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Coronary heart disease

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Time to reperfusion 4 hr 1. HIGH RISK. TIMI risk score in NSTEMI. Age ... be used if hypotension occurs (w/o Base Hospital Physician order) and may be ... – PowerPoint PPT presentation

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Title: Coronary heart disease


1
???????????????????????????????????????????(Coro
nary heart disease)
  • ??? ??.??. ????????? ??????????
  • ???????????????????????? ??????????????????
  • ??????????????????? ????????????????????
  • ????????????? ??????????????????

2
Pathophysiology
Acute MI
  • Platelet cascade
  • Thrombus formation
  • Vasospasm

Complete occlusion
Plaque rupture (55-80)
Healing plaque
Chronic stable
Spontaneous lysis
Exertion BP, HR Vasoconstriction
Incomplete occlusion Distal embolization
Unstable angina Non-Q MI
3
Pre hospital management
  • Health education program
  • Risk control
  • Symptoms
  • Call EMS earlier
  • How to contact?
  • When to contact?
  • Early EKG on site
  • ASA on site.

4
ED management
  • A cardiac-specific troponin is the preferred
    biomarker in patients presenting with symptoms
    consistent with ACS.
  • BNP may be added to the list of biomarkers for
    risk assessment.
  • Nondiagnostic pts with possible ACS should be Rx
    and stress test stratification
  • Low probability and possible ACS can be CT

5
Investigations
  • Electrocardiography
  • Cadiac enzyme
  • Chest film
  • Echocardiography
  • Coronary angiography, CAG
  • Other risk factors FPG, lipid profiles

6
Chest film
  • Cardiac abnormality
  • Determine CHF
  • DDx
  • Aortic dissection
  • Pericardial effusion

7
Echocardiography in ACS
8
Coronary angiogram
9
TIMI risk score in STEMI
  • Historical Score
  • Age, y 75 3
  • Age, 65-74 2
  • Hx of DM, HT or angina 1
  • Examination
  • SBP lt 100 mmHg 3
  • HR gt 100/min 2
  • Killip class II-IV 2
  • Weight lt 67 kg 1
  • Presentation
  • Ant ST elevation or LBBB 1
  • Time to reperfusion gt 4 hr 1

10
TIMI risk score in NSTEMI
  • Age gt 65 yr
  • CAD risk gt 3
  • Stenosis gt 50
  • Chest pain gt 2 times in 24 hr
  • ASA within 1 wk
  • EKG ST diviation gt 0.5 mm
  • Positive Troponin-T
  • SCORE gt 4

Am Heart J 2002 143 966-70
HIGH RISK
  • Heparin Rx.
  • early revasculaization

Am Heart J 2002 143 966-70
J Invasive Cardiol. 2006 Dec18(12)617-39.
11
Principle of ACS management
  • Early Invasive
  • Primary PCI
  • Facilitate PCI
  • Rescue PCI
  • CABG

Adjuvant Rx
  • Aspirin
  • Nitrates
  • Mo
  • Beta blockers
  • ACEI
  • Antithrombin
  • Clopidogrel
  • GPII/IIIa
  • Hemodynamic
  • stabilization
  • Medical
  • Ventilator
  • IABP
  • Pace maker

ACS
  • Early Conservative
  • Fibrinolytic drugs
  • Risk stratification

Elective CAG /- PCI or CABG
12
Medication of ACS
  • Fibrinolytic agents
  • Antinthrombotic agents
  • Anti-platelet therapy
  • aspirin, ticlopidine, clopidogrel, GP IIb/IIIa
    inhibitors
  • Anti-coagulant therapy
  • heparin, low molecular weight heparin (LMWH)
  • Antiischemic agents
  • Activity, Oxygen
  • Morphine, Nitrates, Beta blockers
  • Others ACEIs, ARBs, Statins, Fibrates

13
Efficacy of fibrinolytic agents to mortality
Percentage mortality
0-1h 2-4 h 4-6 h
7-12 h 13-24 h
Lancet 1994343311
14
Fibrinolytic revascularization
  • Indication
  • Anginal in 12 hrs
  • ST elevation or New LBBB
  • Contraindication
  • Internal bleeding
  • Major operation within 2 wks
  • Hemorrhagic stroke anytime or Ischemic stroke
    within 6 mo.
  • Pregnancy
  • Suspected aortic dissection

15
Fibrinolytic agents
Tissue Plasminogen Activator
SK t-PA r-PA TNK Dose 1.5 mu 100 mg/90
min 1010 u 30-50 mg Circulating t
1/2 20 6 18 20 Allergic reaction
Yes No No No Systemic fibrinogen depletion Se
vere Moderate Moderate Mild CNS
bleeding 0.4 0.7 0.8 0.7 Patency
rate 51 73-84 83 77-88 Live
saved/100 3 4 4 4 Cost () 290 2750 2750 27
50
Heparin
LMWH
16
????????????????????? SK
  • ?????? ?
  • ?????? hydrocortisone 100 mg ???? ??? SK
  • ?????? ?????? ???? plasil
  • ????? NSS ???? 5 D/W 100 cc drip in 1 hr
  • ?????????? ???? monitor EKG ??? BP ????
  • ???????????????????????? ????????????? ? ???? cut
    down ???? ??? central line ??? foley cath
    ???????????? ?

17
Antiplatelets ASA
  • ASA should be administered to patients with ACS
    as soon as possible (unless contraindicated) and
    continued lifelong.
  • ASA 162-323 mg/day at least 1 mo for bare stent
    and 3-6 mo for drugs eluting stent.
  • ASA 75-162 mg/day for maintenance or in high risk
    bleeding.

18
Antiplatelets Clopidogrel
  • All STEMI with or without fibrinolytic Rx must be
    use Clopidogrel and ASA at least 14 days.
  • Loading Clopidogrel is 300 mg.
  • All post PCI patients
  • No stent No recommendation but Clopidogrel
    should be Rx at least 1 mo.
  • BMS Clopidogrel at least 1 mo and ideally up to
    12 mo (unless the patient is at increased risk of
    bleeding then it should be given for a minimum
    of 2 weeks).
  • DES Clopidogrel at least 12 mo.

19
CLARITY-TIMI 28 Primary EndpointOccluded Artery
(or D/MI thru Angio/HD)
Odds Ratio 0.64(95 CI 0.53-0.76)
36 Odds Reduction
21.7
25
P0.00000036
20
15.0
15
10
Occluded Artery or Death/MI ()
5
1.0
0.4
0.6
0.8
1.2
1.6
n1752
n1739
0
Clopidogrel better
Placebo better
Placebo
ClopidogrelLD 300 mgMD 75 mg
STEMI, Age 18-75
Sabatine N Eng J Med 20053521179.
20
COMMIT Effect of CLOPIDOGREL on Death In
Hospital
Placebo ASA 1,846 deaths (8.1)
Clopidogrel ASA 1,728 deaths (7.5)
0.6 ARD7 RRR P 0.03
Dead ()
N 45,852 No Age limit 26 gt 70 y Lytic Rx
50 No LD given
Chen ZM, et al. Lancet. 20053661607.
Days Since Randomization (up to 28 days)
21
Antiplatelets GPIIb/IIIa
  • All patients receiving intravenous GP IIb/IIIa
    inhibitors must also receive concomitant UFH or
    another antithrombotic agent.

22
Heparin
  • Antithrombin
  • Indication
  • UFH in AMI with PCI or CABG
  • UFH with fibrin selective firinolytic Rx
  • UFH in high risk of systemic emboli patient
  • UFH in NSTEMI or UA high risk.
  • Adjusted aPTT 1.5-2
  • LMWH may be substituted to UFH (IIb)
  • SK may be combine to LMWH
  • Caution Heparin induce thrombocytopenia

23
Am Heart J 2002 143 966-70
24
ExTRACT-TIMI 25 Primary End Point (ITT) Death or
Nonfatal MI
UFH
12.0
17 RRR
9.9
Enoxaparin
Primary End Point ()
Relative Risk0.83 (95 CI, 0.77 to 0.90)Plt.001
Lost to follow-up 3
Days after Randomization
Adapted with permission from Antman EM, et al. N
Engl J Med. 20063541477-1488.
25
OASIS 5 Cumulative Risk of Death, MI, or
Refractory Ischemia
10
9.0
9
8
7.3
7
Enoxaparin
5.8
5.7
6
Fondaparinux
5
4.1
4
3
2.2
2
1
0
OASIS 5 Death, MI, or refractory
OASIS 5 Major bleeding at 9
OASIS 5 Composite primary
ischemia at 9 days
days
outcome and major bleeding at 9 days
Absolute Risk Reduction -0.1 1.9 1.7 Hazard
Ratio 1.01 0.52 0.81 Confidence
Interval 0.901.13 0.440.61 0.730.89 p 0.007
lt 0.001 lt 0.001
p for noninferiority p for superiority. Yusuf
S, et al. N Engl J Med 2006354146476.
26
Anticoagulants NSTEMI
  • Conservative therapy
  • Fondaparinux, enoxaparin (for 8 days or duration
    of hospitalization) or
  • Unfractionated heparin (UFH) (for 48 hours) (in
    that order).
  • Invasive therapy
  • enoxaparin or UFH-based regimens have the most
    supporting evidence.
  • Bivalirudin can be use in PCI.

27
Oxygen 2008
  • Supplemental oxygen should be administered to pts
    with oxygen sat lt 90 (I)
  • Supplemental oxygen to all pts with uncomplicated
    ACS during the first 6 hrs (IIa)

28
NTG
  • Nitroglycerin changed to 0.4 mg SL every 5
    minutes (no maximum dose) until patient is
    pain-free or hypotension prevents further doses
  • Normal Saline fluid bolus of 250 cc will be used
    if hypotension occurs (w/o Base Hospital
    Physician order) and may be repeated once
  • Morphine is now by Base Hospital Physician order
    only

29
Analgesia
  • Morphine downgraded from I to IIa in NSTEMI and I
    in STEMI but should be caution because may
    increase adverse events in UA/NSTEMI.
  • NSAIDS other than ASA should be discontinued on
    admission because increase mortality,
    reinfarctin, and HF in proportion to degree of
    COX-2 selectivity.
  • Do not initiate during acute phase of management

30
Why does Morphine lead to poor outcomes?
  • Masks myocardial ischemia
  • Reduces preload
  • May increase ischemia in preload dependent hearts
  • May depress heart rate, blood pressure,
  • and oxygen delivery

31
Beta-Blockers
  • Oral BB within first 24 hrs who do not have
    contraindications.
  • IV BB should only for hypertension who do not
    have contraindications.
  • Contraindications
  • Signs of heart failure
  • Evidence of a low output state
  • Increased risk for cardiogenic shock age gt 70
    yr, SBP lt 120 mmHg, HR lt 60 t/min, HR 110
    t/min.
  • Other relative contraindications to beta blockade
  • PR interval gt 0.24 seconds
  • Second- or third-degree heart block
  • Active asthma or reactive airway disease

32
Calcium Channel Blockers
  • Class I indications none
  • Number of studies showing mortality reduction in
    AMI none
  • Class IIb indications
  • Diltiazem (Cardizem) for NSTEMI
  • If no LV dysfunction or pulmonary congestion
  • (41 increase in cardiac events, if present)
  • After first 24 hr, up to 1 yr
  • Class III indications
  • Short acting Nifedipine
  • Diltiazem and Verapamil if LV dysfunction is
    present

Multicenter Diltiazem Reinfarction Trial NEJM
1988, 319385-392.
33
ACEI
  • Indicate in all patents with ACS (all
    atherosclerosis or atherosclerosis risk
    equivalents)
  • Oral ACEI should be start within 24 hrs (without
    contraindication) in the conditions of CHF and
    poor EF (40)
  • ARB can be use if ACEI in tolerate.
  • IV ACEI is contraindicate within 24 hrs of ACS
    except refractory hypertension

34
How to selection of Rx NSTEMI
  • Conservative
  • Based on physician and patient preference.
  • In patients who are stable for 12-24 hours on
    conservative therapy, noninvasive stress testing
    should be performed prior to discharge.
  • Early Late invasive
  • High-risk score patients with ongoing symptoms
  • Hemodynamic instability
  • Sustain VT
  • CHF or new or worsening MR
  • Elevated cardiac biomarkers
  • PCI within 6 mo.
  • Prior CABG
  • Poor LVEF lt 40

35
How to selection of Rx STEMI
  • Invasive Rx.
  • PCI capability should be treated with primary PCI
    within 90 minutes of first medical contact as a
    systems goal.
  • Noninvasive Rx.
  • who cannot be transferred to a PCI center and
    undergo PCI within 90 minutes of first medical
    contact should be treated with fibrinolytic
    therapy within 30 minutes of hospital
    presentation as a systems goal unless
    fibrinolytic therapy is contraindicated.

36
Percutaneous coronary angioplasty
37
Primary PCI and Lytic Therapy



Death Reinfarction
Death Reinfarction 30
days
6 months
Grines CL. Circulation 1999
38
Indication of Primary PCI
  • Angina within 3 hrs and expected
  • DTB DTN less than 1 hr
  • Angina after 3 hrs
  • Severe CHF within 12 hrs of angina (I) or 12-24
    hrs of angina (IIa)
  • Shock within 36 hrs of angina (I) and recommend
    PCI within 18 hrs of shock

39
Coronary Arterial Bypass Graft
40
Indication for CABG
  • Fail or contraindication to PCI or? Fibrinolytic
    drugs
  • Lesion is not suitable to PCI
  • LM disease
  • Triple disease
  • Complicated AMI
  • acute severe MR
  • Rupture LV, VSD

41
Indications for Refer
  • STEMI with candidate thrombolysis. (center is not
    available)
  • STEMI with contraindicate to thrombloysis.
  • ACS with complications.
  • Shock
  • Intractable arrhythmia CHB, VT, VF
  • Intractable heart failure
  • Mechanical complications VSD, MR, Pericardial
    effusion, Perforate heart.

42
RV infarction
  • Associated to inferior wall MI
  • High mortality
  • Physical examination
  • NV engorged and no sign of CHF
  • Volume sensitive MI
  • Diagnosis criteria
  • ECG Inferior MI ST-T elevation in V3,4R
  • High RA pressure (RAPgt10mmHg) and normal PWP
    (RAP/PWP ratio gt 0.8)

43
Right Ventricular Infarction
44
Principle of RV Infarction management
  • Reduce infarction area
  • Adequate volume expansion
  • invasive monitoring CVP, PCWP
  • Caution of vasodilation, morphine and diuretic
  • Inotropic agents
  • IABP
  • AV synchrony
  • DC shock AF, SVT
  • Pacing Heart block

45
Complicated AMI
  • Congestive heart failure
  • Cardiogenic shock
  • Acute mitral regurgitation
  • Acute VSD
  • LV perforation
  • VF, Heart block

46
Congestive heart failure
  • Mechanism
  • Diastolic failure
  • Systolic failure (area infarction gt 40)
  • Arrhythmia
  • Principle of management
  • Reduced infarct area
  • Reduced preload
  • Reduced afterload
  • Increase contractility
  • Medication Diuretic, Inotropic agents,
    Vasodilator
  • Nonmedical Mx. Ventilator, IABP, Pacing

47
Shock
  • Mechanism
  • RV infarction (Volume responsive)
  • LV infarction (impair systolic function)
  • Arrhythmia (Bradycardia.
  • Principle of management
  • Reduce infarct size
  • Adequate volume
  • Invasive monitoring ???? PCWP, A-line
  • Vasopressive agent
  • Nonmedical Mx IABP, Pacing

48
Acute mitral regurgitation
  • Mechanism
  • Papillary m. ischemia
  • Dysfunction
  • Rupture
  • LV dysfunction
  • Increase LVEDP
  • Annulus dilatation
  • Principle of management
  • Reduced infarct size
  • Reduced afterload
  • Medical
  • IABP
  • Increase contraction

49
VSD or LV rupture
  • Mechanism
  • Large infarction
  • Principle of management
  • Reduced infarct size
  • Early surgery in free wall rupture
  • VSD with hemodynamic stable, elective CABG with
    VSD closure should be perform in 2 wks

50
VF, Heart block
  • Mechanism
  • Ischemia induce irritability of myocardium
  • Principle of management
  • ??????????????????????????????????
  • ?? afterload ?????? ???? IABP
  • Early defibrillation in primary VT/VF
  • Antiarrhythmic in secondary VT/VF
  • Pacing according indications

51
Primary Prevention
52
Identification Pts Risk
  • Evaluate the presence and status of control of
    major risk for CAD for all pts at regular
    interval (every 3-5 yrs)
  • Ten yrs risk should be calculated for all pts who
    have 2 or more major risk factors to assess the
    need for 1 prevention.
  • CAD pts and pts with CAD risk equivalent should
    be identified intensive 2 prevention.
  • DM, CKD or 10 yr risk greater than 20 are the
    CAD risk equivalent

53
Secondary Prevention and Long-Term Management
54
Risk Factor Modification
  • Smoking Cessation
  • 2.5 increased mortality risk reduced if quit
  • Diet modification
  • Low fat, low cholesterol
  • Hypertension
  • Poorly controlled BP increases mortality risk
  • Diabetes
  • Tight control, metformin if obese
  • Cardiac rehab (with exercise)
  • Mortality benefits, Quality of Life

55
Secondary Prevention
  • Aspirin
  • Continue indefinitely
  • Benefits established to 27 months (death,
    non-fatal MI/stroke - ARR 4)
  • Betablockers
  • Continue indefinitely
  • Long-term mortality benefits shown BHAT, ISIS-1
  • Titrate dose (according to BP) to HR of 60bpm

56
Secondary Prevention (continued)
  • ACE Inhibitors
  • LVF patients mortality reduction at 1 to 5 yrs
  • Patients without LVF ? reduction in mortality,
    MI, stroke (often initiated months after MI)
    HOPE
  • Lipid therapy
  • Statins have shown long-term mortality benefits
  • Targets
  • LDL lt 70 mg/dl

57
Medications Post-surgical Intervention
  • CABG (Coronary Artery Bypass Graft)
  • anti-anginal medications usually ceased
  • continue secondary prevention medications
  • PTCA (Percutaneous Transluminal Coronary
    Angioplasty) Stent Insertion
  • continue clopidogrel and higher dose (300mg)
    aspirin daily for 9 month post-stent then low
    dose aspirin indefinitely CLASSICS

58
Secondary Prevention
  • BP goal
  • General goal below 140/90 mmHg
  • DM and CKD below 130/80 mmHg
  • Statin goal
  • LDL-C lt 100 mg/dL I (A)
  • consider LDL-C lt 70 mg/dL IIa (A)
  • DM goal HbA1c lt 7

59
Secondary Prevention
  • Ask, advise, assess, and assist patients to stop
    smoking
  • Daily physical activity 30 min 7 d/wk, minimum 5
    d/wk
  • Hormone replacement therapy (HRT) should not be
    started in patients with ACS. Patients on HRT at
    the time of ACS should be advised to discontinue
    it.
  • Annual influenza immunization

60
??????????????????????????????????? ACS
61
??????????????????? 1
  • ??????????????????????????????? ??????????
  • ??????????
  • ?????????????????
  • ???????????????????????????????????
  • ??????????????????????????????????????? 35
    ????????????????? 3 ??????? ??????????????????????
    ?????????????? ???????????? ???????????????
    ???????????????????

62
??????????????????? 2
  • ??????????????????????????????????????????????????
    ???????????????????????????????
  • ????????????
  • ??????????????????
  • ??????????????????????????????????????????????????
  • Stroke
  • PAD
  • CAD

63
??????????????????? 3
  • ??????????????????????????????????????????????????
    ?????
  • ?????????????????????????
  • ??????????????????? ????????????????
  • ???????????????????????????????????
  • ?????????????????????????
  • ??????????, ???????????, ?????????????????????????
    ???????????????????
  • ??????????????????????? NSAIDS
  • ????????????????????????????????????
  • ????????????????????????????????????????????????
    (Primary prevetnion)
  • ASA, Statin, ACEI or ARB.

64
????????????????????
  • ????????????????????????????????????? ????????
    angina, syncope, CHF
  • ??????????????????? Nitrate ???????????? angina
  • ???????????????????????????????.???? 1669
    ?????????????????
  • ??????????????????????????????????????????????????
    ??????????? ??????
  • ????????????????????? angina ??? Guideline
    ??????????????????????????
  • ????????????????????????????
  • ?????? ASA V ?????????????????????????? ??????
    Nitrate ?????? Oxygen therapy
  • ????????????????????????????? Thrombolytic

65
???????????
  • ??????????????????????????????????? ????????
    angina ??? Guideline ??????????????????????????
  • ????????????????????????????????? 10 ????
    ???????????????
  • ?????? ASA V ??????????? ???????????????
  • ???????????????????
  • ?????? Oxygen therapy
  • ????????????? ????????????????????????????????????
    ????? ???? CBC, BS, BUN, Cr, Elyte, Cardiac
    enzyme, Lipid profile
  • ?????? Nitrate ???????????????
  • ?????? Morphine ???????????????
  • ????????????????????????????? Thrombolytic
    ????????????????????? Guideline

66
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67
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68
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69
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70
?????????
  • ??????????????????????????????????????????????????
    ????
  • ??????????????????? chest pain score
  • ???????????????????? ????????? cardiopulmonary
    examination.
  • ???????????????????????? (monitor EKG, serial EKG
    q 6 hr.) ???????????????? Throbolytic
    ??????????????????????????????????????????? 90
    ???????????????????????????????????? ??? ST
    segment ??????????? 50 ????????????????
  • ???????????????????????????????? (Cardiac enzyme
    q 6 hr.)
  • ????????????????????????????????????? 24 hr.
    ??????????????????????????

71
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72
?????????????
  • ??????????????????????????????????????????????????
    ??? ???????????? Guideline ???????????
    ?????????????????????????? ????????????? Fax EKG
    ??????????? 13 ???? ??? Code ????????????????????.
    ?????????????????
  • ??????????????????????????????????????????????????
    ???????????????????????
  • ????????????????????? monitor, ventilator,
    medications
  • ???????????????????????????????????????
  • ?????????????????????????????????????????????
  • ????????.??????? Refer ?????????.???????? Refer
    ?????????????.??????????????????

73
???????????????????????? ?????????????????????????
??????????????????????????????????????????????????
???????? (Pilot Project of Comprehensive
Cardiac Referral System in Khon Kaen
Province) ???? ...................................
...................... ??????? ...................
.................................................
???? ................????? O ??? O
???? ?????????????????? .....................
............................. ??????
..............................???????????? O
??????? O ??????? O ????? O ????????? O
??????????????????????????????????? O
UA O NSTEMI O STEMI??????????????
?????? O ????????????????????? O
???????????????????? O ???????????????????? 1.
??????????????? ???? ............................
...... ?. 2. ?????????????? ????
.................................. ?. 3.
???????????????????? ????? .......................
..... ?????/???? ??????? .....................
... ??. ???? 4. ???????????????? O
?? O ????? 5. ???????????????
O STEMI O NSTEMI ???? UA
???? ...................... ?.
6. ???????????? O ?? O ?????
74
???????????????????????? (???) 7.
???????????????? O ASA O ??? O ??????
O Clopidogrel O ??? O ?????? 8.
??????????????? (NTG) O ??? O ??????
???? .......................................
.............. 9. ????????? O ??? O
?????? ???? ............................
???? .................. ?. 10.
???????????????????????????? (LMWH) O ??? O
?????? ???? ..............................
...................... ???? .....................
....... ???? .................. ?. 11.
???????????????? (Thrombolytic) O ??? O
?????? ???? ..............................
...................... ???? .....................
....... ???? .................. ?. 12.
????????????????????? O Dopamine ????
............................ O Adrenaline
???? ............................ 13. ??? ET
tube O ??? O ?????? 14. ????????? CPR O
??? O ?????? 15. ???????????????????????????
? O ???? O ??????? 16. ??????????????????????
?? ????? .................................
?????/???? 17. ???????????????????
..................................................
............................... 18.
?????????????????? Refer ???? ....................
.................................................
???????????? ...................................
................................
75
??????????????????
  • ?????????????? ???????? ????????? ??????????????
  • ????????????????????????????????? ??????????????
    ?????????????? ???????? ??????????????????
  • ??????????????????????????????????????????????????
  • ????????????????? ????????????????????????????????
    ?????????????????????????????? ???????????????????
    ???????????????? Echo ?????????????????

76
??????????????????
  • ???????????? ?????????
  • ???????????????????????????????????????????
  • ??????????????????????????????????
    ????????????????? Echo EST CAG ??????????????
  • ???????????????????????????????????????????????
    LDL lt 70 mg/dl, BS lt 140, HbA1c lt 7
  • ??????????????????????????????????????????????

77
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