心臟內科個案討論

【見習醫學生】

林品瀚
 Chief Complaint
 Dyspnea since last admission,became
serious on 2/12
 Present illness
 78 y/o female,with history of NSTEMI s/p
PCI+DES in RCA(95%stenosis) on 1/27,and
AF,Peptic ulcer disease,chronic back pain
 Dyspnea since last admission,relieve after
resting
 Without history of smoking and taking alcohol
 Wheezing-like breathing sounds after
discharging home
 No nausea,vomiting,angina,diaphoresis
,palpitation,paroxysmal nocturnal
dyspnea,orthopnea
 PE
 T/P/R/BP:37° C/90/18/125,74
 HEENT:Normal
 Neck：no bruit, no jugular vein engorgement, no
thyroid enlargement
 Heart sound:normal
 Breathing sound:normal
 No peripheral edema,hepatomegaly,cyanosis,cold
extremity
Chest X ray
EKG on 1/26
EKG on 2/12
Lab data
Lab data
 Differential diagnosis

 Acute decompensated heart failure

 Ticagrelor-induced dyspnea
 COPD
 Asthma
Pulmonary function test
 Medication

 DAPT(Aspirin+Ticagrelor
Aspirin+cloprdogrel)
 PPI H2 blocker(famotidine)
 NOAC:Rivoroxabin
 amiodarone
 Combivent
 diltiazem
PPI and P2Y12 inhibitor
Discussion:NSTEMI
treatment
 General treatment

 O2:Supplemental oxygen is indicated if blood oxygen saturation is less

than 90% or if there is evidence of respiratory distress.
 Nitrate:Repeated sublingual nitroglycerin every 5 min formaximal 3 doses is
recommended in NSTE-ACS patients
 Beta blocker:Early administration of beta-blockers within 24 h of
hospitalization is recommended for NSTE-ACS patients who have no risk
factors for shock
 ACEIs :recommended for all NSTE-ACS patients during hospitalization
unless contraindicated
 Statin :statin/ezetimibe combination is recommended for all NSTE-ACS
patients during hospitalization unless contraindicated
 Antiplatelet:Aspirin, P2Y12 inhibitor(clopidogrel,prasugrel,ticagrelor)
 Anticoagulation:UFH/Enoxaparin
 Coronary angiography

 An early coronary angiography should be

considered and performed as soon as
possible within 24 h for NSTE-ACS patients
who have unstable hemodynamics,acute
pulmonary edema, tachy- or
bradyarrhythmiasand refractory angina with
dynamic ECG changes.
 Revascularization therapy

• For NSTE-ACS patients with multivessel disease and the

culprit lesions can be identified clearly, ad hoc PCI could
be performed especially in very high risk patients with
unstable hemodynamics, acute pulmonary edema,
tachy- or bradyarrhythmias or refractory angina with
occlusion of the culprit artery. (COR I, LOE C)
• For NSTE-ACS patients with multivessel disease, the
Heart Team should use shared decision making to
decide the revascularization strategy. (COR I, LOE C)
syntax>=33,CABG superior to PCI
DAPT
NSTE-ACS and AF
Treatment