แนวปฏิบัติบริการสาธารณสุขหัตถการรักษาโรคหลอดเลือดโคโรนารีย์ผ่านสายสวน พ.ศ. 2551

(Percutaneous Coronary Intervention, PCI)
.. 2551
Percutaneous Coronary Intervention, PCI

.. 2551
1 .. 2552
2,000
National Library of Thailand Cataloging in Publication Data

.
. - : , 2552
100 .
1. -- . 2. . l. .
816.123
ISBN 978-616-11-0147-3
:
(.)
120 3 2-4

. 10210
0-2141-4000 0-2143-9730
www.nhso.go.th
:
0-2214-4660 0-2612-4509
( )
.
.
.

.. 2551
.

.
. .


(Percutaneous
Coronary Intervention, PCI)
.. 2551
.. 2551

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.................................................................................................................. 1
......................................................................................... 5
................................................. 6
............................... 7
............................................................... 12
................................................. 13
........ 14
(KPI: Key point indicator) .......................................... 15
NHLBI....................................... 17
........................................................................................ 18
Chronic stable angina pectoris ............... 19

Stable angina pectoris
................. 22
PCI Left main coronary artery disease...................... 23
PCI .......................... 28
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PCI .............................................................. 31
Aspirin Cilastazol PCI .............................. 33
Glycoprotein IIb/IIIa inhibitor
................................ 36
PCI........ 38
ST segment ................................................................... 40
ST elevation

(Primary PCI) .......................... 45
PCI
ST segment 12 48
..................................................................................... 54
PCI
24 ..................................................................................... 55
PCI STEMI
........................................................................ 57
............................................... 59
PCI
.............................................................. 60

STEMI ............................................................ 62
PCI unstable angina NSTE-ACS ........................ 67
NSTE-ACS
.......................................... 69
Low molecular weight heparin
PCI NSTE-ACS ..................................................... 75
NSTE-ACS .......................................................................... 81
Drug eluting stent ........................................ 85
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2535
(percutaneous coronary intervention)

(balloon catheter)

41 25
150 - 160 PCI
10,000

(diagnosis-related group)

1.
(PCI)

(coronary stent implantation)

2.

3.

4.

.. 2551

1.
2.
3.
4.

Guidelines for Percutaneous Coronary Interventions
2005 European Society of Cardiology Update for Percutaneous
Coronary Intervention ACC/AHA/SCAI 2005
2
(Full text)
electronic Medline Embase 2005
2007 randomized
clinical trials meta-analysis

Evidence table considered judgment on quality of evidence

(Clinical Expert Consensus)

.. 2551

(Interventional cardiologist)

(Quality of evidence)
1 meta-analysis systematic
review randomized controlled clinical trials well designed
randomized controlled clinical trial
2 systematic review controlled
clinical trials well designed controlled clinical trial

cohort study, case-control study
3 descriptive studies controlled clinical trial
4 (consensus)

(Strength of recommendation)
++
+

+/-

-
- -
6
.. 2551
1.
2.
3.
4.

1. (complication)
2.
3.
- Left main coronary artery disease
- Severe aortic dissection
4.

1.
2.
3.
4.

1.
epicardium

20
2. (diagnostic coronary
arteriography) 1%
3.

(interventional) 3%
4.

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1.
2.
steroid ( antihistamine) 24
non-ionic
3.
3.1 hydration
3.2
non-ionic
3.3 acetylcysteine
nephrotoxicity
4.
4.1
4.2 Metformin

Creatinine
48
5.
5.1
5.2 Warfarin
INR 1.8
5.3 Warfarin
INR 1.8 K Fresh
frozen plasma
5.4 Heparin
5.5 activated clotting time (ACT)
- 300
- Glycoprotein IIb/IIIa inhibitors
200 - 250
- ACT 175
1.
2.
-
Echocardiography
- (Provocative test)
1)
constrictive pericarditis restrictive cardiomyopathy
2) afterload Maximal intraventricular gradient
- Hypertrophic cardiomyopathy
- Aortic stenosis low output & normal or near
normal pressure gradient
10
.. 2551
3)
( )
4) Pulmonary vasodilators
3.

-
-
-
- Percutaneous closure device collagen plug, suture
device
- Hematoma pseudoaneurysm
- 7
11

1. 1
1
2.
2.1

2.2 scrub
2.3
2.4
3.

4.

12
.. 2551

1. (As low as reasonable
achievable, ALARA)
2. DNA Cell
3. 0.1 rem/year
0.004 - 0.016 rem/case NCRPM
= 5 rem/year
rem exposure x ( 50 rems)
4. 20% 0.04% x
rem
5.
0.05 rem/ 0.5 rem
6. Radiation exposure X-ray film badge
transluminsecent dosimeter (TLD) badges
( ring dosimeter
)
7.
-
- digital-only cine runs
- image intensifier
8. fluoroscopy
cine
9. left anterior oblique (LAO) cranial view
Right anterior oblique (RAO) caudal view 6
X-ray
10. collimation
13
..1977

1. (stent) (elastic
recoil) (scaffold coronary dissection)
2. (drug eluting
stent)
3.
(glycoprotein IIb/IIIa inhibitor)
4.

Extraction atherectomy
Directional coronary atherectomy
Rotational atherectomy
Rheolytic thrombectomy catheter
Proximal and distal embolic protection devices
Excimer laser coronary atherectomy
Local radiation device
Thrombus aspiration catheter
Intravascular ultrasonography
Fractional flow reserve measurement
14
.. 2551
(KPI: Key point indicator)
1.
Angiographic Success
stent
50% TIMI 3 flow

20%
Procedural success angiographic success
major complication
,
CABG
Clinical success
- Short term clinical success procedural success

- Long term clinical success short term clinical
success
6

(restenosis)
15
2. Procedural Success
major complication
6
1. Death
2. Myocardial infraction
3. Emergency coronary artery bypass graft (CABG)
4. Stroke
5. Vascular access site complications
6. Contrast agent nephropathy
16
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NHLBI:
National Heart, Lung and Blood Institute
1.
2.
3.
4.
Angiographic success 96 - 99%

acute Q-wave MI 1 - 3%
Emergency coronary artery bypass graft (CABG) 0.2 - 3%
0.5 - 1.4%
NHLBI PTCA
10 89.5% (95% single vessel
disease 81% multivessel disease)
1985 - 1986 5 92.9% single vessel
disease, 88.5% double disease 86.5% triple vessel disease
1.
2.
3.
4.
5.
6.
7.
8.
9.
Anatomical factor
Clinical factor
Risk of death
Coronary angioplasty coronary artery bypass graft

17
Objective large ischaemia ECG stress testing, Nuclear imaging,

Stress Echocardiography, Ambulatory ECG monitoring, Intracoronary physiologic measurement ( +/+,
1) Parisi, Folland, & Hartigan, 1992a; Hartigan
et al., 1998a; Pepine et al., 1994b
Objective moderate ischaemia ( +)
Objective small area ischaemia ( +/-)
Chronic total occlusion (CTO) ( +,
3)
High surgical risk, including left ventricular ejection fractions
(LV-EF) <35% ( +, 2)
Morrison et al., 1999
Multi-vessel disease/diabetics ( +/-,
3)
Unprotected left main (LM) stenosis in the absence of other
revascularization options ( +/-,
3)
Routine stenting of de novo lesions in native coronary arteries
( ++, 1) Serruys et al.,
1994; Fischman et al., 1994
Routine stenting of de novo lesions in venous bypass grafts (
++, 1) Savage et al., 1997;
Hanekamp et al., 2003
18
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Chronic stable
angina pectoris
PCI
1.
2. 1
1

( +,
2)
3. 1
1-2

(
+, 2)
4. 3

( +,
2)
19
PCI

3

ECG stress testing, nuclear
imaging, stress echocardiography, ambulatory ECG monitoring, intracoronary physiologic measurement (
+/-, 2)
1
1
2 - 3
Proximal LAD
( +/-,
4)
20
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PCI

PCI
-
-
-
-
-
- left main
- 50%
( -, 4)
21
Stable angina pectoris
-

- coronary imaging
left main
3 (left ventricular contraction) 40%
22
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PCI Left main coronary artery

disease
Unprotected left main coronary artery disease (ULMCA)

( 50 )
revascularization CABG PCI
CABG
2

PCI 600
150
bifurcation crush, culotte technique ( +,
2)
23

CABG 1
PCI unprotected left main coronary artery (ULMCA)
2-7
1. Ideal cases for LM-PCI :
Low-risk patients, with good LV function
Anatomy suitable for simple stenting:
Ostial LM (length > 8 mm, diameter > 3.5 mm)
Mid-shaft LM (diameter > 3.5 mm)
Distal LM normal LCX ostium/Diminutive LCX
2. Non-surgical patients
Emergent clinical situation: acute LM occlusion
Contra-indication for surgery:
High risk or nonsurgical patient
Comorbidity (advanced chronic obstructive lung

disease, dialysis-dependent renal failure)
MVD with anatomic characteristics which may preclude
satisfactory placement of grafts
ULMCA-PCI DES resteonsis rate
BMS (7.0% vs. 30.3%)8
PCI

sudden death
BMS
(3 - 6 )3, 5 DES (4 8 )
8, 9
24
.. 2551
Reference
1. Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004
guideline update for coronary artery bypass graft surgery:
summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee to Update the 1999 Guidelines for
Coronary Artery Bypass Graft Surgery). J Am Coll Cardiol 2004;
44:1146-310.
2. Ellis SG, Tamai H, Nobuyoshi M, et al. Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial
results from a multicenter registry analysis 1994-1996.
Circulation 1997; 96:3867-72.
3. Silvestri M, Barragan P, Sainsous J, et al. Unprotected left main
coronary artery stenting: immediate and medium-term outcomes
of 140 elective procedures. J Am Coll Cardiol 2000; 35:1543-50.
4. Black A, Cortina R, Bossi I, Choussat R, Fajadet J, Marco J.
Unprotected left main coronary artery stenting: correlates of
midterm survival and impact of patient selection. J Am Coll
Cardiol 2001; 37:832-8.
5. Park SJ, Hong MK, Lee CW, et al. Elective stenting of unprotected left main coronary artery stenosis: effect of debulking
before stenting and intravascular ultrasound guidance. J Am
Coll Cardiol 2001; 38:1054-60.
6. Kelley MP, Klugherz BD, Hashemi SM, et al. One-year clinical
outcomes of protected and unprotected left main coronary
artery stenting. Eur Heart J 2003;24:1554-9.
25
7. Park SJ, Park SW, Hong MK, et al. Long-term (three-year)

outcomes after stenting of unprotected left main coronary artery
stenosis in patients with normal left ventricular function. Am J
Cardiol 2003; 91:12-6.
8. Park SJ, Kim YH, Lee BK, et al. Sirolimus-eluting stent
implantation for unprotected left main coronary artery stenosis:
comparison with bare metal stent implantation. J Am Coll Cardiol
2005;45:351-6.
9. Chieffo A,Stankovic G, Bonizzoni E, et al. Early and mid-term
results of drug-eluting stent implantation in unprotected left
main.Circulation 2005; 111:791-5.
10. Takagi T, Stankovic G, Finci L, et al. Results and long-term
predictors of adverse clinical events after elective percutaneous
interventions on unprotected left main coronary artery. Circulation 2002; 106:698-702.
11. Tan WA, Tamai H, Park SJ, et al. Long-term clinical outcomes
after unprotected left main trunk percutaneous revascularization
in 279 patients. Circulation 2001; 104:1609-14.
12. Sakai K, Nakagawa Y, Kimura T, et al. Primary angioplasty of
unprotected left main coronary artery for acute anterolateral
myocardial infarction. J Invasive Cardiol 2004; 16:621-5.
13. de Lezo JS, Medina A, Pan M, et al. Rapamycin-eluting stents
for the treatment of unprotected left main coronary disease. Am
Heart J 2004; 148:481-5.
26
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14. Agostoni P, Valgimigli M, Van Mieghem CA, et al. Comparison

of early outcome of percutaneous coronary intervention for
unprotected left main coronary artery disease in the drug-eluting
stent era with versus without intravascular ultrasonic guidance.
Am J Cardiol 2005; 95:644-7.
15. Valgimigli M, Van Mieghem CA, Ong AT, et al. Short- and
longterm clinical outcome after drug-eluting stent implantation
for the percutaneous treatment of left main coronary artery
disease: insights from the Rapamycin-Eluting and Taxus Stent
Evaluated At Rotterdam Cardiology Hospital registries (RESEARCH and TSEARCH). Circulation 2005; 111:1383-9.
27
PCI
(Chronic total occlusion angioplasty)
(CTO)

( ++,
1)
CTO
(
+, 4)
chronic total occlusion angioplasty

drug-eluting stent
1-5 coronary perforation
6-8
collateral flow8
28
.. 2551
References
1. Nakamura S, Muthusamy TS, Bae JH, Cahyadi YH, Udayachalerm
W, Tresukosol D. Impact of sirolimus-eluting stent on the outcome of patients with chronic total occlusions. Am J Cardiol
2005;95(2):161-6.
2. Migliorini A, Moschi G, Vergara R, Parodi G, Carrabba N,
Antoniucci D. Drug-eluting stent-supported percutaneous
coronary intervention for chronic total coronary occlusion.
Catheter Cardiovasc Interv 2006;67(3):344-8.
3. Aoki J, Hoye A, Staferov AV, Alekyan BG, Serruys PW. Sirolimuseluting stent implantation for chronic total occlusion of the left
main coronary artery. J Interv Cardiol 2005;18(1):65-9; discussion 9.
4. Ge L, Iakovou I, Cosgrave J, et al. Immediate and mid-term
outcomes of sirolimus-eluting stent implantation for chronic
total occlusions. Eur Heart J 2005;26(11):1056-62.
5. Lotan C, Almagor Y, Kuiper K, Suttorp MJ, Wijns W. Sirolimuseluting stent in chronic total occlusion: the SICTO study. J Interv
Cardiol 2006;19(4):307-12.
29
6. Hamood H, Makhoul N, Grenadir E, Kusniec F, Rosenschein U.

Anchor wire technique improves device deliverability during PCI
of CTOs and other complex subsets. Acute Card Care 2006;8(3):
139-42.
7. Tsuchikane E, Suzuki T, Asakura Y, et al. Debulking of chronic
coronary total occlusions with rotational or directional atherectomy
before stenting: Final results of DOCTORS study. Int J Cardiol
2007.
8. Zimarino M, Ausiello A, Contegiacomo G, et al. Rapid decline of
collateral circulation increases susceptibility to myocardial
ischemia: the trade-off of successful percutaneous recanalization
of chronic total occlusions. J Am Coll Cardiol 2006;48(1):59-65.
30
.. 2551
PCI
single vessel CAD

class I II angina
( +, 4)
2- 3- vessel CAD proximal LAD lesion
PCI
(CABG
with arterial conduit) ( +/-,
4)
PCI DES BMS
( +, 2)
31
References
1. The BARI Investigators. The Final 10-year follow-up results
from the BARI randomized trial. J Am Coll Cardiol 2007;
49: 1600-6.
2. Serruys PW, Ong ATL, van Herwerden LA, et al. Five-year
outcomes after coronary stenting versus bypass surgery for
the treatment of multivessel disease. J Am Coll Cardiol 2005;
46: 575-81.
3. Sabate M, Jimenez - Quevedo P, Angiolillo DJ, et al. Randomized comparison of sirolimus-eluting stent versus standard stent
for percutaneous coronary revascularization in diabetic patients:
The diabetes and sirolimus-eluting stent (DIABETES) trial.
Circulation 2005; 112: 2175-2183.
4. Boyden TF, Nallamothu BK, Moscucci M, et al. Meta-analysis
of randomized trials of drug-eluting stents versus bare metal
stents in patients with diabetes mellitus. Am J Cardiol 2007;
99: 1399-1402.
32
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Aspirin Cilastazol PCI
PCI aspirin
aspirin 75 - 325
( ++, 1)
PCI aspirin
aspirin 300 - 325
24 2
( ++, 4)
PCI
aspirin 325 1
3
75 - 162 / ( ++,
4)
33

aspirin
acute MI
stroke 22% stable CAD 46% NSTEMI
placebo1
2
ISIS-2 trial STEMI aspirin
streptokinase 2
Aspirin ischemic complications PCI

75 - 162
aspirin 300 - 325 PCI 2
24 3 aspirin
100 - 162 /3,4
aspirin resistant 5 - 20%
arterial thrombosis5
cilostazol 200 /
clopidogrel 75 / aspirin 200 /
1 stent thrombosis
6 instent restenosis
aspirin, clopidogrel cilostazol
restenosis 40% (22%-cilastazol vs. 34%-placebo, p= 0.0071)
3
7
34
.. 2551
References
1. Collaborative meta-analysis of randomised trials of antiplatelet
therapy for prevention of death, myocardial infarction, and stroke
in high risk patients. Bmj 2002;324(7329):71-86.
2. Randomised trial of intravenous streptokinase, oral aspirin, both,
or neither among 17,187 cases of suspected acute myocardial
infarction: ISIS-2. ISIS-2 (Second International Study of Infarct
Survival) Collaborative Group. Lancet 1988;2(8607):349-60.
3. Smith SC, Jr., Feldman TE, Hirshfeld JW, Jr., et al. ACC/AHA/
SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (ACC/AHA/
SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention). Circulation 2006;113(7):e166-286.
4. Silber S, Albertsson P, Aviles FF, et al. Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous
Coronary Interventions of the European Society of Cardiology.
Eur Heart J 2005;26(8):804-47.
5. Eikelboom JW, Hirsh J, Weitz JI, Johnston M, Yi Q, Yusuf S.
Aspirin-resistant thromboxane biosynthesis and the risk of
myocardial infarction, stroke, or cardiovascular death in patients at
high risk for cardiovascular events. Circulation 2002;105(14):1650-5.
6. Lee SW, Park SW, Hong MK, et al. Comparison of cilostazol and
clopidogrel after successful coronary stenting. Am J Cardiol
2005;95(7):859-62.
7. Douglas JS, Jr., Holmes DR, Jr., Kereiakes DJ, et al. Coronary
stent restenosis in patients treated with cilostazol. Circulation
2005;112(18):2826-32.
35
Glycoprotein
IIb/IIIa (GPIIb/IIIa) inhibitor
(Stable coronary
artery disease)
GPIIb/IIIa inhibitor

( ++,
4)
(acute
thrombotic occlusion) unstable angina
(complex lesions)
(bail-out medication)
threatening/actual vessel closure visible thrombus
no/slow-reflow phenomenon ( +,
4)
GPIIb/IIIa inhibitor

( -, 2)
36
.. 2551

Kong 1 meta-analysis
GPIIb/IIIa 30
2,3 clopidogrel 600
PCI 2 GPIIb/IIIa
stable angina
(major and minor bleeding), (thrombocytopenia)
References
1. Kong DF, Hasselblad V, Harrington RA, et al. Meta-analysis of
survival with platelet glycoprotein IIb/IIIa antagonists for percutaneous coronary interventions. Am J Cardiol 2003;92(6):651-5.
2. Mehilli J, Kastrati A, Schuhlen H, et al. Randomized clinical trial
of abciximab in diabetic patients undergoing elective percutaneous coronary interventions after treatment with a high loading dose of clopidogrel. Circulation 2004;110(24):3627-35.
3. Kastrati A, Mehilli J, Schuhlen H, et al. A clinical trial of abciximab
in elective percutaneous coronary intervention after pretreatment with clopidogrel. N Engl J Med 2004;350(3):232-8.
37

PCI
PCI 3 - 6
9 - 12

(treadmill stress test)
left main angioplasty, long diffuse vessel
angioplasty, chronic total angioplasty bifurcation angioplasty
( +,
1)
38
.. 2551
1-3

Heparin
SIAM III4 PCI stent 24

ischemic events target lesion
revascularization 25.6% vs. 50.6%, p = 0.001
GRACIA-I5 thrombolysis 12
PCI 6 thrombolysis
1
PCI primary endpoint (23 [9%] vs 51 [21%], risk ratio 0.44
[95% CI 0.28-0.70], p=0.0008),
(7% vs 12%, 0.59 [0.33-1.05], p=0.07)
major bleeding vascular complications
39
(Percutaneous
coronary intervention)
ST segment
(ST elevation myocardial infarction)
acute STEMI new LBBB

12
PCI ( ++,
1)
primary PCI 90
(door-to-balloon) (Rating I, level of evidence B)
3 thrombolytic agent
30 (Door-to-Drug) primary PCI
( ++, 2)
Killip III PCI
12 ( ++,
1)
12 - 24 evidence of ischemia,
severe heart failure hemodynamic unstable ( ++,
1)
acute STEMI 36 shock
18 PCI
75 ( ++, 1)
75 ( +, 2)
40
.. 2551

primary PCI 12
coronary patency
(reocclusion) (recurrent ischemia)
(recurrent myocardial infarction)
(stroke)
1,2
meta-analysis 23 randomized trials
7,739 primary PCI
4-6 (9.3% vs. 7.0%, P=0.0002),
non-fatal reinfarction (6.8% vs. 2.5%, P<0.0001), total stroke (2.0% vs.
1.0%, P=0.0004) combine endpoints (14.5% vs. 8.2% ,P<0.0001)
6-18 primary
PCI recurrent ischemia
(6% vs. 21%, P=0.0001) (22% vs. 39%,
P<0.0001)3

4,120
(stent)
stent
4

ST-segment () 5
primary PCI
aortic dissection, hemorrhagic stroke
ischemic stroke
( 3 )
6,7
41

PCI
3 2
PCI

3 - 12 PCI 30
(15.3% vs 6%, P=0.002)8
primary PCI 90
(Door-to-Balloon)
TIMI flow 2 - 3 90%, emergency CABG <2%,
85% PCI
7%9
cardiogenic shock
emergency PCI
SHOCK trial
primary PCI 6 1 (53%
vs 66%, P<0.03) 75
30 (absolute reduction 15%, P<0.02)
75 10
42
.. 2551
References
1. Tamis-Holland JE, Palazzo A, Stebbins AL, et al. Benefits of
direct angioplasty for women and men with acute myocardial
infarction: results of the Global Use of Strategies to Open Occluded
Arteries in Acute Coronary Syndromes Angioplasty (GUSTO II-B)
Angioplasty Substudy. Am Heart J 2004;147(1):133-9.
2. Goldenberg I, Matetzky S, Halkin A, et al. Primary angioplasty
with routine stenting compared with thrombolytic therapy in
elderly patients with acute myocardial infarction. Am Heart J
2003;145(5):862-7.
3. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus
intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet
2003;361(9351):13-20.
4. Zhu MM, Feit A, Chadow H, Alam M, Kwan T, Clark LT. Primary
stent implantation compared with primary balloon angioplasty
for acute myocardial infarction: a meta-analysis of randomized
clinical trials. Am J Cardiol 2001;88(3):297-301.
5. Loubeyre C, Morice MC, Lefevre T, Piechaud JF, Louvard Y,
Dumas P. A randomized comparison of direct stenting with
conventional stent implantation in selected patients with acute
myocardial infarction. J Am Coll Cardiol 2002;39(1): 15-21.
43
Eur Heart J 2005;26(8):804-47.
8. Widimsky P, Budesinsky T, Vorac D, et al. Long distance
transport for primary angioplasty vs immediate thrombolysis in
acute myocardial infarction. Final results of the randomized
national multicentre trialPRAGUE-2. Eur Heart J 2003;24(1):
94-104.
9. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA
guidelines for the management of patients with ST-elevation
myocardial infarctionexecutive summary. A report of the
American College of Cardiology/American Heart Association Task
Force on Practice Guidelines (Writing Committee to revise the
1999 guidelines for the management of patients with acute
myocardial infarction). J Am Coll Cardiol 2004;44(3):671-719.
10. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization
in acute myocardial infarction complicated by cardiogenic shock.
SHOCK Investigators. Should We Emergently Revascularize
Occluded Coronaries for Cardiogenic Shock. N Engl J Med
1999;341(9):625-34.
44
.. 2551

ST elevation
(Thrombolysis)
(Primary PCI)

3
30 (door to needle time
< 30 )
primary PCI
(door to balloon time < 90 )

( ++, 1)
3 12
primary PCI (left ventricular failure)
KILLIP class III primary PCI
12
(door to balloon time
< 90 )

12 - 24 evidence of ischemia, severe heart
failure hemodynamic unstable ( ++,
1)
45
(
++, 1)
door to balloon time 90
poor vascular access
( +,
4)
ASTEMI 36 shock
18 primary PCI
75 ( ++,
1)
ASTEMI 36 shock
18 primary PCI
75 ( +/-, 2)
46
.. 2551
12

30 (door
to needle time < 30 ) ( ++,
1)
transfer PCI (1st contact to balloon
time < 120 PCI center )
12 transfer
PCI
( ++,
1)
Transfer
PCI
(cardiogenic shock) (
++, 3)
47

1. primary PCI 3
12 coronary
patency (reocclusion)
(recurrent ischemia) (recurrent myocardial
infarction)
(stroke) 1, 2
2. meta-analysis 23 randomized trials
7,739 primary PCI
4 - 6 (9.3% vs. 7.0%, P=0.0002),
non-fatal reinfarction (6.8% vs. 2.5%, P<0.0001), total stroke (2.0% vs.
1.0%, P=0.0004) combine endpoint (14.5% vs. 8.2% ,P<0.0001)
6-18 primary PCI
recurrent ischemia (6% vs.
21%, P=0.0001) (22% vs. 39%, P<0.0001)3
3. 4,120
(stent)
stent
4

ST-segment () 5
4. primary PCI
aortic dissection, hemorrhagic stroke
ischemic stroke
( 3 ) 6, 4
48
.. 2551
5. PCI
3
infarct size mortality 3 - 12
PCI 30
thrombolytic (15.3% vs 6%, P=0.002)7
6. primary PCI 90
(Door-to-Balloon)
TIMI flow 2-3 90%, emergency CABG <2%,
85% PCI 7%8
7. cardiogenic shock emergency PCI

SHOCK trial
primary PCI 6 1 (53%
vs 66%, P<0.03) 75
30 (absolute reduction 15%, P<0.02)
75 9
8.
Primary PCI

9.
3
primary
PCI PCI
(
60 ) primary PCI
49
10.

12
11. 3
primary PCI

I. contact to balloon or D-B

90
II. primary PCI TIMI 2/3 flow 90%
III. (emergency CABG) 2%
IV. primary
PCI 85%
V. 7% ( )
12.

primary PCI
13. Door to needle
( 30 )
14. Door to balloon

PCI 90
90
3
50
.. 2551
References
1. Tamis-Holland JE, Palazzo A, Stebbins AL, et al. Benefits of
direct angioplasty for women and men with acute myocardial
infarction: results of the Global Use of Strategies to Open
Occluded Arteries in Acute Coronary Syndromes Angioplasty
(GUSTO II-B) Angioplasty Substudy. Am Heart J 2004;147(1):
133-9.
2. Goldenberg I, Matetzky S, Halkin A, et al. Primary angioplasty
with routine stenting compared with thrombolytic therapy in
elderly patients with acute myocardial infarction. Am Heart J
2003;145(5):862-7.
3. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus
intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet
2003;361(9351):13-20.
4. Thygesen K, Alpert JS, White HD, et al. Universal definition of
myocardial infarction: Kristian Thygesen, Joseph S. Alpert and
Harvey D. White on behalf of the Joint ESC/ACCF/AHA/WHF
Task Force for the Redefinition of Myocardial Infarction. Eur
Heart J 2007;28(20):2525-38.
5. Loubeyre C, Morice MC, Lefevre T, Piechaud JF, Louvard Y,
Dumas P. A randomized comparison of direct stenting with
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myocardial infarction. J Am Coll Cardiol 2002;39(1):15-21.
51
7. Widimsky P, Budesinsky T, Vorac D, et al. Long distance transport for primary angioplasty vs immediate thrombolysis in acute
myocardial infarction. Final results of the randomized national
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myocardial infarctionexecutive summary. A report of the
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9. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization
in acute myocardial infarction complicated by cardiogenic shock.
SHOCK Investigators. Should We Emergently Revascularize
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1999;341(9):625-34.
52
.. 2551
10. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major
morbidity results from all randomised trials of more than 1000
patients. Fibrinolytic Therapy Trialists (FTT) Collaborative Group.
Lancet 1994;343(8893):311-22.
11. Grines CL, Cox DA, Stone GW, et al. Coronary angioplasty with
or without stent implantation for acute myocardial infarction.
Stent Primary Angioplasty in Myocardial Infarction Study Group.
N Engl J Med 1999;341(26):1949-56.
myocardial infarction; A report of the American College of
Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee to Revise the 1999 Guidelines for the
Management of patients with acute myocardial infarction). J Am
Coll Cardiol 2004;44(3):E1-E211.
SCAI 2005 guideline update for percutaneous coronary
interventionsummary article: a report of the American College
of Cardiology/American Heart Association Task Force on
Practice Guidelines (ACC/AHA/SCAI Writing Committee to
update the 2001 Guidelines for Percutaneous Coronary Intervention). Catheter Cardiovasc Interv 2006;67(1):87-112.
53
PCI
ST segment
(ST Elevation myocardial infarction)
12 48
PCI ST elevation MI
12 reperfusion therapy
hemodynamic electrical instability (
++, 3)
PCI ST elevation MI 12 - 48
reperfusion therapy
( +/-,
2)
BRAVE-21 ST elevation
MI 12 - 48 reperfusion therapy
365 PCI
myocardial infarction
stroke 30
References
1. Schomig A, Mehilli J, Antoniucci D, et al. Mechanical reperfusion
in patients with acute myocardial infarction presenting more
than 12 hours from symptom onset: a randomized controlled
trial. JAMA 2005;293(23):2865-72.
54
.. 2551
PCI
24
(Recent myocardial infarction)
1. primary PCI
24 ( -,
1)
2. 1 PCI
24 (post myocardial infarction angina)
( +, 4)
3.
(left ventricular ejection
fraction <40%) (open
artery concept) ( +/-, 4)
recent myocardial infarction PCI 3 - 28

(stable) post MI
angina occluded infarct related vessel
(Left ventricular ejection fraction)
(re-infarction), (congestive heart
failure) 4
(OAT and TOSCA 2)
ACC/AHA guideline 2004
left ventricular ejection fraction <40%
55
References
1. Hochman JS, Lamas GA, Buller CE, Dzavik V, Reynolds HR,
Abramsky SJ and et al for the Occluded Artery Trial Investigators. Coronary Intervention for Persistent Occlusion after
Myocardial Infarction. N Engl J Med 2006;355:2395-2407
2. Dzavk V, Buller CE, Lamas GA, Rankin JM, Mancini GBJ,
Cantor WJ and et al. for the TOSCA-2 Investigators. Randomized Trial of Percutaneous Coronary Intervention for Subacute
Infarct-Related Coronary Artery Occlusion to Achieve Long-Term
Patency and Improve Ventricular Function The Total Occlusion
Study of Canada (TOSCA)2 Trial. Circulation 2006;114:2449-2457
3. Madsen JK, Grande P, Saunamki K, Thayssen P, Kassis E, Eriksen
U and et al; on behalf of the DANAMI Study Group. Danish
Multicenter Randomized Study of Invasive Versus Conservative
Treatment in Patients With Inducible Ischemia After Thrombolysis
in Acute Myocardial Infarction (DANAMI) Circulation 1997;96:748-755
4. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarctionexecutive summary. A report of the American
College of Cardiology/American Heart Association Task Force
on Practice Guidelines (Writing Committee to revise the 1999
guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol 2004;44(3):671-719
56
.. 2551
PCI STEMI
(Rescue PCI after failed thrombolysis)

60 - 90 (failed thrombolysis*)
(rescue PCI)
12 ( ++ ,
1)
* ST segment resolution ( lead ST segment
elevation ) 50 %
60 - 90
REACT trial1 meta-analysis trials2-4

(recurrent myocardial ischemia)

(failed thrombolysis)
(minor bleeding)
(stroke) 4 MERLIN trial

(conservative treatment)
(minor bleeding) 5
57
References
1. Gershlick AH, Stephens-Lloyd A, Hughes S, et al. Rescue
angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med 2005;353(26):2758-68.
2. Patel TN, Bavry AA, Kumbhani DJ, Ellis SG. A meta-analysis of
randomized trials of rescue percutaneous coronary intervention
after failed fibrinolysis. Am J Cardiol 2006;97(12):1685-90.
3. Collet JP, Montalescot G, Le May M, Borentain M, Gershlick A.
Percutaneous coronary intervention after fibrinolysis: a multiple
meta-analyses approach according to the type of strategy. J Am
Coll Cardiol 2006;48(7):1326-35.
4. Wijeysundera HC, Vijayaraghavan R, Nallamothu BK, et al.
Rescue angioplasty or repeat fibrinolysis after failed fibrinolytic
therapy for ST-segment myocardial infarction: a meta-analysis
of randomized trials. J Am Coll Cardiol 2007;49(4):422-30.
5. Sutton AG, Campbell PG, Graham R, et al. A randomized trial of
rescue angioplasty versus a conservative approach for failed
fibrinolysis in ST-segment elevation myocardial infarction: the
Middlesbrough Early Revascularization to Limit INfarction
(MERLIN) trial. J Am Coll Cardiol 2004;44(2):287-96.
58
.. 2551

STEMI congestive heart
failure, cardiogenic shock, unstable hemodynamics, poor left
ventricular ejection fraction <30%
( +, 4)

low risk high risk
new heart murmur, ventricular septal rupture

59

PCI

( +,
1)
1-3

Heparin
SIAM III4 PCI stent 24

ischemic events target lesion
revascularization 25.6% vs. 50.6%, p = 0.001
GRACIA-I5 thrombolysis 12
PCI 6 thrombolysis
1
PCI primary endpoint (23 [9%] vs 51 [21%], risk ratio 0.44
[95% CI 0.28-0.70], p=0.0008),
(7% vs 12%, 0.59 [0.33-1.05], p=0.07)
major bleeding vascular complications
60
.. 2551
References
1. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines
for the management of patients with ST-elevation myocardial
infarction; A report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Committee
to Revise the 1999 Guidelines for the Management of patients with
acute myocardial infarction). J Am Coll Cardiol 2004;44(3):E1-E211.
2. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines
for the management of patients with ST-elevation myocardial
infarction: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Committee
to Revise the 1999 Guidelines for the Management of Patients with
Acute Myocardial Infarction). Circulation 2004;110(9):e82-292.
3. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarctionexecutive summary: a report of the American
College of Cardiology/American Heart Association Task Force
on Practice Guidelines (Writing Committee to Revise the 1999
Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation 2004;110(5):588-636.
4. Scheller B, Hennen B, Hammer B, et al. Beneficial effects of
immediate stenting after thrombolysis in acute myocardial
infarction. J Am Coll Cardiol 2003;42(4):634-41.
5. Fernandez-Aviles F, Alonso JJ, Castro-Beiras A, et al. Routine
invasive strategy within 24 hours of thrombolysis versus ischaemia-guided conservative approach for acute myocardial
infarction with ST-segment elevation (GRACIA-1): a randomised
controlled trial. Lancet 2004;364(9439):1045-53.
61

STEMI

75 - 325 PCI ( ++,
1)

300 - 325 2 PCI (
PCI 24 ) ( ++,
4)
PCI 325
1 bare metal stent
325 3
drug eluting stent 75 - 100
( ++, 4)
62
.. 2551
ADP antagonist
PCI ADP antagonist
clopidogrel 300 ticlopidine
500 ( ++,
1)
clopidogrel 6 PCI
( ++, 2)
clopidogrel 300
( +,
2)
PCI bare metal stent
clopidogrel 75 ticlopidine 250
2 1 drug
eluting stent clopidogrel 75
ticlopidine 250 2 12
( ++, 4)
(glycoprotein IIb/IIIa receptor antagonist)
glycoprotein IIb/IIIa receptor antagonist
CAG PCI acute coronary syndrome clopidogrel
( ++, 1)
clopidogrel glycoprotein IIb/IIIa
receptor antagonist (
+, 2)
STEMI PCI glycoprotein IIb/IIIa
receptor antagonist abciximab ( +,
2)
63

unfractionated heparin 70 - 100
PCI ( ++,
4)
unfractionated heparin low molecular
weight heparin enoxaparin 0.5 - 0.7
PCI ( +/-,
2)
(heparin-induced thrombocytopenia)
bivalirudin argatoban heparin (
++, 2)
nitroglycerine
PCI
( ++,
4)
slow-flow adenosine, verapamil
nitroprusside ( +,
4)
1. 75 cardiovascular event
325
2. clopidogrel PCI
300
600
64
.. 2551
References
1. Grines CL, Bonow RO, Casey DE, Jr., et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with
coronary artery stents: a science advisory from the American
Heart Association, American College of Cardiology, Society for
Cardiovascular Angiography and Interventions, American College
of Surgeons, and American Dental Association, with representation
from the American College of Physicians. Circulation 2007;115(6):
813-8.
2. Mehta SR, Yusuf S, Peters RJ, et al. Effects of pretreatment with
clopidogrel and aspirin followed by long-term therapy in patients
undergoing percutaneous coronary intervention: the PCI-CURE
study. Lancet 2001;358(9281):527-33.
3. Patti G, Colonna G, Pasceri V, Pepe LL, Montinaro A, Di Sciascio
G. Randomized trial of high loading dose of clopidogrel for
reduction of periprocedural myocardial infarction in patients
undergoing coronary intervention: results from the ARMYDA-2
(Antiplatelet therapy for Reduction of MYocardial Damage
during Angioplasty) study. Circulation 2005;111(16):2099-106.
4. Silber S, Albertsson P, Aviles FF, et al. Guidelines for percutaneous
coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur
Heart J 2005;26(8):804-47.
65
6. Steinhubl SR, Berger PB, Mann JT, 3rd, et al. Early and sustained
dual oral antiplatelet therapy following percutaneous coronary
intervention: a randomized controlled trial. JAMA 2002;288(19):2411-20.
66
.. 2551
PCI unstable angina

NSTE-ACS
1, 2
1. PCI stable CAD
thrombotic risk

48
( ++, 1)
1. Recurrent resting pain
2. Dynamic ST-segment changes: ST-segment depression
0.1 mV or transient (<30 min) ST-segment elevation
0.1 mV
3. Elevated Troponin-I, Troponin-T, or CK-MB levels
4. Haemodynamic instability within the observation period
5. Major arrhythmias (ventricular tachycardia, ventricular
fibrillation)
6. Early post-infarction unstable angina
7. Diabetes mellitus
2. (urgent coronary angiography) refractory recurrent angina dynamic
ST-deviation, heart failure, life-threatening arrhythmias hemodynamic instability ( ++, 3)
67
3. (early {<72 h} coronary

angiography) PCI CABG
intermediate high risk ( ++,
1)
4. routine invasive evaluation
intermediate high risk ( -,
3)
5. non-invasive assessment
inducible ischemia ( ++,
3)
6. PCI (
-, 3)
Reference
Eur Heart J 2005;26(8):804-47.
2. Bassand JP, Hamm CW, Ardissino D, et al. Guidelines for the
diagnosis and treatment of non-ST-segment elevation acute
coronary syndromes. The Task Force for the Diagnosis and
Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology. Eur Heart J
2007;28(13):1598-660.
68
.. 2551
NSTE-ACS
(Invasive strategy)
(Conservative strategy)
Early invasive strategy

(coronary arteriography) 72
revascularization
therapy PCI
NSTE-ACS ( risk stratification
in NSTE-ACS)
Early conservative strategy

( ++, 1)
69

NSTE-ACS 30 STEMI
1 STEMI

revascularization therapy 2 early
invasive strategy coronary angiography
24 7 ( 72 )
revascularization early
PCI early CABG early conservative strategy
coronary angiogram
/ revascularization

noninvasive stress test
2
1-3
glycoprotein IIb/IIIa inhibitors4-8

FRISC-II6 early invasive strategy
6 early
conservative strategy (9.4% vs 12.1%, p = 0.031)
1, 2 5
RITA-34 early invasive strategy

4
(9.6% vs. 14.5%, p=0.001)
1 2 (7.6% vs 8.3%, p = 0.58)
5 (16.6% vs. 20.0%,
p = 0.044)
70
.. 2551
VINO trial5 coronary angiogram

6 6.2% vs. 22.3%
(p<0.001) (3.1% vs. 13.4%, p = 0.03)
(3.1% vs. 14.9%, p < 0.02)
(n = 113 )
7, 9
TACTICS-TIMI 18
early invasive strategy early conservative strategy
( troponin TIMI risk score )
GP IIb/IIIa inhibitors
8
ICTUS trial GP IIb/IIIa inhibitors early invasive strategy early conservative strategy

1 (22.7% vs. 21.2%, p = 0.33)
(15% vs. 10%,
p = 0.005)
early invasive group procedure-related CK-MB
1 upper normal limit
CK-MB 1.5-3 upper normal limit
clopidogrel
early conservative strategy metaanalysis10-12 early invasive strategy early conservative
strategy ,
NSTE-ACS
71
References
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3. Boden WE, ORourke RA, Crawford MH, et al. Outcomes in
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angiography/angioplasty in evolving Non-ST segment elevation
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6. Invasive compared with non-invasive treatment in unstable

coronary-artery disease: FRISC II prospective randomised
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InStability in Coronary artery disease Investigators. Lancet
1999;354(9180):708-15.
7. Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison
of early invasive and conservative strategies in patients with
unstable coronary syndromes treated with the glycoprotein
IIb/IIIa inhibitor tirofiban. N Engl J Med 2001;344(25):1879-87.
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versus selectively invasive management for acute coronary
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in unstable angina and non-Q-wave myocardial infarction
following treatment with tirofiban: rationale and study design of
the international TACTICS-TIMI 18 Trial. Treat Angina with
Aggrastat and determine Cost of Therapy with an Invasive or
Conservative Strategy. Thrombolysis In Myocardial Infarction.
Am J Cardiol 1998;82(6):731-6.
73
10. Mehta SR, Cannon CP, Fox KA, et al. Routine vs selective
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74
.. 2551
Low molecular weight heparin

PCI NSTE-ACS
NSTE-ACS PCI unfractionated

heparin (UFH) 70 PCI
enoxaparin 1
12 2 PCI 8 enoxaparin
PCI enoxaparin 8
enoxaparin 0.3
PCI ( ++, 1)
enoxaparin PCI
( 2)
TIMI 11B1 ESSENCE2, 3 unstable

angina enoxaparin UFH enoxaparin
recurrent ischemia UFH
4-6
meta-analysis enoxaparin
7, 8
FRISC
FRISC-II9 dalteparin
recurrent ischemia UFH
FRAXIS Nadoparin UFH
LMWH enoxaparin NSTE-ACS
NSTE-ACS PCI
75
SYNERGY10 enoxaparin UFH

NSTE-ACS PCI PCI
22 enoxaparin 1
12 2 PCI enoxaparin
8 enoxaparin 0.3
PCI PCI enoxaparin
8 UFH
60
prothrombin time 1.5 - 2 PCI
activated clotting time 250
nonfatal MI 30
enoxaparin
UFH
UFH enoxaparin
enoxaparin 0.3
PCI (arterial
sheath) 4 - 6 enoxaparin
enoxaparin
6 - 8
76
.. 2551
NICE-311(2) enoxaparin GP
IIb/IIIa antagonist NSTE-ACS PCI
UFH GP IIb/IIIa antagonist
myocardial infarction
urgent revascularization
12
ATLAST UA 50 MI 43
PCI enoxaparin 14
aspirin ticlopidine MI
urgent revascularization 30 PCI
event rate
enoxaparin
ACC/AHA Guidelines for the management of patients with
UA/NSTEMI 200713 enoxaparin UFH
NSTEMI PCI ( +)
14
ESC Guidelines for PCI 2005 enoxaparin
NSTEMI PCI
enoxaparin PCI
enoxaparin (UFH
protamine) UFH CABG
77
References
1. Antman EM. TIMI 11B. Enoxaparin versus unfractionated
heparin for unstable angina or non-Q-wave myocardial
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3. Fox KA. Low molecular weight heparin (enoxaparin) in the
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for preventing clinical events at 1-year follow-up of TIMI 11B
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7. Low-molecular-weight heparin during instability in coronary

artery disease, Fragmin during Instability in Coronary Artery
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coronary-artery disease: FRISC II prospective randomised
multicentre study. FRagmin and Fast Revascularisation during
InStability in Coronary artery disease Investigators. Lancet
1999;354(9180):708-15.
10. Ferguson JJ, Califf RM, Antman EM, et al. Enoxaparin vs
unfractionated heparin in high-risk patients with non-STsegment elevation acute coronary syndromes managed with
an intended early invasive strategy: primary results of the
SYNERGY randomized trial. JAMA 2004;292(1):45-54.
11. Ferguson JJ, Antman EM, Bates ER, et al. Combining enoxaparin
and glycoprotein IIb/IIIa antagonists for the treatment of acute
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12. Batchelor WB, Mahaffey KW, Berger PB, et al. A randomized,
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79
13. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007
guidelines for the management of patients with unstable
angina/non-ST-Elevation myocardial infarction: a report of the
Force on Practice Guidelines (Writing Committee to Revise the
2002 Guidelines for the Management of Patients With Unstable
Angina/Non-ST-Elevation Myocardial Infarction) developed in
collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by
the American Association of Cardiovascular and Pulmonary
Rehabilitation and the Society for Academic Emergency
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14. Silber S, Albertsson P, Aviles FF, et al. Guidelines for percutaneous
coronary interventions. The Task Force for Percutaneous
Eur Heart J 2005;26(8):804-47.
80
.. 2551
Glycoprotein IIb/IIIa
(GPIIb/IIIa) inhibitor NSTE-ACS
GPIIb/IIIa inhibitor troponin-T

1, 2 ( +/-, 1)
70 GP IIb/IIIa inhibitor
( +, 1)
eptifibatide tirofiban4 pretreatment (upstream)
intermediate to high risk
elevated troponin, ST depression, diabetes ( +,
1)
pretreatment5, 6 eptofibatide tirofiban

PCI ( +, 2)
Abciximab NSTE-ACS7 pretreatment
( - , 2)
high risk GP inhibitor PCI
abciximab PCI8 (
+, 2)
GP inhibitor anticoagulant4 (
++, 1)
81

Boersma 9 meta-analysis 6
NSTE-ACS 31,402 GPIIb/IIIa
absolute risk reduction 1
10
Roffi
meta-analysis 6
NSTE-ACS 6,458 GPIIb/IIIa
absolute risk reduction 30 1.6
3 70% 4.0
1.2
GUSTO IV-ACS ACS 7,800
abciximab placebo troponin
82
.. 2551
References
1. Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison
of early invasive and conservative strategies in patients with
unstable coronary syndromes treated with the glycoprotein
IIb/IIIa inhibitor tirofiban. N Engl J Med 2001;344(25):1879-87.
2. Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban
in unstable angina and non-Q-wave myocardial infarction. Platelet
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IIIa inhibitors reduce mortality in diabetic patients with non-STsegment-elevation acute coronary syndromes. Circulation
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4. Cannon CP, Weintraub WS, Demopoulos LA, Robertson DH,
Gormley GJ, Braunwald E. Invasive versus conservative strategies in unstable angina and non-Q-wave myocardial infarction
following treatment with tirofiban: rationale and study design of
the international TACTICS-TIMI 18 Trial. Treat Angina with
Aggrastat and determine Cost of Therapy with an Invasive or
Conservative Strategy. Thrombolysis In Myocardial Infarction.
Am J Cardiol 1998;82(6):731-6.
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.. 2551
Drug eluting stent (DES)
(Drug eluting stent)

(Bare metal stent)
angina
3
15

(DES)
(BMS) 6
SIRIUS1, TAXUS-IV2, TAXUS-VI3 randomized controlled trial

Sirolimus Paclitaxel
angina
2.5 - 3.75 10 - 40
Acute MI Post MI
CK/CK-MB bifurcational ostial lesion, unprotected left main,
visible thrombus, severe tortuosity / calcification
4
National Institute for Clinical Excellence
3
15

85
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(Percutaneous Coronary Intervention, PCI)

Percutaneous Coronary Intervention, PCI

(Percutaneous Coronary Intervention, PCI)

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Percutaneous Coronary Intervention, PCI

Percutaneous Coronary Intervention, PCI

(Percutaneous Coronary Intervention, PCI)

Percutaneous Coronary Intervention, PCI

(Percutaneous Coronary Intervention, PCI)

Percutaneous Coronary Intervention, PCI

Percutaneous Coronary Intervention, PCI

Chronic stable angina pectoris ............... 19

Percutaneous Coronary Intervention, PCI

Percutaneous Coronary Intervention, PCI

Percutaneous Coronary Intervention, PCI

Percutaneous Coronary Intervention, PCI

Percutaneous Coronary Intervention, PCI

Percutaneous Coronary Intervention, PCI

(KPI: Key point indicator)

Percutaneous Coronary Intervention, PCI

Angiographic success 96 - 99%

Coronary angioplasty coronary artery bypass graft

Percutaneous Coronary Intervention, PCI

Objective large ischaemia ECG stress testing, Nuclear imaging,

Percutaneous Coronary Intervention, PCI

Percutaneous Coronary Intervention, PCI

Stable angina pectoris

PCI Left main coronary artery

Unprotected left main coronary artery disease (ULMCA)

Percutaneous Coronary Intervention, PCI

High risk or nonsurgical patient

Comorbidity (advanced chronic obstructive lung

Percutaneous Coronary Intervention, PCI

7. Park SJ, Park SW, Hong MK, et al. Long-term (three-year)

14. Agostoni P, Valgimigli M, Van Mieghem CA, et al. Comparison

Percutaneous Coronary Intervention, PCI

chronic total occlusion angioplasty

Percutaneous Coronary Intervention, PCI

6. Hamood H, Makhoul N, Grenadir E, Kusniec F, Rosenschein U.

single vessel CAD

Percutaneous Coronary Intervention, PCI

Aspirin Cilastazol PCI

Percutaneous Coronary Intervention, PCI

Aspirin ischemic complications PCI

Percutaneous Coronary Intervention, PCI

SIAM III4 PCI stent 24

Percutaneous Coronary Intervention, PCI

acute STEMI new LBBB

Percutaneous Coronary Intervention, PCI

Percutaneous Coronary Intervention, PCI

Percutaneous Coronary Intervention, PCI

Percutaneous Coronary Intervention, PCI

Percutaneous Coronary Intervention, PCI

Percutaneous Coronary Intervention, PCI

recent myocardial infarction PCI 3 - 28

(Rescue PCI after failed thrombolysis)

REACT trial1 meta-analysis trials2-4

Percutaneous Coronary Intervention, PCI

SIAM III4 PCI stent 24

Percutaneous Coronary Intervention, PCI

Percutaneous Coronary Intervention, PCI

PCI unstable angina

Percutaneous Coronary Intervention, PCI

3. (early {<72 h} coronary