急性冠心症治療的最新進展

100 7

ၡāāࢋ

( acute coronary syndrome ) ST ST ST ASSENT-4 PCI

ST

1 ICTUS ICTUS

ᙯᔣෟĈާّ݄͕া ( Acute coronary syndrome )

ܳซّགྷϩ݄ҕგڼᒚ ( Facilitated percutaneous coronary intervention ) ԩҕ̈ڕڼᒚ ( Antiplatelet therapy )

ԩҕং጖ඕڼᒚ ( Anticoagulant therapy )

຅௟ࡪڼᒚ ( Stem cell-based therapy )

ૄЯវᗁጯ ( Genomic medicine )

݈֏

ᐌ඾ᗁᒚ׶̳В኎Ϡ۞ซՎĂధк็ߖ়ّ

ঽצזଠטĂˠᙷ۞ု׻˵ు႙ᆧܜĄΐ˯Яன

΃Ϡ߿ݭၗ̈́฼ࢴ௫ၚ۞ԼតĂ׎΁ధк়ঽ˵

Яᑕ҃ϠĂ׎̚˫ͽЯඓېજਔർ̼யϠ۞৿ҕ

ّ݄͕াᆧΐ۞಼ޘ౵ࠎមˠĂ˵˘ۡ੼ҫѪ˸

த۞݈ೀҜĄॲፂ 2002 ѐ͵ࠧ኎Ϡ௡ᖐ௚ࢍྤ

फ़ĂБ͵ࠧ 57,029,155 ۞Ѫ˸ˠᇴ̚Ăੵ˞็ߖ

়ّঽγĂ͕ҕგ়ঽ ( Βӣཝҕგ়ঽ )Ѫ˸

த੼ҫௐ˘ҜĂВѣ 16,733,160 ˠĂҫБొѪ˸

ˠᇴ۞ 29.3% Ą׎̚Ă˫ͽ৿ҕّ݄͕াҜاௐ

˘ҜĂҫ׎̚ 43.1% Ąͽ઼̰ଐڶ҃֏Ă኎Ϡཌ ϔ઼ 94 ѐѪ˸த۞௚ࢍĂБ઼͕ҕგ়ঽѪ˸

த ( ̙Βӣཝҕგ়ঽ̈́੼ҕᑅ ) Вѣ 1 2 , 9 7 0 ˠĂҫБొѪ˸த 9.3% ĂҜاѪ˸தௐˬҜĄ

ٙͽ݄͕ঽ۞֨ڼĂдܕ˩ೀѐֽ˘ۡߏЧ઼ᗁ ᒚ̳̈́В኎Ϡ۞ࢦᕇĄ

Ϥٺ˯࣎͵ࡔ୎ഇ̂ณ۞ˠ˧̈́ۏ˧Ըˢࡁ տĂ݄͕া۞࡭ঽ፟ᖼ̏ѣ࠹༊۞˞ྋĂֹ଀ᘽ ۏ̬̈́ˢّڼᒚᒔ଀಼̂ซՎĂٙͽ̙ኢߏާّ

ٕၙّ݄͕াĂ࿰ޢౌѣ಼̂ԼචĄॲፂ઼࡚͕

᝙ጯੰ઼࡚͕̈́᝙םົ੫၆ާّ݄͕া۞ڼᒚ఍

ཉĂͽঽଈܑனܐഇ۞͕࿪ဦߏӎѣ ST ߱˯̿Ă

̶ј׌̂ᙷĈ ST ˯̿ݭ͕҉ୟ๫( ST elevation my- ocardial infarction ) ( Β߁ν͕ވޢጨୟ๫ )Ă̈́ܧ ST˯̿ݭ݄͕া ( non ST elevation acute coronary syndrome )Ąͽ˭ಶͽѩ੅ኢܕֽ൴ܑѣᙯާّ

݄͕াڼᒚ۞ᓜԖྏរ̝౵າซणĄ

ST ˯̿ݭ͕҉ୟ๫

ާّ݄͕া۞ڼᒚ̶ј׌̂ొ̶Ĉൺഇ۞ڼ ᒚϫᇾ͹ࢋٸдᔖҺٕߏഴ͕͌҉ᗼѪ۞ቑಛć

҃ܜഇ۞ϫᇾߏࢫҲν͕ވГ๬׶͕਽ა۞൴Ϡ தĂͽഇܳซх߿தĄ

Я ST ˯̿ݭ͕҉ୟ๫̈́ܧ ST ߱˯̿ݭާّ

݄͕া۞ঽϠந፟ᖼ̙֭ԆБ࠹ТĂٙͽॲፂϫ

઼݈࡚͕᝙ጯੰ઼࡚͕̈́᝙םົޙᛉ۞఍ཉ޽

͔Ăܐഇ۞ڼᒚ఍ཉ̙֭ԆБ࠹ТĄ ST ߱˯̿

ݭާّ͕҉ୟ๫ߏЯࠎٽ਑ّඓېർ̼೹๴யϠ

৔ෘٕ৔ຫ҃யϠާّܡ๫ّҕংĂ҃ౄј͕҉

ᗼѪĄٙͽ౵ࢦࢋٙග̟۞ާّڼᒚӈߏ֝ిซ Җѣड़ͷᘦؠ۞ҕგГ఼ၰّڼᒚ ( revascular- ization )Ăͽഴ͕͌҉ᗼѪ۞ቑಛĂ҃ࢫҲୟ๫

ޢ͕਽ა۞፟தĄॲፂϫ݈۞఍ཉ޽͔ĂҕგГ

఼ၰّڼᒚΞᏴፄۡତགྷϩ݄͕ҕგڼᒚăᘽۏ ҕং໘ྋڼᒚăٕߏ݄ېજਔᖒ྽͘ఙĄ

˘ăܳซّགྷϩ݄ҕგڼᒚ ( facilitated percuta- neous coronary intervention )

ഴ͕͌҉ᗼѪ۞׎̚˘ีᙯᔣдٺᒺൺާّ

াې൴үזග̟ҕგГ఼ၰڼᒚ۞ॡมม෼Ą҃

ͷॡมม෼۞ᒺൺϺົࢫҲѪ˸தĄҭன၁̚Ă

͕҉ୟ๫൴үޢĂঽଈ૱෹࿅׌̈ॡޢ̖ົజྻ

ਖ਼ז྿ᗁੰĄֶፂፋЪ̶ژ ( meta-analysis ) ൴ன д ST ˯̿ݭ͕҉ୟ๫ާّ൴үޢ 1 ז 12 ̈ॡ̰

ග̟ᘽۏҕং໘ྋڼᒚĂх߿த׶ତצڼᒚ۞ॡ มม࿣Ӕϒ࠹ᙯ¹Ą҃ͷͧྵۡତགྷϩ݄͕ҕგ ڼᒚ̈́ᘽۏҕং໘ྋڼᒚड़ڍĂ̏ᙋ၁݈۰Ξͽ ѣड़ࢫҲ ST ˯̿ݭ͕҉ୟ๫ޢᜈ۞׀൴া^{2, 3}Ą

ҭࡶ ST ˯̿ݭ͕҉ୟ๫ଈ۰ࢋତצۡତགྷ ϩ݄͕ҕგڼᒚĂன̫၁ᅫેҖ˯Ăଂާّাې

൴үזග̟ڼᒚ۞ॡมม෼ົͧග̟ᘽۏҕং໘ ྋڼᒚٙᅮࢋ۞ֽ଀ܜĄॲፂ઼࡚ 1999 ז 2002 ѐ۞௚ࢍྤफ़Ă੼྿ 6 0 % ۞ଈ۰Ă׎ତצۡତ གྷϩ݄ҕგڼᒚĂ෹࿅ 90 ̶ᛗ۞ޙᛉॡม⁴ĄΩ

˘͞ࢬĂ̏ѣᙋፂពϯާّ͕҉ୟ๫ତצۡତགྷ ϩ݄͕ҕგڼᒚॡĂࡶயϠ͕҉ୟ๫࠹ᙯ݄ېજ ਔ ( infarct-related artery Ă IRA ) ̏ѣҕ߹ޭೇ

۰âѐх߿தͧྵр⁵Ą

ЯѩĂࠎ˞ᒺൺާّাې൴үזග̟ҕგГ

఼ၰڼᒚ۞ॡมม෼Ă˫ࢋܲ঻ତགྷϩ݄͕ҕგ ڼᒚ۞ᐹ๕Ăੵ˞ঽˠ۞ҋ֗ᛋᛇّ۞ކጱ׶ྻ

ਖ਼࿅඀۞ԼචγĂГӀϡᘽۏҕং໘ྋڼᒚ۞͞

ܮّĂඕЪٺזੰ݈дା᜕֘˯ٕާ෧ވ̚ซҖ ᘽۏҕং໘ྋڼᒚͽഇ྿јొ̶ٕБొҕং໘ྋ

҃ᒺൺ͕҉৿ҕॡมĂזੰޢГซҖགྷϩ݄ҕგ ڼᒚĂѩ࿅඀Ⴭࠎܳซّགྷϩ݄ҕგڼᒚĂјࠎ ܕֽᓜԖྏរ۞ࢦᕇ̝˘Ą

ܐഇᓜԖࡁտ޽΍ ST ˯̿ݭ͕҉ୟ๫ঽଈ ତצזੰ݈Η጗ณҕং໘ྋ጗۞ܳซّགྷϩ݄ҕ გڼᒚඉரĂͧΪତצۡତགྷϩ݄ҕგڼᒚĂ͕

࿪ဦ˯ S T ߱˯̿۞ޭೇֽ଀р⁶Ąҭ౵ܕ A S - SENT-4ᓜԖྏរ̚ᒔ଀۞ඕኢݒ΄ˠε୕Ąд S T˯̿ݭ͕҉ୟ๫ଈ۰াې൴ү 6 ࣎̈ॡ̰Ă Бొତצזੰޢགྷϩ݄ҕგڼᒚĄ၁រ௡--ӈซ Җܳซّགྷϩ݄ҕგڼᒚ--ΐ˯ତצזੰ݈Б጗

ณҕং໘ྋ጗ tenecteplase ( TNK )Ăҭݒ൴னܳ

ซّགྷϩ݄ҕგڼᒚֹ҃ͅ 90 ͇̰۞׀൴াᆧ ΐ⁷Ą҃ͷĂ౵ܕ۞௚Ъ̶ژ ( Β߁ ASSENT-4 P- CI ) ˵޽΍Ăᔵ൒ܳซّགྷϩ݄ҕგڼᒚѣྵ੼

ּͧ۞ଈ۰дซҖགྷϩ݄ҕგڼᒚ݈ѣྵָୟ๫

࠹ᙯ݄ېજਔ۞᛿߹Ăҭ׎Ѫ˸தăܧ࡭׻ّ۞

͕҉Гୟ๫፟தă̈́΍ҕ׀൴াݒ࠹၆ྵ੼⁸Ą ҭΩ˘͞ࢬĂܳซّགྷϩ݄ҕგڼᒚݒᙋ၁

ͧΪତצᘽۏҕং໘ྋڼᒚඕڍྵָĄ C A P I - TAL-AMIྏរ̚Ăࡁտ੼Пᐍ ST ˯̿ݭ͕҉ୟ

๫ঽଈତצܳซّགྷϩ݄ҕგڼᒚٕΪତצᘽۏ ҕং໘ྋڼᒚĄ൴ன݈۰Ξព඾ࢫҲ 6 ̰࣎͡׀

൴াĂ҃ᚑࢦ΍ҕ۞፟தݒ̙ົᆧΐ⁹Ą

ٙͽĂͽϫ݈۞ᓜԖྏរඕڍ҃֏Ă̙ޙ ᛉд୬ତצۡତགྷϩ݄ҕგڼᒚ۞ ST ˯̿ݭ͕

҉ୟ๫ঽଈĂග̟זੰ݈Б጗ณҕং໘ྋ጗۞ڼ ᒚć҃Ҍٺזੰ݈Η጗ณҕং໘ྋ጗۞ڼᒚĂ݋

ᅮซ˘Վ۞ᓜԖྏរᙋፂĄ၆ٺֱ֤ ST ˯̿ݭ

͕҉ୟ๫ঽଈߏତצᘽۏҕং໘ྋڼᒚޢĂϲӈ ซҖགྷϩ݄ҕგڼᒚĂдᓜԖ˯ຕᏴࠎ੼Пᐍཏ

۞ঽଈ҃֏Ăߏѣٙӄৈ۞Ą

дέ៉ĂЯڱޠᆸࢬإϏ׹ྎĂϫ݈֭൑ڱ ឰௐ˘ቢ۞ღާᗁᒚା᜕ˠࣶдזੰ݈ ( ӈдঽ

൴னಞٕା᜕֘˯ ) ග̟ҕং໘ྋ጗Ą

˟ăᅈბ᜕ܲ̈́ҕংၡੵ྅ཉ

д ST ˯̿ݭ͕҉ୟ๫ঽଈତצۡତགྷϩ݄

ҕგڼᒚॡĂࡶயϠᅈბҕংং๫ ( distal em- bolization )Ă̏གྷѣࡁտᙋ၁ົѣྵ੼۞ 5 ѐѪ

ܑ˘Ĉᙯٺᅈბং๫᜕ܲ̈́ҕংၡੵ྅ཉ̝ᓜԖྏរ

Trial Setting Intervention Primary end-point Results

REMIEDIA¹⁵

XAMINE-ST¹⁶

EMERALD¹⁷

PROMISE¹⁸

DEAR-MI¹⁹

Ali et al.¹⁰

Kaltoft et al.¹²

100 pt. with anterior AMI, <12 h, receiving primary PCI

201 pt. with AMI, <12 h, baseline TIMI flow grade 0 or 1

501 pt. with AMI, <6 h

200 pt. with STEMI or NSTEMI, <48 h

148 pt. with STEMI,12 h

480 pt. with STEMI, 12 h

215 pt. with STEMI, 12 h

manual aspiration with Diver catheter before primary PCI with stent- ing

Primary PCI with stent- ing + thrombectomy with X-Sizer device

PPCI + distal embolic protection with GuardWire device

Primary PCI + distal embolic protection with FilterWire

Primary PCI + throm- bus aspiration

Primary PCI + rheolytic thrombectomy

Primary PCI + thrombectomy with Rescue catheter

Post-PCI TIMI myocar- dial perfusion grade (TMPG) >=2 and >=

70% ST elevation reso- lution (STR)

STR 1 hr after PCI

Infarct size by single photon emission com- puted tomography (SPECT) 5-14 days later. STR 30 min after PCI

Maximal adenosine-in- duced Doppler flow ve- locity after PPCI STR (>=70%) and my- ocardial brush grade (MBG) 3

Infarct size by SPECT 14-28 days after PCI

Myocardial salvage at 30 days by SPECT

Manual aspiration had increased the percentage of post-PCI TMPG >=2 and STR

Use of X-Sizer had in- creased complete STR and lowered the inci- dence of distal em- bolization

No difference in prima- ry end-point

No difference in prima- ry end-point

The group of thrombus aspiration had better re- sults of STR and MBG 3

Large infarct size and even worse in TIMI flow grade and 30-day major adverse cardiac events (MACE) in the thrombectomy group Final infarct size, not myocardial salvage, was increased in the thrombectomy group

˸த¹⁰ĄּҖֹّϡҕგᅈბ᜕ٕܲҕংၡੵ྅

ཉĂߏϫ݈ᓜԖ˯ϡͽֽԓ୕ࢫҲᅈბҕংং๫

፟த׶Լච࿰ޢ۞͞ڱ̝˘Ąҭॲፂϫ݈۞ᓜԖ ࡁտඕڍ֭൑ព඾۞ৈ఍Ąтܑ˘Ăᔵ൒ѣֱࡁ տពϯ΍Ξͽܳซ͕࿪ဦ˯ ST ߱˯̿۞аೇ̈́

͕҉Г᛿߹ćҭд౵ܕ׌࣎ᓜԖྏរ̚ĂּҖّ

ֹϡ఺ֱ྅ཉĂ҃ͅᆧΐ͕҉ୟ๫ࢬ᎕̈́ 30 ͇

̰۞͕ҕგ׀൴া^11,12Ą

̙࿅Ăд౵ܕ˘ቔϤ Giuseppe De Luca ඈ൴

ܑ۞ፋЪ̶ژࡁտĂќะଂ 1990 ѐז 2006 ѐд ഇΏ൴ܑ׶ጯົ൴ܑ۞ಡӘВ 21 ࣎ᓜԖྏរĂ ϡͽᑭរާّ͕҉ୟ๫ଈ۰ֹϡҕგᅈბ᜕ٕܲ

ҕংၡੵ྅ཉ۞ᓜԖड़ৈĄඕڍ൴னֹϡҕგᅈ ბ᜕ٕܲҕংၡੵ྅ཉ̙֭ົࢫҲ 30 ͇۞Ѫ˸

தĂҭΞͽࢫҲགྷϩ݄ҕგڼᒚޢᅈბҕং൴Ϡ தĂ׶ྵָ۞݄ېજਔҕ߹߹ి ( TIMI grade 3 )

׶͕҉᛿߹඀ޘ ( myocardial blush grade 3 )¹³Ąд Kunadian B.ඈ۞௚Ъ̶ژࡁտĂ˵଀ז൑ڱࢫҲ 30͇Ѫ˸தٕГ͕҉ୟ๫۞፟த¹⁴Ą

̙࿅Яࠎ௚Ъ̶ژࡁտѣ׎А͇۞ࢨטĂּ

тĈᏴፄྏរঽଈ۞ᇾ໤̙˘ă൑ڱפ଀ྏរࣧ

ؕྤफ़ăྏរඕڍ̶ژᇾ໤मளඈĂٙͽдإϏ ѣځቁ۞ᓜԖྏរඕڍĂᙋ၁၆ٺֱࣹপؠଐԛ

˭۞ާّ͕҉ୟ๫ঽଈѣځቁ۞ৈ఍̝݈Ăϫ݈

ߏ̙ޙᛉּҖֹّϡҕგᅈბ᜕ٕܲҕংၡੵ྅

ཉĄ

ˬăᄥᜨܛᛳ͚ߛ׶๮ᘽ͚ߛ

੫၆ ST ˯̿ݭ͕҉ୟ๫ঽଈĂ౵ܕѣ׌࣎

ᓜԖᐌ፟ྏរͧྵ๮ᘽ͚ߛ׶ᄥᜨܛᛳ͚ߛ ( ӈ ņܧ๮ᘽ͚ߛ” ) ۞ڼᒚड़ڍĄ PASSION ྏរߏ

ͧྵ paclitaxel ๮ᘽ͚ߛ׶ᄥᜨܛᛳ͚ߛĂ൴ன

݈۰֭൑ځពࢫҲ 1 ѐ̰۞׀൴া²⁰Ąҭд TY- PHOONྏរ̚Ăତצ sirolimus ๮ᘽ͚ߛ۞ঽ ଈĂ 1 ѐ̰۞׀൴াݒѣځពࢫҲ²¹ć׎̚͹ࢋ

ߏЯࠎ݈۰ѣྵҲ۞ҕგГڼᒚ۞፟தĄѩγĂ

̙ኢߏ paclitaxel ٕ sirolimus ๮ᘽ͚ߛ֭൑൴ன

ົᆧΐ͚ߛҕং፟தĄٙͽॲፂѩ׌࣎ᓜԖྏរ ඕኢĂΞ଀ۢ๮ᘽ͚ߛдڼᒚ ST ˯̿ݭ͕҉ୟ

๫ঽଈĂ̙֭ົᆧΐ׀൴াٕПᐍّć̙࿅ࢋڦ ຍ۞ߏĂЯࠎ఺׌࣎ྏរତצ๮ᘽ͚ߛ۞ˠᇴ̙

ზкĂЯѩᔘࢋѣՀ̂ݭ۞ᓜԖྏរ̖ਕᙋ၁୎

ഇ͚ߛҕং ( late stent thrombosis ) ۞൴ϠதĄΩ

˘࣎ࢋ޽΍۞ߏĂ࠹၆ٺᄥᜨܛᛳ͚ߛĂ఺׌჌

๮ᘽ͚ߛ࠰൑ࢫҲ 1 ѐ۞Ѫ˸தٕ͕҉Гୟ๫፟

தĄ

̙࿅Ăϫ઼݈࡚ࢴۏᘽݡგநԊٙॲፂϡͽ

఼࿅๮ᘽ͚ߛ۞ዋᑕা۞ᓜԖྏរ̚Ăϫ݈̙֭

Βӣ 48 ̈ॡ̰൴Ϡ͕҉ୟ๫۞ঽଈĄҌٺ pacli- taxel ٕ sirolimus ๮ᘽ͚ߛң۰ࠎᐹĂ݋ᅮࢋՀ кᓜԖྏរᙋፂ̖ਕ଀ۢĄ

ܧ ST ˯̿ݭާّ݄͕া

ѝഇܬˢّڼᒚඉர ( early invasive strategy ) vs.Ᏼፄّܬˢّڼᒚඉர ( selective invasive strategy )

ܧ ST ˯̿ݭާّ݄͕াΒ߁̙ᘦؠݭ͕ඔ ൭ ( unstable angina ) ̈́ܧ ST ˯̿ݭ͕҉ୟ๫ ( non ST elevation myocardial infraction )Ą׶ ST ˯̿ݭ

ާّ͕҉ୟ๫̙Т۞ߏĂާّҕং͹ࢋϤҕ̈ڕ ԛј۞ϨҒҕংĂซ҃யϠ͕҉৿ҕ͕̈́҉ᗼ ѪĄٙͽܐഇ۞ڼᒚͽԩҕ̈ڕ̈́ԩ጖ҕ۞ᘽۏ ڼᒚࠎ͹Ąҭࡶঽଈдዋ༊۞ᘽۏڼᒚ˭̪ѣ޺

ᜈّ͕҉৿উĂ͕਽აĂٕ͕ވᐛਔඈাېĂϫ

݈̝ВᙊࠎޙᛉጐѝซҖགྷϩ݄͕ҕგڼᒚ - ѩ ڼᒚඉரӈࠎᏴፄّܬˢّڼᒚඉர²²Ąҭѣֱ

࿬ߐ۞ᙋፂݒ޽΍ѝഇܬˢّڼᒚඉரͧᏴፄّ

ܬˢّڼᒚඉரՀΞလ೎ٺܧ ST ˯̿ݭާّ݄

͕াଈ۰Ąҭܕֽ൴ܑ۞ ICTUS ྏរඕኢݒ̙

ߏтѩĄд੠ᖸ 1 ѐ۞ಡӘ̚Ă൴ன׌჌ڼᒚඉ ரд׀൴া൴Ϡத˯֭൑मள²³Ą

ҭΩ˘͞ࢬĂ ౵ܕ׌ቔ௚Ъ̶ژ൴ܑ 2 ѐ̈́

2ѐͽ˯۞ඕኢҬͼѣ̙Т̝ඕڍć൴னଳפѝ ഇܬˢّڼᒚඉரΞព඾ࢫҲ 2 Ҍ 5 ѐ̰۞Ѫ˸

த׶͕҉ୟ๫^{24, 25}ĄٙͽĂΞਕࢋඈז ICTUS ྏ រ൴ܑ׌ѐͽ˯۞੠ᖸඕڍĂ̖ົѣྵځቁ۞ඕ ኢĄ

ԩҕ̈ڕᘽۏ

ϫ݈дᓜԖڼᒚ˯ĂΞ൴னԩҕ̈ڕڼᒚܡ ԩّĂдܠ೻̽ី̂ࡗࠎ 5.5 ז 60%²⁶Ă҃ clopi- dogrelࡗѣ 24%²⁷ĄЯࠎ൴னԩҕ̈ڕڼᒚܡԩ

ّ׶ާّ݄͕া۞ᓜԖ׀൴াјϒ࠹ᙯ²⁸Ăٙͽ

ܕֽᓜԖྏរ၆ٺԩҕ̈ڕᘽۏߏӎЪ׀ֹϡă clopidogrel۞࢑ఈ጗ณ ( loading dose ) ̈́ග̟۞

ॡมᕇѣซ˘Վ۞ଣ੅Ą

ᙯٺܠ೻̽ី׶ clopidogrel ۞Ъ׀

ֹϡ

ϫ݈дٺֹϡ͚ߛ۞ঽଈ֗˯ĂЪ׀ֹϡܠ

೻̽ី̈́ clopidogrel Ăੵܧѣ༰ԟাĂ̏གྷᛳٺ

૱ၗֹّϡĄࡶߏдֹϡᘽۏҕং໘ྋڼᒚ S T

˯̿ݭ͕҉ୟ๫۞ଐԛĂ CLARITY-TIMI 28 ྏ រᙋ၁Ă࠹၆ٺщᇐ጗Ăග̟ clopidogrel ࢑ఈ጗

ณ 300 mg Ă൒ޢՏ͇ග̟ 75 mg ĂΞͽࢫҲ 30

͇۞׀൴াĂ҃ͷ̙ົᆧΐ΍ҕ፟த²⁹Ą

Clopidogrel ۞࢑ఈ጗ณ׶ග̟۞ॡ มᕇ

ALBIONྏរಶ੫၆ܧ ST ˯̿ݭ݄͕াଈ ۰Ăග̟ˬ჌̙Т c l o p i d o g r e l ۞࢑ఈ጗ณ- - 300Ă 600 Ă 900 mg Ą൴ன࢑ఈ጗ณ̂ٺ 300 mg ѣͧྵр۞ԩҕ̈ڕड़ϡĂͷ̙ົᆧΐ΍ҕ፟

த^{3 0}ĄΩ˘ྏរ݋൴னдܧ ST ˯̿ݭ݄͕াଈ ۰Ăдତצགྷϩ݄ҕგڼᒚҌ͌ 12 ̈ॡ̝݈Ă ග̟ clopidogrel 600mg ࢑ఈ጗ณĂ̙Ϊѣྵָ۞

ԩҕ̈ڕड़ڍĂ˵Ξព඾ࢫҲ 1 ̰࣎͡۞ᓜԖ׀

൴া³¹Ą

ΩγĂ CLARITY-TIMI 28 ྏរ˵ซ˘Վд ᘽۏҕং໘ྋڼᒚ۞ާّ͕҉ୟ๫ঽଈ༊̚Ă̶

ژ׌჌̙Тଐԛ˭۞ঽଈ࿰ޢĄ˘࣎ߏ P C I - CLARITYࡁտĂӈߏ੫၆ѣซҖགྷϩ݄ҕგڼ ᒚ۞ঽଈĂ൴ன఺ֱঽଈ̚ĂࡶְА̏གྷڇϡ 2 ז 8 ͇۞ clopidogrel ĂΞͽځពࢫҲ׀൴াĂ˵

̙ົᆧΐ΍ҕ፟த³²ĄΩ˘ొЊĂ੫၆дזੰ݈

ಶڇϡ clopidogrel ࢑ఈ጗ณ 300 mg ۞ঽଈΐͽ

̶ژĄ൴ன࠹ྵٺщᇐ጗Ăੰ݈ڇϡ clopidogrel

۞ঽଈੵ˞˘ᇹΞͽࢫҲ 30 ͇۞׀൴াĂ˵Ξ ͽᆧΐୟ๫જਔ۞ၰ఼த³³Ą

ॲፂϫ݈ޙᛉ఍நࣧ݋Ă clopidogrel 300 mg

࢑ఈ጗ณᑕྍдତצགྷϩ݄ҕგڼᒚ݈Ҍ͌ 6 ࣎

̈ॡගᘽĂ̖ົѣځព۞ᓜԖᒚड़ĄٙͽĂϫ݈

၆ٺତצۡତགྷϩ݄ҕგڼᒚ۞ ST ˯̿ݭ͕҉

ୟ๫ঽଈĂᔵ൒ѣֱົତצ clopidogrel 300 mg ٕ

ͽ˯۞࢑ఈ጗ณĂҭ఺ڼᒚ጗ณإᅮࢋซ˘Վ۞

̂ݭᓜԖྏរΐͽᙋځ³⁴Ą

ᙯٺ glycoprotein IIb/IIIa inhibitor

Яࠎܠ೻̽ី̈́ clopidogrel ۞ԩҕ̈ڕڼᒚ ܡԩّ۞҂ณĂΐ˯ glycoprotein IIb/IIIa in- hibitorsᘽۏүϡ੓ؕॡมྵൺ ( ᐖਔڦड͞ёĈ tirofibanĂ 5 ̶ᛗć eptifibatide Ă 5 ̶ᛗć abcix- inabĂ 2 ̈ॡ )Ăдٺڼᒚॡม̶ࡋυۋ۞ާّ

݄͕া۞ڼᒚ˯ߏѣ׎гҜĄ

Glycoprotein IIb/IIIa inhibitors ۞ڼᒚĂдܧ ST˯̿ݭާّ݄͕া͞ࢬд 2000 ѐ൴ܑ۞ڼᒚ

޽͔̚Ăдঽଈࡶ޺ᜈѣ͕҉৿ҕன෪ă੼П ᐍ୉ཏăٕߏࢍထซҖགྷϩ݄͕ҕგڼᒚĂ̏

གྷځቁࠎ class I ޙᛉ^{3 5}ĄҌٺฟֹؕϡ۞ॡม ᕇ Ă ᙋ ፂ Ҭ ͼ إ Ϗ ˘ ࡭ Ą д ˘ ࣎ ̈ ఢ ሀ ۞ EVERESTྏរ̚Ăѝഇܬˢّڼᒚܧ ST ˯̿

ݭާّ݄͕াĂ࠹၆ٺซҖགྷϩ݄͕ҕგڼᒚ ॡ̖ග̟੼጗ณ۞ tirofiban ٕᇾ໤጗ณ abcix- imabĂְАග̟ tirofiban ۞ڼᒚົѣྵָ۞ఙ ޢ͕҉᛿߹³⁶Ą൒҃౵ܕ۞ ACUITY TIMING ྏ រ̚ĂВѣ 9,207 Ҝତצѝഇܬˢّڼᒚ۞ܧ ST

˯̿ݭާّ݄͕াঽଈĂͽ glycoprotein IIb/IIIa inhibitorsฟؕڼᒚ۞ॡมᕇĂ̶ј׌௡ĈּҖ

ְֹّ݈ϡ׶ఙ̚ᏴፄֹّϡĄݒ൴னּҖّ

ְֹ݈ϡ glycoprotein IIb/IIIa inhibitors ֭൑ځព ᐹٺᏴፄֹّϡĂ҃ͷᏴፄֹّϡ͞ё˵ࢫҲ

΍ҕ۞፟த³⁷Ą

ΩγĂ glycoprotein IIb/IIIa inhibitor ׶ clopido- grel׀ϡĂՀΞᆧΐԩҕ̈ڕүϡĄд ISAR-RE- ACT 2ྏរ̚Ăдܧ ST ˯̿ݭ݄͕া۞ଈ۰ĂБ

ొ ࠰ д ତ צ གྷ ϩ ݄ ҕ გ ڼ ᒚ 2 ࣎ ̈ ॡ ݈ ତ צ 600mg clopidogrel࢑ఈ጗ณĂ൴னࡶЪ׀ֹϡ ab- c i x i m a bਕૉࢫҲ 3 0 ͇̰۞׀൴াĂ҃ͷ׀ϡ clopidogrel׶ abciximab ̙֭ົᆧΐ΍ҕ׀൴া³⁸Ą

҃дٺ ST ˯̿ݭ͕҉ୟ๫ଈ۰ତצۡତགྷ ϩ݄͕ҕგڼᒚ˯Ă˵ౙᜈѣࡁտಡӘĄд AD- MIRALࡁտ̚Ăֹϡ abciximab д ST ˯̿ݭ͕

҉ୟ๫ଈ۰ତצۡତགྷϩ݄͕ҕგ͚̈́ߛٸཉ۞

ڼᒚĂགྷ࿅ 3 0 ͇ז 3 ѐ۞ᓜԖ੠ᖸĂ࠰ѣྵָ

۞ᓜԖ࿰ޢ^39,40Ą

ᙯٺฟؕڼᒚ۞ॡมᕇĂд TITAN-TIMI 34

ྏរ̚Ăಶ൴னтڍ ST ˯̿ݭ͕҉ୟ๫ଈ۰Ă

࠹၆ٺд͕ጱგވ̖ฟֹؕϡ eptifibatide Ăࡶд

ާ෧ވಶְАฟֹؕϡĂ݋ୟ๫࠹ᙯજਔдۡତ གྷϩ݄͕ҕგڼᒚ݈ಶΞͽ྿ྵָ۞ҕ߹׶͕҉

᛿߹⁴¹Ą

Ҍٺߏӎٺགྷϩ݄͕ҕგڼᒚ̚Ăтң׀ϡ glycoprotein IIb/IIIa inhibitor׶ clopidogrel Ăᔵ൒

PCI-CLARITYࡁտ۞Ѩ৺̶ژ̚ ( subgroup anal- y s i s )ĂҬͼѣৈ఍Ăҭ̪ᅮซ˘Վ፾ϲ۞ࡁ տĄ

ϫ݈ԧ઼ઉֹܲϡ tirofiban ۞ఢቑâߏ̙

ᘦؠ͕ඔ൭ٕܧ Q گ̝͕҉ୟ๫ĂΩ˘ߏާّț گ͕҉ୟ๫ٺাې൴Ϡ˩˟̈ॡ̰ĂٺેҖ PT- CAॡ଀׀ϡĄ҃ͷֹϡͽ̙෹࿅ాᜈα˩ˣ̈

ॡĂ጗ณ 37.5 mg ࠎࣧ݋Ą

ԩҕং጖ඕ጗

࠹၆ٺ็௚ք৵۞ాᜈّ۞ᐖਔڦड ( ࢑ఈ

጗ณࠎ 60IU/kg Ă౵̂጗ณࠎ 4000IU ćତ඾ࠎా

ᜈᐖਔڦडĂ጗ณࠎ 1 2 I U / k g / h r Ă౵੼ࠎ 1000IU/hr )Ă׶ᓄኑ۞ҕ୵጖ඕᑭീ ( aPTT Ăჯ

޺д 50-70 ࡋ )⁴²Ăϫ݈Ҳ̶̄ณք৵ĂЯѣྵᘦ ؠ۞ᘽۏүϡĂ̙ΪΞͽҺΝ˯ࢗՎូĂ֭ͷᓜ Ԗ˯˵ᙋ၁ѣྵָ۞࿰ޢĄ౵ܕ൴ܑ۞ CLARI- TY-TIMI 28ྏរ˵൴னд ST ˯̿ݭ͕҉ୟ๫ঽ ଈତצᘽۏҕং໘ྋڼᒚॡĂЪ׀ֹϡҲ̶̄ณ ք৵Ξព඾ࢫҲ 30 ͇̰۞׀൴া⁴³Ą

ΩγтңࢫҲЯֹϡԩҕং጖ඕڼᒚ͔੓۞

΍ҕ׀൴াĂ˵ߏᓜԖ˯ڼᒚާّ݄͕াঽଈ۞

ࢦᕇĄညߏ fondaparinux ( ˘჌Ъј۞ pentasaccha- ride )Ăٕߏ bivalirudin ( ˘჌ۡତّ጖ҕᅔ৵Ժט

጗ )Ăдܕֽ൴ܑ۞ᓜԖྏរ˯ĂܐՎ̏ᙋ၁׎щ БّĂ҃ͷΞࢫҲ΍ҕ׀൴া۞፟த^44-47Ą

Statin ڼᒚ

PROVET IT TIMI 22ྏរߏֹϡ statin ڼᒚ

ާّ݄͕াঽଈ౵ࢦࢋ۞޽ᇾ⁴⁸Ăࡁտ൴னдତ צགྷϩ݄͕ҕგڼᒚ̝ޢĂާّഇ 14 ͇̰ฟؕ

ତצ੼጗ณ۞ statin ڼᒚĂΞͽ૟Ҳ૜ޘᓙ׽ዔ ࢫҌ 62 mg/dl Ă֭ͷព඾гࢫҲ 2 ѐ̰۞ᓜԖ׀

൴াĄд౵ܕ൴ܑ۞௚Ъ̶ژ̚Ă׎̶ژ˞Β߁ PROVET IT TIMI 22ĂВ 13 ࣎ྏរĂ൴னдާّ

݄͕া 14 ͇̰ฟֹؕϡ statin ڼᒚĂ۞ቁົព඾

۞ࢫҲᓜԖ׀൴াĂҭ఺ड़ڍࢋڼᒚ 4 ࣎͡ޢ̖

ົពனĂ҃ͷΞ޺ᜈ 2 ѐ⁴⁹Ą

຅௟ࡪڼᒚ

ҋଂдજۏ၁រ˯൴னд͕҉ୟ๫ޢ੻ល຅

௟ ࡪ Ξ ͽ ̶ ̼ ј ͕ ҉ ௟ ࡪ ซ ҃ Լ ච ν ͕ ވ Α ਕ⁵⁰Ăᔵ൒׎̚ቁ၁۞፟ᖼإϏజᗃ୻Ăҭ̏གྷ ѣధкᓜԖྏរຐֽቁؠߏӎТᇹ۞ड़ᑕ˵Ξֹ

͕҉ୟ๫۞ˠᙷঽଈயϠ͕҉௟ࡪГϠĂᔖҺய Ϡν͕ވГ๬Ă౵ޢ྿זࢫҲ͕਽ა̈́Ѫ˸த۞

ϫ۞Ąϫ݈Ӏϡ຅௟ࡪڼᒚާّ͕҉ୟ๫۞͞ё Ξ̶ј׌჌Ĉ˘ߏӀϡۡତ٩פ੻ល຅௟ࡪٕӀ ϡᔺ௕஧కϨϠܜו፬Я̄ ( granulocyte-colony stimulating factor, G-CSF ) ڦडޢଂ׹ᙝҕ୵̶ᗓ

΍੻ល۞຅௟ࡪĂГ૟຅௟ࡪགྷϤ͕ጱგ᛿ڦˢ யϠ͕҉ୟ๫࠹ᙯ̝݄ېજਔ̰ٕགྷϤপঅጱგ

ۡତڦडˢ͕҉̚ćΩ˘ߏۡତڦडᔺ௕஧కϨ Ϡܜו፬Я̄ڼᒚĂ̙҃૟຅௟ࡪଂҕ୵̶̚ᗓ

΍ֽĂ࠹၆ٺ݈۰۞р఍ಶߏྵܧܬˢّڼᒚ҃

ͷڼᒚ࿅඀ྵࠎᖎܮĂҭ৿ᕇಶߏ൑ڱ໤ቁଠט

`౗ᛩ຅௟ࡪ۞ᇴณ׶׎΁჌ᙷ຅௟ࡪΞਕ૲ֽ

۞ઘүϡĄ

ᔵ൒຅௟ࡪڼᒚ˘ۡజෛࠎሕ˧൑቎۞ڼᒚ ሀёĂҭזϫ݈ࠎͤĂд ST ˯̿ݭ͕҉ୟ๫ঽ ଈ֗˯ĂᓜԖྏរ۞ඕڍݒ̙΄ˠॎጬĄ ( ܑ˟ ) дͽ̶ᗓ຅௟ࡪ͞ёڼᒚ۞ᓜԖྏរ˯Ă 4 ז 6

࣎͡۞੠ᖸඕڍҬͼ̙˘࡭Ą׎̚Ϊѣ REPAIR- AMIྏរពϯ΍Ă຅௟ࡪڼᒚΞͽࢫҲ 12 ࣎͡

̰۞׀൴া፟த^{5 1}Ąҭдϫ݈੠ᖸॡม౵ܜ۞

BOOSTྏរĂ 18 ࣎͡੠ᖸಡӘݒ޽΍຅௟ࡪڼ ᒚ֭൑ព඾гᆧΐν͕ވड΍̶த^{5 2}ĄΩ˘͞

ࢬĂᙯٺۡତڦडᔺ௕஧కϨϠܜו፬Я̄ڼᒚ ሀёĂ˵ѣᙷҬ۞ඕኢĄд FIRSTLINE-AMI ྏ រ̚Ăۡତڦडᔺ௕஧కϨϠܜו፬Я̄ົᆧΐ 4࣎͡ޢ̈́ 12 ࣎͡ޢ۞ν͕ވड΍̶த⁵³Ąҭܕ

ֽ൴ܑ۞ˬ࣎ᓜԖࡁտ ( ܑˬ )ݒ൑൴னۡତڦ डᔺ௕஧కϨϠܜו፬Я̄ڼᒚ۞ڼᒚ௡ᐹٺ၆

໰௡Ą̙࿅ۡତڦडᔺ௕஧కϨϠܜו፬Я̄۞

щБّҌ͌д STEMMI⁵⁴׶ MAGIC Cell-3-DES⁵⁵

ྏរ̚ᙋ၁̙֭ົᆧΐ͚ߛٸཉޢГব৫۞፟

தĄ

ٙͽĂტЪϫ݈۞ᓜԖྏរඕڍĂΞਕࢋඈ

຅௟ࡪڼᒚ۞үϡ፟ᖼĂ੓ؕڼᒚ۞ॡมᕇĂᅃ ӄᘽۏ۞Ъ׀ֹϡĂ̈́ѣड़ڼᒚ۞௟ࡪ჌ᙷඈజ

ܑ˟Ĉᙯٺާّ͕҉ୟ๫ঽଈତצ੻ល຅௟ࡪڼᒚ̝ᓜԖྏរ

Trial Setting Processing and delivery of stem cells Primary end-point Results BOOST^52,56

REPAIR- AMI^51,57

ASTAMI⁵⁸

Jassens et al.⁵⁹

MAGIC Cell-3-DES⁵⁵

60 pts with STEMI re- ceiving primary PCI (30 pts treated with BMCs at mean 4.8 days after PCI) 199 pts with STEMI receiving primary PCI with BMS (101 pts treated with BMCs at mean 4.3 days after P- CI)

100 pts with STEMI receiving primary PCI with stenting (47 pts treated with BMC at mean 6 days after PCI) 67 pts with STEMI re- ceiving primary PCI (33 pts treated with BMCs at 1 day after P- CI)

50 pts in AMI arm re- ceiving DES stenting, mean administration day: 4 days

Intracoronary (IC) infusion into IRA with unfractionated 2.5 x 10⁹BMCs ( including 9.5 x 10⁶ CD34+ cells)

IC infusion into IRA with Ficoll- separated 2.4 x 10⁸BMCs ( includ- ing 3.6x10⁶ CD34+/CD45+ &

2.5x10⁶ CD34+/CD133+/CD45+

cells)

IC infusion into IRA with Ficoll- separated 7x10⁷BMC ( including 7x10⁵CD34+ cells)

IC infusion into IRA with Ficoll- separated 3x10⁸BMCs ( including 2.8x10⁶ CD34+ cells & 2x10⁶ CD133+)

PBSCs collected at the day after G-CSF 10ɢg/kg for 3 days; IC infu- sion at IRA with 1-2x10⁹mononu- clear cells

LVEF by MRI

LVEF by LV angiography

LVEF by SPECT, echocardiogra- phy, & MRI

LVEF by MRI

LVEF by MRI

6mo: increased LVEF in BMC group

18mo: No difference be- tween two groups

4 mo: LVEF improved in BMC group

12mo: reduced combined end-point of death, recur- rent MI, or revasculariza- tion in BMC group 6mo:no benefits

4mo: no difference in LVEF; reduced infarct size and improved regional function in BMC group

6mo:IC infusion of PBSCs improved LVEF

ܑˬĈֹϡᔺ௕஧కϨϠܜו፬Я̄ٺާّ͕҉ୟ๫ঽଈ̝ᓜԖྏរ

Trial Setting Subcutaneous G-CSF Markers for peripheral

Primary end-point Results use after PCI stem cells

G-CSF-STEMI⁶⁰

STEMMI⁶¹

REVIVAL-2⁶²

44 pt. with STE- MI, receiving PP- CI with BMS stenting 78 pt. with STEMI of <12 h receiving primary PCI

114 pt. with STEMI of <12 h receiving primary PCI

10ɢ g/kg for 5 days

10ɢ g/kg for 6 days

10ɢ g/kg for 5 days

CD34+/CD133+

Cd34+/CD31+

CD34+/c-kit+

CD45-/CD34- CD45-/CD34- /CXCR4+

CD45-/CD34- /VEGFR2+

CD34+

Global and re- gional LV func- tion at 7days and 3 months by MRI LV wall

thickening from baseline to 6 months by MRI

Infarct size by Tc^99msestamibi from baseline to 4-6 months

No benefits

No benefits

No benefits; no improvement in LVEF by MRI

ᗃ୻ޢĂ̖Ξਕѣࡎ৔ّ۞ඕኢĂ˵̙࡭ٺ঎෱

ధкˠ˧̈́ۏ˧ĂՀཨਖ਼˞఺ᇹѣ൴णሕ˧۞ڼ ᒚሀёĄ

ૄЯវᗁጯ၆ٺާّ݄͕া࿰֨׶

࣎ˠ̼ᗁᒚ۞ᇆᜩ

࿰֨ާّ݄͕া۞൴Ϡᑕྍߏٙѣڼᒚ۞௣

ໂϫᇾĄ˵ಶߏԱ΍੼Пᐍཏঽଈ֭ΐૻଠטП ᐍЯ̄۞ڼᒚĂͽഇࢫҲާّ݄͕া۞൴ϠதĄ

ੵ˞˘ֱ็௚̏ۢ۞ПᐍЯ̄ĂּтĈ٩໬ă੼

ҕᑅăᎤԌঽă੼ҕ਌ඈĂ࣎ˠ᏷็ຏצّ ( ge- netic susceptibility ) ˵෸ֽ෸צࢦෛĄॲፂϫ݈

۞ࡁտĂާّ݄͕া֭ܧϤಏ˘ૄЯٙౄјĂӈ ᛳ ٺ к ૄ Я ۞ ܧ ؜ ͩ ᏷ ็ ͞ ё Ą ϫ ݈ Ӏ ϡ genome-wide scanning͞ёĂ̏གྷ̶ژДफ 296

࣎ छ ୉ Ă Ա ז ׌ ࣎ Ξ ਕ ۞ ૄ Я Ą ˘ ࣎ ߏ Ҝ ٺ 12q22ĂకϨኳயۏࠎ leukotriene A4 hydrolase ( LTA4 )⁶³ĂΩ˘࣎д 13q12-13 ĂకϨኳயۏࠎ 5-lipooxygenase activation protein ( FLAP )⁶⁴Ą఺׌

࣎ᅔ৵࠰׶൴ۆ௟ࡪ፬৵--Ϩˬ஛ ( leukotriene )

۞Ъјѣᙯ ( ဦ˘ ) ĄӀϡ఺׌࣎ૄЯ༊үᇾ

੃ĂԱ΍ 191 Ҝᛳٺ͕҉ୟ๫੼Пᐍ۞ঽଈĂග

̟ FLAP ޻ԩ጗ڼᒚĂᙋ၁ΞͽࢫҲϨˬ஛ B4

྿ 26%⁶⁵Ąϫ݈఺ีᘽۏ૟ซҖ˭˘ՎᓜԖྏរ ᙋ၁ߏӎਕૉࢫҲ͕҉ୟ๫۞፟தĄ дΞ࿰֍

۞૟ֽĂົѣດֽ෸кૄЯ࠹ᙯ۞̶̄ᇾ੃జ൴ ଧĂ˵ֹ଀࣎ˠ̼ᗁᒚՀᔌٺΞҖĄ

ڼᒚ޽͔̝ར၁

ᔵ൒઼࡚͕᝙םੰ઼࡚͕̈́᝙ጯົ੫၆ާّ

݄͕া۞ڼᒚ޽͔ᐌ඾̙ᕝ൴ܑ۞ࡁտᙋፂ޺ᜈ

۞ՀາĂҭன၁ᓜԖ˯၆ٺঽଈ۞໰᜕ߏӎѣར मĂߏ࣎ܕֽ౯צࢦෛ۞ᛉᗟĄ҃ CRUSDAE ࡁ տĂಶߏ੫၆઼࡚ဩ̰෹࿅ 400 छᗁੰĂଂ 2001 ѐ੓Ă̶ژ෹࿅ 165,000 Ҝܧ ST ˯̿ݭާّ݄

͕াঽଈĂ၁ᅫତצᗁᒚ໰᜕۞ېڶĄፋវ҃

֏Ă၆ٺڼᒚ޽͔۞ᏲଂּͧπӮࠎ 74% Ąͽ

ٙᅮฟϲ۞ᘽۏ҃֏ĂҲٺπӮ۞ࠎĈާّഇڼ ᒚٙᅮ۞ glycoprotein IIb/IIIa inhibitors ć׶΍ੰ

ϡᘽ̚۞ angiotensin converting enzyme inhibitors

׶ clopidogrel⁶⁶Ą

ᔵ൒ϫ݈൑ԧ઼۞၁ᅫᆸࢬેҖڼᒚ۞ѣᙯ

ྤफ़ĂٙᏜĺ΁̝̋ϮĂΞͽԽ᏾ĻĂੵ˞੠Ր າ̝ۢዶĂ˵ᑕᇜ˧ٺ၁াᗁጯ۞၁ኹĂֽ೩੼

ԧ઼ᗁᒚ໰᜕ݡኳĄ

זϫ݈Ϥٺާّ݄͕া۞ڼᒚ۞ซՎĂ̏གྷ

̂̂ࢫҲާّഇ۞Ѫ˸தĄд੠ՐՀԆච۞ڼᒚ ඉரТॡĂ˵ᑕྍ҂ᇋтңቁ၁гдᓜԖ˯ેҖ

ٙޙᛉ۞ڼᒚ఍ཉĄѩγĂд 1 9 7 0 ѐௐ˟ۍ ňThe Heartʼn̚Ă Paul Dudley White ೩ז࿰֨۞

ࢦࢋّĈňthe most advance of all . . . is the em- phasis on the prevention of the very diseases which we have prided ourselves to be so clever to diagnose and to treat.ʼnٙͽĂѣड़࿰֨ާّ݄͕া۞൴ ϠĂᑕྍ̖ߏڼᒚ۞௣ໂϫᇾĄ

ણ҂͛ᚥ

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30Q-35Q.

Advances in the Therapy of Acute Coronary Syndrome

Hung-Ju Lin, and Ming-Fong Chen

Acute coronary syndrome consists of two categories: ST-elevation myocardial infarction (STEMI) and non- ST-elevation acute coronary syndrome (NSTE ACS). Recent results of clinical trials relating to STEMI were fo- cused at how to shorten myocardial ischemic time, and how to reduce the distal embolization resulting from pri- mary percutaneous intervention (PCI). As to the former, ASSENT-4 PCI trial did not find facilitated PCI improved the clinical outcomes. As to the later, clinical trials about routine use of thrombectomy or distal protection devices did not have consistent results, and even some of them revealed the association with the routine use of the de- vices and the outcome of increased infarct area. Besides, whether early invasive strategy is better than selective invasive strategy in patients with NSTE ACS was not confirmed in the 1-year follow-up of ICTUS trial. The long- term result might be essential to the final conclusion. Up to date, clinical evidence on the stem cell-based ther- apy in STEMI treatment did not show the consistent and robust improvement of left ventricular ejection fraction or other clinical outcomes, no matter with infusion route of bone marrow cells or with subcutaneous injection of granulocyte-colony stimulating factor. More knowledge of mechanism of stem cell-based therapy may be need- ed to make a significant progress. In addition to exhaustive efforts to put the advances in therapy for acute coro- nary syndrome into clinical practice, utilizing the advances in genomic medicine might be a critical step to achieve the ultimate treatment goal-modifying environmental and genetic risks to avoid irreversible myocardial damage.

( J Intern Med Taiwan 2008; 19: 91- 102 )

Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan