycerin

-Adrenergic receptor blockers

Thienopyridine
Heparin (UFH or LMWH)

( 1)
Troponin

12

>12 hours

admission ICU /CCU

admission ICU/CCU No

EKG 12 lead
cardiac markers (Serial cardiac markers)

<12 hours

8

( 1)

- Door-to-balloon inflation (PCI)
90
- Door-to-needle (fibrinolysis)
30
:
- ACE inhibitors/angiotensin
receptor blocker (ARB)
24
- Statin

ASA, heparin
Statin
ACE inhibitor/ARB



revascularization
1)
2) ST depression
3) Ventricular tachycardia
4)
5)
6) 40 %
7) stress test
8) 6
9)
10) 48 .

( 1)
Troponin

23



( 30 ) streptokinase
* 1.5 60
steroid streptokinase

0.3-1.0
*

streptokinase

ST-segment elevation
12

1. hemorrhagic stroke
2. nonhemorrhagic stroke 1
3.
4. 4
5.
6. 180/110
7. warfarin (INR > 2)
8. (CPR) 10
9.

1. streptokinase streptokinase

2. /
streptokinase
3.

4.

24


1.

2. 12 lead 30
ST segment 50 90-120

3.
90-120

1.
2. ST (ST resolution) 120

3.
- accelerated idioventricular rhythm
- frequent premature ventricular complexes ( 2 90
)
- nonsustained ventricular tachycardia
4. cardiac enzyme CK-MB 12 (
reperfusion CK-MB 24-36 )

25

ST elevation
1:

2:

15 12 ?

EKG 12 lead ST segment 2 lead / LBBB ?

(streptokinase)
1

1. 180/110
2. hemorrhagic stroke
2. nonhemorrhagic stroke 1
3.
4. 6
5. 15 .
6. warfarin (INR > 2)
8. (CPR) 10
9.

3:

1. > 100 100 .

2.
3. 90/60 .
4.
5.
streptokinase

26

nitrate (sublingual spray)

beta blockers

beta blockers

* calcium antagonists
/ long-acting nitrates

* calcium
antagonists / long-acting nitrates

* beta blockers calcium

antagonists / long-acting nitrates beta blockers

(HbA1c1C < 7%)

( < 140/90 . 130/80
. )
(BMI < 23 ..)
( < 80 . , 90 . )
(LDL-C < 100 ..)

Invasive procedure
(ASA 75-325 ./)

ACE inhibitor

* short-acting dihydropyridine calcium antagonists

27

cardiac
markers

(HIGH RISK)
(INTERMEDIATE RISK)
- -

48
, ,

-

- - 20
20

-

- S3 gallop
(rales)
- ,

- 75
-
ST-segment
depression > 0.05 .
- BBB
- sustained VT
- Troponin ( >
0.1 ng/mL)
- cardiac enzyme

(LOW RISK)

(
CCS class III IV)
2
20

- 70 75

- symmetrical T-wave
inversion 0.2 .
- pathologic Q waves

- Troponin ( > 0.01-0.1 - troponin

ng/mL)
- cardiac enzyme
- cardiac enzyme

28

 2 noninvasive stress test

Exercise treadmill test
ischemic ST-segment shifts 6.5 METs
ischemic ST-segment shifts 120
ST-segment depression elevation 0.2 mV(2 mm)
ST-segment shifts leads
ST-segment shifts 6
10 . 130 .
ST-segment shifts
ST-segment elevation
sustained ventricular tachycardia (VT)
Stress radionuclide imaging
myocardial perfusion 1
reversible defect anterior wall
myocardial perfusion lung uptake
resting ejection fraction (EF) 0.35
exercise EF 0.50 EF stress 0.10
Stress echocardiography
resting EF < 0.35
wall motion abnormality 2 segments low dose dobutamine
( < 10 mg/kg/min) 120

29

Aspirin (ASA)

-
- 160-325 .

75-325 .
-


(secondary
prevention)

/
-
bronchospasm, angioedema,
anaphylaxis
-
(active bleeding)

Thienopyridine

-
ASA (
ASA)
-
(coronary
stents) ASA
1
-

ASA
1-9

- Clopidogrel 300 .
75 .
- Ticlopidine 500 .
250 . 2

rash, severe
neutropenia, thrombotic
thrombocytopenic purpura
(TTP) ticlopideine
clopidogrel

Fibrinolytic
Agents

-
ST elevation 12 .

- SK 1.5 mU IV drip 60 1
- rt-PA 15 mg IV bolus
0.75 mg/kg ( 50 mg)
IV 30 0.5 mg/kg
( 35 mg) IV 60
- APSAC 30 mg IV 5
- rPA 15 mU IV 2
30
- TNK-tPA 0.5 mg/kg IV bolus

30


Heparin (UFH)

Low molecular
heparin

GP IIb/IIIa
receptor
antagonists

Warfarin

-
3-5
-

24
- rt-PA, rPA,
TNK-tPA, SAK
24-48 .
-

systemic emboli
-
3-5
-
reperfusion therapy
48-72 .

/
50-70 U/kg ( 5000 -
U) IV bolus IV drip - heparin-induced
thrombocytopenia (HIT)
12-15 U/kh/hr ( 1000
U/hr) aPTT
1.5-2.5

- Enoxaparin 1 mg/kg SC
12 .
- Dalteparin 120 U/kg (
10000 U) SC 12 .
- Nadroparin 0.1 cc/kg SC
12 .
- - Abciximab 0.25 mg/kg IV
(Eptifibatide bolus 10
Tirofiban)
0.125
- g/kg/min ( 10

g/kg/min) IV drip 12 .
(Abciximab)
- Eptifibatide 180 g/kg IV
bolus 2.0 g/kg/min IV
drip 72-96 . ( 24
. PCI)
- Tirofiban 0.4 g/kg IV 30
0.1 g/kg/min IV
drip 48-96 . ( 12-24
. PCI)
- - INR
2-3
systemic emboli
ASA

-
- HIT UFH
-
creatinine clearance
30
- immunogenicity

Abciximab

- drug-drug fooddrug interaction

31


Beta-blockers

-
-
(
)
-

- AF
ventricular rate

:
- Propanolol 1 . 5
0.15 ./.
- Metoprolol 5 .IV 5
x 3
- Atenolol 5 .IV 10 x
2
:
- Atenolol 50-200 .
- Metoprolol 50-200 .
- Propanolol 20-80 . 2

- Bisoprolol 5-10 .

/
- Betablockers
- (
60
)
-
- 100
.
- PR interval 0.24
sec
- second third degree
AV block bifascicular
block
-

Calcium
antagonists

-
Betablockers
-

Beta-blockers nitrates
-

Betablockers
- AF
ventricular rate
Beta-blockers
(verapamil diltiazem)
-

- Diltiazem 120-320 .
- Verapamil 120-480 .
- Amlodipine 5-10 .
- Felodipine 5-10 .

- LVEF<0.40
-
(pulmonary
congestion)
- 2nd 3rd degree AV
block bifascicular block

32


ACEIs

Nitrates

Statin

Morphine

-

(secondary
prevention)
-

LVEF<0.40, large
anterior wall MI,

-
LVEF<0.40 /

-

Betablockers nitrates
-
(
)
-

- Captopril 150 .
- Enalapril 40 .
- Lisinopril 40 .
- Fosinopril 40 .
- Ramipril 10 .
- Quinapril 40 .

/
- ACEIs
( )
-

- 2
(bilateral renal artery stenosis)
- angioedema
ACEIs
-
-

- 1
1 5
-
NTG 10 g/min 5
IV NTG 200
g/min longacting nitrates 24

- Rosuvastatin 10-40 .
- Atorvastatin 10-80 .
- Simvastatin 10-80 .
- Pravastatin 10-40 .

-
90 .
- 50

- right
ventricular MI

-

(secondary
prevention)
-

-
- 2 - 5 .
5-15

nitrates

-
-

-
Morphine
-

33

 2
.. . .... ..
..

1. .
2.
3. systolic .
4. < 40/

5.

6.

7. dopamine, adrenaline

8. cardiac arrest

9.

10. ET tube

11.

- .

1. .
2.

3.

4.

5.

6.

7.

1.
2.
3.
4. (IABP)
5.

34

4 .

- > 20

ST elevation

SK

Non ST elevation

(Streptokinase)
35

 5 .
, non invasive procedure

ST elevation

SK

Non ST elevation

(SK)

SK

ICU/CCU

Invasive procedure

6 .

36

1. (demographic data)

2.

3.

4. (compliance)


5.
6.

7.

37

8. (gold standard)

9.

38