:ACS_190327-2.pdf


20172018
2018 JCS 2018 Guideline on Diagnosis and Treatment of Acute Coronary Syndrome
2



1 11
1. 11 1 12 2. 13
2.1 13 2.2 13 2.3 14
2 15
1. 15 2. 15 3. 15 4. 16
3 17
1. 17 1.1 17 1.2 17 2 18 1.3 19 3 Killip 19 1.4 20 4 20 1.5 21 5 ACS 21 1.6 23 6 ACS 23
3
25
1.7 24 7 ACS X 24 8 ACS 25
1.8 26 9 26 10 27 11 NSTE-ACS TIMI
28
2. 30 2.1 30 14 30
4

2.2 30 15 30
2.3 31 16 31 2.4 31 17 31
4 ST 33
1. primary PCI 33 1.1 33 18 STEMI primary PCI 33 1.2 34
19 primary PCI
34
1.3 34 20 primary PCI 34 1.4 35 21 primary
PCI 35
1.5 35 22 Primary PCI 35 1.6 35 23 Primary PCI 35 1.7 36 24 Primary PCI 36
25 Primary PCI
36
26 Primary PCI 37 27 Primary PCI
38
1.8 38 28 PCI 38 2. 39
2.1 39 29 STEMI 39 2.2 39 2.3 PCI 40 30 PCI 40
3. 40 31 STEMI CABG 40 4. 41 5. 41
5.1 41 32 41 5.2 42 33 42 5.3 Remote ischemic conditioning 42 5.4 42
5 ST 43
1. 43 34 NSTE-ACS 43 2. 44
2.1 NSTE-ACS 44 35 NSTE-ACS 44 2.2 45 36 NSTE-ACS 46 2.3 47
3. 47 3.1 47 37 NSTE-ACS 47 3.2 48 38 NSTE-ACS 48 3.3 PCI 48 39 NSTE-ACS PCI 48 3.4 CABG 49 40 NSTE-ACS CABG 49
5

6 50
1. CCU 50 41 CCU 50 1.1 CCU 50 1.2 CCU 50 1.3 CCU 51
2. 51 42 CCU 51 2.1 52 2.2 52 2.3 52 2.4 52 2.5 52 2.6 52 2.7 CCU 53
3. 53 3.1 53 43 53 3.2 β 54 44 β 54
3.3 55
45 RAAS 55
3.4 55 46 55 3.5 Ca 56 47 Ca 56 3.6 56 48 56
4. 57 4.1 IABP 57 49 IABP 57 4.2 IMPELLA 58 4.3 VA-ECMOPCPS 58 50 VA-ECMO 58 4.4 LVAD 59 51 LVAD 59
5. 60 5.1 60 52 60
53 61 54 ICD 61 55 WCD 61
5.2 61 56 61 5.3 62 57 62
58 63 6. 63
6.1 63 6.2 64 59 64 6.3 65 6.4 65 60 65
7. 66 61 67 8. 67 62 67
8.1 LVFWR 68 8.2 VSR 68 8.3 PMR 69
9. 70 63 CAGPCI AKICIN 70
6

64 AKI 71 10. 72 65 72 11. 72
11.1 72 66 72 11.2 73 11.3 73 11.4 73
12. 73 12.1 73 67 73 12.2 74 12.3 74 68 CMR 74 12.4 75
13. 75 13.1 75 4 75 13.2 76 69 76
70 CCU
77
78
79
78
13.4 78 75 78 13.5 80 76 80 13.6 80 77 80
6
7 81
1. 81 78 ACS 81 2. 82 3. 82 7 83 4. 83
4.1 83 4.2 84 4.3 84 79 84
8 85
1. 85 1.1 85 80 85
81 5A 86
7

1.2 86 82 86 2. 87
2.1 87 83 87 84 PRECISE-DAPT DAPT 88
2.2 β 89 85 β 89
2.3 90
86 RAAS 90
2.4 90 87 90 2.5 Ca 91 88 Ca 91 2.6 91 89 91 2.7 94 90 94 2.8 95 91 95
3. 96 3.1 96
8 96
3.2 96
92 96
93 ACS QI
100
112
CK-MB creatine kinase MB MB
CMR cardiovascular magnetic resonance
CPAP continuous positive airway pressure
CTR cardiothoracic ratio
DHA docosahexaenoic acid
DP double product
DPP-4 dipeptidyl peptidase-4 4
eGFR estimated glomerular filtration rate
EAS European Atherosclerosis Society
ECC emergency cardiovascular care
EPA eicosapentanoic acid
ER emergency room
FDG fluorodeoxyglucose
FiO2 fraction of inspiratory oxygen
GLP-1 glucagon-like peptide 1 1
GOT glutamic oxaloacetic transaminase



ACE angiotensin converting enzyme
ACS acute coronary syndrome
ACT activated coagulation time
ADL activities of daily livings
ADP adenosin diphosphate
ANP atrial natriuretic peptide
APTT activated partial thromboplastin time


AT anaerobic threshold
ATP adenosine triphosphate
BE base excess
BMI body mass index
BMS bare metal stent
BLS basic life support
CABG coronary artery bypass grafting
CAG coronary angiography

ICU-AW intensive care unit acquired weakness

KDIGO Kidney Disease, Improving Global Outcomes
LAD left anterior descending artery
LCX left circumflex artery
LDH lactic acid dehydrogenase
LDL-C low density lipoprotein cholesterol

LVAD left ventricular assist device
LVEF left ventricular ejection fraction
LVFWR left ventricular free wall rupture
MO/MVO microvascular obstruction
NSTE-ACS non-ST-elevation acute coronary syndrome
ST
N
PCI percutaneous coronary intervention
PCWP pulmonary capillary wedge pressure
PDE phosphodiesterase

QI quality indicator
RAAS renin-angiotensin-aldosterone system
SAT spontaneous awakening trial
SCAI Society for Cardiovascular Angiography and Interventions
SCAD spontaneous coronary artery dissection
SGLT sodium glucose transporter
SPECT single photon emission computed tomography

STEMI ST-elevation myocardial infarction ST
STS Society of Thoracic Surgeons
TG triglyceride
UA unstable angina
VF ventricular fibrillation
VT ventricular tachycardia
WMSI wall motion score index
10


AHAESC ACC/AHAESC 1 2 III ACC/AHA no benefitharm
1
II
IIa
IIb
III
III No benefit
III Harm

11
3
2018 12
1
necrotic core vulnerable plaque ACS 4 calcified nodule ACS 5
2
12

AMI ST STEMI STNSTEMI UAAMI UANSTEMI ST NSTE-ACS 1
STEMIACS ST ST 6 AMI Fletcher Chazov 7, 8 1979 Rentrop5 STEMI
91980 GISSI ISIS-2 AMI 10, 11AMI PCIAMI STEMI
NSTE-ACS ST T NSTE-ACS STEMI NSTEMIUA NSTE-ACS 12 CK/
1
MBCK-MB 2000 99% universal definition 13 CK/CK-MB UA universal definition universal definition J-MINUET NSTEMICK/CK-MB 14CK/CK-MB NSTEMI CK/CK-MB NSTEMI NSTEMI AMI 1 28 universal definition 5 15 spontaneous myocardial infarctionType 1 myocardial infarction secondary to an ischemic imbalance
Type 2 7
2

AMI
2.2
ACS AMI 1 10AMI 1979 7.42008 27.0 30 4 24 10824 823605508314 270 25AMI 1990 200126 10 100.7 35.7 1994 199627 41.9 5.3 10 AMI1979 18.7 4.22008 46.49.6 AMI30 3 24AMI
14

AMI 29–31 AMI STEMI 30AMIACE IIARB STEMI 30AMI 32 AMI 1985 2014 30 10 3AMI 1985 1994 10 1995 2014 20 33 2005 2014 10 AMI KACE2004 2011 AMI 34 702005 2014 1059 30 33 50% 30% 23, 35, 36 AMI 1990 2000AMI 37, 38 2006 39 2000

AMI30 OASIS 7.1% 40HIJAMI 9.4% 22 AMI J-MINUET STEMI 7.1% CKNSTEMI 7.8% CK NSTEMI 1.7% 2 41 CCU STEMI 7.7%NSTEMI 5.1% Killip 42
primary PCI 1980 2000 31, 43 1990 2000 37, 381985 2014 30 10 1985 2004 20 2005 2014 10 80 33AMI PCI AMI 24, 33 PCI 44, 45
ACSGRACE 6 STEMI 4.8%NSTEI 6.2%UA 3.6% 46 STEMI
15
41, 49 STEMINSTEMI1995 2015 20 STEMI NSTEMI 2010 51 ACS
2
ACS 119 52, 53ACS STSTEMI ACS ACS 3 1.2.1 3 5 3 1 1 54
2.

12 3 2. 119 STEMI 12 STEMI 55 STEMI primaryPCI 56–59 STEMI primary PCI 4 2.
3.

16

4.

JRCJRC 201571

1.2
ACS 79 1.2.1 ACS ACS ACS 80–82 83 , 20 80, 81 80, 81, 84, 85 UA 15 20 2020 ACS AMI

18

1 5

ACS
ACS 6 HEART 86https://www.mdcalc.com/heart-score-major-
cardiac-eventsHistoryECG AgeRisk FactorsInitial Troponin HEART TIMIGRACE 87–89
1.2.2 CAG CABG
2
1 V4R V7-9 2 3
112110 223 X

ST
ST

55 65 1.2.4 ACS3
1.3
1.3.1 Bezold-Jarisch 30 90 mmHg 30 mmHg AHA scientific statement 90 wet or dry cold or warm 4AMI 2/3 “cold and wet” SHOCK trial28% “cold and dry” 91, 92 1.3.2 a. III Killip 93 3 ACS VSP thrill VSP 4
3 Killip
I III
II 50% III
III 50%
IV 90 mmHg
20

1.4
STEMI 5 10% STNSTEMI 15 20%UA 10% 15%50% 94–99 ACS 4100 X
1.4.1
Ca 1.4.2 AMI 15 mmHg Stanford A STEMI Stanford A 5%RCA CTCAG
4



/

Ibanez B, et al. 2018 100
21
1.5
STSTEMINSTE-ACS ACS 111 102, 112 1 110 1.5.2 ST ST 15 ST ST ST V2-3 113 universal definition15 ST 2 V2-340 2.0 mm ST40 2.5 mm ST 1.5 mm STV2-3 1.0 mm ST ST J10 mm 1.0 mVST STEMI 114–116
2 V1-6IIIIIIaVR
aVLaVF Cabrera aVL I -aVRaVR IIaVF III Cabrera IaVL IIIII aVF 15, 117
5 ACS
AMI 510 12
I C
I C
12 V4R105–
107 I B
IIa C
STEMI 103, 104 ST ST T hyperacute T waveSTEMI 15 LAD LAD ST ST 118, 119 LAD aVR ST 118, 119 V4R 1.0 mm ST 105–107 12 V4R 10 ST 107 ST LCX 12 V7-9V4V7 V8 V9 108, 109 ST 2 0.5 mm STEMIAMI 4% ST 108 AMI AMI
118, 120, 121 WPW ST-T Sgarbossa 122 QRS 1.0 mm ST QRS V1-3 1.0 mm ST QRS 5.0 mm ST QRS 1.0 mm ST STEMI 123, 124 AMI ST-T AMI 125 126 AMI CAG 1.5.4 NSTE-ACS STT
QRSU STEMI a. ST
ST ST0.5 mm 127, 128 ST 127ST V4-6 STST ST 127, 129 aVR 11 aVR ST aVR ST 127, 130–132 CABG ST ST STST
23
15 e.
ST-T 15, 114-116, 127, 136, 139, 140 ST-T
1.6

6 ACS
I C
I A
III No benefit A
24

TI T 6% STEMI 12 18 1 90 120 2 21 I 158CK 159, 160 160CK-MB CK CKCK-MB CK-MB 5% STEMI 3 810 24 3 6 CK
CKCK-MB 99 CK ACS 30 10 12 point of care system T 2 161–163 164–167ACS 3 168 ACS
1.7
ACS X X AMI X CT CT X X X
7 ACS X


X
I C
IIa C
25

IIa C
IIa C
IIa C
ER 82.1% 170 BholasinghER T 171Kang ST Q AMI 93% 63%UA 59% 96% ACS 172 TongER 173
1.8

12 ACS ACSACS 4 ACS
9


, 72, 174–177
I A
I A

1.8.1 UA
1989Braunwald 10187 188, 189 108, 190CAG 191–193 PCI II III B C Braunwald 20III 187
NSTE-ACS TIMI 11https://www.mdcalc.com/ timi-risk-score-ua-nstemi65 3 50% 7 24 2 0.5 mm ST 7 2
76, 194NSTE-ACS
STEMIKillip 45, 195–197Killip 3 93 Killip IV 40 70% 75, 198, 199 30 90 mmHg 90 mmHg
STEMINSTE-ACS ACS GRACE ACS 12 https://www.mdcalc.com/grace-acs-risk-mortality-
calculator8 Killip ST
10

II • 1 148
III • 48 1

A B A C 2

28

6 STEMINSTE-ACS 6 77, 183 GRACE GRACE 100101 120121 140 141 3.9 2.0%6.3%11.8%16.8% 200
TIMI GRACE 201GRACE 183, 184
STEMITIMIGRACE simple risk indexCADILLAC simple risk index × /102 / 202CADILAC PCI CAG Killip3 LVEFPCI TIMI
11 NSTE-ACS TIMI
Antman EM, et al. 2000 76
65 No0 Yes 1
3
No0 Yes 1
7 No0 Yes 1
24 2 No0 Yes 1
0.5 mm ST No0 Yes 1
No0 Yes 1
12 GRACE ACS
Granger CB, et al. 2003 179, Eagle KA, et al. 2004 183

7089 7
90109 13
110149 23
150199 36
STEMIQ PCI 204, 205 QRS 206 Q CREDO- Kyoto AMI 24 primary PCI STEMI 2,607 QRS 5 121 STEMI 100LAD ST aVR ST 118, 119RCA V4R 1.0 mm ST 107 STEMI ST-T 100
NSTE-ACS ST0.5 mm 127ST ST ST 127 ST aVR ST 127ST T 134 T 6 128 T LAD 135
QRS ST STEMINSTE-ACS QRS 127
1.8.3
13
I B
IIb B
IIb B
ACS ACS 43AMI 33% 74 vs 6749% vs 38%33% vs 25%26% vs 12% 129 AMI 2.21 CCU
2.

2.1

2.2

I C
III No benefit A
15
2.3

2.4

23± 4%
16
ACS 162200 mg 10, 238–244
I A
III Harm C

90 mmHg 30 mmHg 50/ 100/
III Harm C
III Harm B
PPI 247
Primary PCI STEMI 248, 249 STEMIPCI 300 mg 75 mg/ Primary PCI 6 3.1 NSTEMI 250
33
PCIPCI
18 STEMI primary PCI


12 primary PCI 251–253
I A
Primary PCI DES 254, 255 I A
3 PCI 1 256–259
I B
12 24 primary PCI 260, 261
IIa B
12 24 primary PCI 260
IIb B
III No benefit B
24 primary PCI 265
III No benefit A
III Harm C
STEMI primary PCI BMS 254, 255 STEMI DES STEMIBMS 267, 268 DES 2 deferred delayed DANAMI 3-DEFER 269 STEMI deferred STEMI
1.2
1.3

19 primary PCI


IIa B


75 primary PCI 271–273 IIa B
35
1.5

Primary PCI no reflow 284 2013ACC/ AHA 70 2013 233 IIa TOTAL 281 TASTE 282 17 283 2832015 ACC/ AHA/SCAI 285 III IIb 286IVUS 5 mmattenuated PCI no-reflow 287
1.6

ACS
MATRIX 288ACS RIVAL 289STEMI RIFLE-STEACS 290
21 primary PCI


12 ST CAG PCI 275–279
I B
12 ST CAG PCI 275–278, 280
IIa C


IIb C
III No benefit A


291
1.7
Primary PCI ADP ADP ADP P2Y12 ADP P2Y12
301 A2 24 AMI PCI 10 1 302
ACS PCI PCI P2Y12 162 325 mg 200 mg / PCI 300 mg 75 mg/ BMS 1DES 1 298 3 P2C19 TRITON- TIMI 38 299 60 mg10 mg 1/3 20 mg 3.75 mg 303 ACS
25 Primary PCI


I A
Primary PCI 20 mg 3.75 mg/ 299, 303
I A
IIb C


81162 mg/ 295–
297 I A
IIb/IIIa UA IIb/IIIa 305 c. 2 1DESBMS 1 2DAPT 2009 2 3 DES DAPT DAPT DAPT ACS PCI WOEST 309 2 PCI 3 6 3.1
1.7.2 a.
ACS PCIPCI Primary PCI 2013 ACC/AHA 70 100 /kg ACT 250 70ACS 308 ACT APTT 309, 310 3%HIT 308 10 HIT I III 10 20% 2 3 II PF4HIT 5 14 50% STEMI
26 Primary PCI


Primary PCI 70100 /kg ACT 250 70, 307
I C
tPA tPA APTT
IIa C
38

311–314 315, 316 STEMI PCI b.
318HIT ACS PCI 317HIT 2011HIT PCI
PCI0.1 mg/kg 3 5 4 6μg/kg/ 10 ACT 4 ACT 250 450 319 4 0.7 μ/kg/ APTTAPTT 1.5 33 4 0.2 μg/kg/
1.8
1.8.2 PCI
PCI PCI primary PCI staged PCI 262–264, 331–334 STEMI 214 3 staged PCI 2.5 320 PCI 5 Primary PCI PCI PRAMIn465 23321 Compare-Acuten885 12323 TRANSLATE-ACS Observationaln6,601 12335 staged PCI DANAMI-3-PRIMULTIn627 27 324 immediate PCI staged PCI CvLPRITn296 12325 PRAMICAG 50% CvLPRIT 70% 2 FFR PCI PRAMI DANAMI-3-PRIMULTI Compare-Acute TRANSLATE-ACS Observational 6
27 Primary PCI


28 PCI

I B
IIa A
AMI 329STEMI primary PCI staged PCI staged PCI culprit-only PCI 5 staged PCI 9.5% vs 16.0% P 0.001HR 0.6995%CI 0.50–0.96P0.03 AMI PCI AMI 706 CULPRIT-SHOCK 70% PCIn355 PCI FFR PCI staged PCIn351 30 330 PCI staged PCI PCI 30 PCI hibernation PCI PCI
2.

2.1

2.2
29 STEMI


12 2 PCI 10, 336–341
I A
IIa C
ST 130, 336, 343–345
III Harm B

1 2 6 3 4 5 1 6 7 1 2 3 1 4 180/110 mmHg 5 6 7
2.3
Facilitated PCIPCI PCI PCIrescue PCI PCI STEMI 2 PCI PCI 3 24 CAG PCI systematicPCI 256, 257 Systematic PCI primary PCI systematic PCI PCI 256–259
3.

30 PCI

I B
I C
IIa B
24 1 PCI 265, 349, 350, 355–360
IIb B
23 PCI 256, 257, 361–364
III No benefit B


365–369
I C
4.

Primary PCICAG TIMI TIMI0 1 2 3 4 TIMI 3 388PCI TIMI 2 TIMI frame count 389 no reflow 1/4 390myocardial blush grade
blush 391, 392 393 STST
resolutionST resolution 394, 395 396
5.

ANP AMI RAAS 397, 398 J-WIND-ANPAMI 569primary PCI 399 14.7% LVEF 5.1% ST
32
IIb B
5.2

5.3
Remote ischemic conditioning Remote ischemic conditioningRIC
408 STEMI 409–416 RIC 200 mmHg 5 5 4 primary PCI RIC 417 ER
5.4
Post-conditioning 418 411, 419, 420 421 1GLP-1 422 primary PCI 423 A 424, 425
STEMI 426
33
IIb B
5 ST
STNSTE-ACS ACS ACSACS 4 ACS Braunwald
3 1.8.1 188, 189CAG 192, 193
CCU 427 12 CCU 428 142, 146 ACS ER , ,
GRACETIMI PURSUIT 76, 178–180 3 1.8.1 NSTE-ACS ACS 429 STSTEMI STNSTEMI IIb/IIIa 430CRUSADE
5 ST
34 NSTE-ACS
I A
CCU 428 I B
ACS 142, 146
I B
IIa B
2.
CAG CAG 2 PCIUA Q TIMI IIIB6 65 435 DANAMI 1 3 UA 350 QVAN- QWISH 1 436 CABG 11.6% PCI FRISC II
TACTICS-TIMI 18RITA 3 FRISC II6 9.4% 12.1% 192 IIb / IIIa tirofiban TACTICS-TIMI 18 22 CAG 6 15.9% 19.4% 432 ICTUS TNSTEMI
35 NSTE-ACS
76, 179, 192, 432, 433 I A
CCU
I C
IIb B
III Harm C
ACS
III Harm C
ST ST-T ST-TGRACE 140 36
45
433 TACTICS-TIMI 18FRISC II TIMI TST 192, 432 437, 438 PCI IIb / IIIa CK 433, 439–441 CURRENT-OASIS 7 2009 25,086ACS PCI 600 mg 300 mg0.7% vs 1.3%P 0.000130 3.9% vs 4.5%P 0.035 600 mg 1.6% vs 1.1%P 0.009294, 442ACS P2Y12 TRITON-TIMI 38 PLATO P2Y12 299, 443 CAG

2.2
ABOARD 70 21 PCI abciximab I 1 445NSTE- ACS VT CAG ST CAG
46

2.2.2 24 24 CAG 36 1
CRUSADE PCI 23.4 46.3 446 ISAR-COOL tirofiban 6CAG 3 5 86 11.6% 5.9% CAG CAG 447 TI- MACSNSTE-ACSCAG 24 14 36
50 9.6% 11.3% 9.5% vs 12.9%P 0.003 4 434GRACE GRACE 3 140 13.9% vs 21.0%P 0.006GRACE 109 140 109 2 434
VERDICT 12 NSTE-ACS 12 4.7 48 72 61.6 4.3 448 GRACE 14012
36 NSTE-ACS

24 ST-T GRACE140
72
60 mL / /1.73 m2 LVEF40% PCICABG GRACE 109140
GRACE109
47
GRACE 140 CAG 2.2.3 72 72 CAG 36 1 CAG 72
2.3
3.

3.1

CABG 199
LAD PCI CAG PCI PCI PCI PCI PCI 450–453ACS PCI 454 LAD PCI CABG
37 NSTE-ACS
I C
3.3
PCI
FRISC II PCI 4 TACTICS-TIMI 18 4 48 25 192, 432TIMACS24 36 434
1990ACS PCI PCI 458, 459 PCI 1996 TIMI IIIB 97% 4.3% 1.4% 437 PCI 437, 444, 460, 461 PCI 6 1 434, 451 4626 CAGISAR-COOL 48 CAG 447, 4634 5 464
PCI 288, 289ACS 8,404 MATRIX 288
ACSDES STEMI DES BMS 267, 465–470NSTE-ACS Kandzari CRUSADE NSTE-ACS DES BMS 471DES DES
38 NSTE-ACS


I A
PCI PCI PCI 450–453
IIb B
5 ST
4569,013 DESBMSNORSTENT NSTE-ACS43.5% 5 0.8% vs 1.2%P 0.0498 16.5% vs 19.8%P 0.001 BMSDES 457
STEMI NSTEMI 281, 282, 472, 473 474, 475 P2Y12 296 FRISC II TACTICS-TIMI 18 6 192, 432
3.4
CABG
NSTE-ACS CABG 372, 476–479 CABG CABG 480 CABG PCI 377, 481–485
PCI 481 CABGPCI LAD CABG CABG CABG 377 CABG 449 CABG
ACS CABG 482, 483 CABG CABGACS 24 377, 482, 483, 485, 486 PCI CABG CABG 487–489
CABG


I C
I C
CCU ACS ACS ACS CCU AMICCU ACS Braunwald 10187, 437, 439 76, 98, 178, 179, 492 ACS TIMI 11 GRACE PURSUIT 201GRACE 12 https://www.mdcalc.com/grace-acs-risk-mortality- calculator
183, 184 CCU
CCU 1 Killip 195 CKD T I BNPN NT-proBNP STSTSTEMI 493, 494Primary PCI 495, 496 STEMI primary PCI 20 36 CAGPCI
1.2
41 CCU
I B
I B
1.3
CCU CCU 1 CCU CCU 1 2 1 CCU 1.5 1 CCU CCU general ICUCCU CCU
2.

42 CCU
I C
I C
I C
233, 504
IIa C
180 mg/dL 510, 511
IIb A
2.2
2.3
mg/dL 180 mg/dL 518 510, 511 90 mg/dL180 mg/dL
2.4
2.5
2.6
53
3.

3.1

81 162 mg/ STEMI 314, 523 STEMI PCI PCI 300 mg 75 mg/ 298 28 524 ACS PRASFIT-ACS PCI 20 mg 3.75 mg/ PCI 3 303 299 1/3 STNSTEMI CAG PCI 20 mg 3.75 mg/ 303 P2Y12 P2Y12
PLATO STEMI/NSTEMI 180 mg 90 mg 2 300 mg 75 mg 1 1 443
43
PCI 162200 mg 314, 523
I A
PCI 300 mg 20 mg 75 mg/ 3.75 mg/ 298, 303, 524
I A
I A
525 I B
DAPT 443, 526
IIa B
PCI 2 306, 527, 528
IIa B
3.2
β
β STNSTE-ACS
STEMIβ β 539 STEMI βNSTE-ACS PCI ACSβ
NSTE-ACSβ CRUSADE 533 NSTEMI 72,054 24β 34% 534 1.25 2.5 mg 4 5 24
45,852 STEMI 9COMMIT 538
primary PCIβ primary PCIβ 3 4
44 β

LVEF 40% β 530–532
I A
β 538
III Harm B
ACE LVEF 40% 237ACE Inhibitor Myo- cardial Infarction Collaborative Group ACEAMI 0 36 30 547 1ACE Killip II III 100/ IIARB
AMIVALIANT 542ACEARB ACE ACE
REMINDER 24 STEMI 548 NT-proBNP ALBATROSS 200 mg 25 mgSTEMI 80% 549
3.4
45 RAAS


LVEF 40% 24 ACE 237
I A
I A
LVEF 40% ACE β 544
I A
46


I C
IIb B
III Harm B
90 mmHg 30 mmHg 50/ 100/
III Harm C
3.6

563–565IVUS LDL-C LDL-C 566ACS ACS ACS 567, 568 569-574ACS LDL-C 70 mg/dL ACS LDL-C 70 mg/dL 574, 578 LDL-C 578 3.6.2 FH LDL-C 3 LDL-C FH 200 500 1 10 FH 575AMI 9 mm 3.5 1 FH 3 576ACS FH LDL-C 577 3.6.3 LDL-C LDL-C AMI
47 Ca
I B
III No benefit A
III Harm A
560
FH 575–577 I A
57
6
LDL-C FH 70 mg/dL 50% / 9PCSK-9 PCSK-9
4.

4.1
IABP
49 IABP

IABP 579, 580 IIa C
IABP IIa C
IABP 579, 581
III No benefit B
4.2
ACS IMPELLA STEMI 588IABP IMPELLA 589, 590 ACS IMPELLA
4.3
50 VA-ECMO

IIb C
IIb C
VA-ECMO VA-ECMO ACS VA-ECMOACS 591 ACS VA-ECMO 592 CI 598 ACS PCI VA-ECMO ACS 591 4.3.1 ER VA-ECMO ACS ERVA-ECMO ACLS VSP VA-ECMO 593, 599 VA-ECMO IABP VA-ECMO IABP VA-ECMOIMPELLA
VA-ECMO IMPELLA IABP CULPRIT-SHOCKVA-ECMO 20%IMPELLA 330 ACS
JRC ECPR PCI 600–602 JRC 594 4.3.2 VA-ECMO VA-ECMO 1.0 L/ ON-OFF LVEFCI BE 603APACHE II 604
4.4
LVAD
51 LVAD
IABP VA-ECMOIMPELLA LVAD 594, 603
IIb C
LVAD LVAD LVAD 2013 606
5.

5.1
ACSVT/VF PCI ICU CCU VT/VF 607GUSTO IIb GUSTO IIIAMI 19,190 1,1265.9%VT/VF 622 PCIAPEX AMI 104 VT/VF STEMI 5,745 3295.7% 9282 STEMI 48 STEMI 57,158 ST VF 623 VT/VF 624, 625 a. 30 60 ACS β AMIβ VF 626 ACC/AHA ESC β 70, 100 VT/VF 617 4.0 mEq/L 2.0 mg/dL b.
ACSVT/VF 616VF VT 2 300 mg 5 mg/kg VF VT 609, 610
52
I B
VT VTVF 609–615
I B
VT 618
IIa C
VT/VF electrical storm 619, 620
IIa C
VT VT 100, 621
IIb B
PVC PCI AIVR 12 VT/VF AMI AIVR
5.1.3 48
ACS VT/VFACS 40 ICD 6 12 100 WCD WCDAMI 40 LVEF 35%NYHA II III 636
5.2

III No benefit B
PVC 100,
I B


AMI 40 LVEF 35% NYHA II III WCD 636
IIb C
I C
I C
646 Ca 647ACS 648 649 2014AHA 650AMI IIa AMI 651 60 6 Valsalva ATP1 2 10 mg 1 2 20 mg 20 mg 653
5.3
594
IIa C
IIa C
IIa C
IIa C
III Harm B
1 660 1RCA 2018 661
6.

6.1
58
594
Mobitz II 2 2
I C
IIa C
64

198, 667 45, 196, 197, 668
Swan-Ganz 669Forrester 200 AMI PCWPCI 4hemo- dynamic subset 670
IPCWP 18 mmHgCI 2.2 L/ /m2
ACE ARBβ IIPCWP 18 mmHgCI 2.2 L//m2
IIIPCWP 18 mmHgCI 2.2 L//m2
IVPCWP 18 mmHgCI 2.2 L//m2
IABP VA-ECMOPCPS
Nohria Nohria-Stevenson 662, 671 Forrester 4 AMI X 672Swan-Ganz
2005ICU Swan-Ganz 673 Swan-Ganz 5 674
6.2
59


LVEF 40% ACE 542, 675
I A
I A
676, 677 I C
90% NPPV 678–681
I C
682, 683 IIb B
90 mmHg 30 mmHg 677
IIb C
65
6.3
1 5μg/kg/ IABP PCI CABG VSP IABP
6.4

677, 693 I C
677, 693 I C
677, 693 I C
678–681 I C
IABP 662, 677 I C
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695 IIb B
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1264% 59% 42% 702AMI PCI CABG 152 150 2 301 SHOCK trial 30 46.7% vs 56%153.3% vs 66.4%P 0.03 27175 30 199, 271 primary PCI 4 1.3 703βACE
7.

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67
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69
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70

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9.

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63 CAGPCI AKICIN


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11.

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Valgimigli M, et al. 2018 928 Translated and reproduced by permission of Oxford University Press on behalf of the European Society of Cardiology. OUP and the ESC are not responsible or in any way liable for the accuracy of the translation. The Japanese Circulation Society is solely responsible for the translation in this publication/reprint. Please visit: www.escardio.org/Guidelines/ Clinical-Practice-Guidelines/2017-focused-update-on-dual-antiplatelet-therapy-dapt
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TG HDL-C 981 TG HDL-C b. HDL-C HDL-C HDL-C 999, 1000 LDL-C 70 mg/dLHDL-C 40 mg/dL 1001TG HDL-C CETP c. n-3 n-3 EPADHA 1002–1004 1005–1007REDUCE-IT 1008 EPA 4 g/ 8,179 UA 25%NNT 21 TG 150 mg/dL EPA 26.1μg/mL EPA 1990 JELIS 1009 EPA EPA 982EPA 23% PCI EPA 41% EPA /AA EPA/AA PCI 1010 EPA/AA
94

2.7

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