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1、Circulation Journaldoi:10.1253/circj.CJ-19-0133J-STAGE Advance Publication released online March 29,2019Mailing address:Scientific Committee of the Japanese Circulation Society,18F Imperial Hotel Tower,1-1-1 Uchisaiwai-cho,Chiyoda-ku,Tokyo 100-0011,Japan.E-mail:meetingj-circ.or.jpThis document is an
2、 English version of JCS 2018 Guideline on Diagnosis and Treatment of Acute Coronary Syndrome reported at the Japanese Circulation Society Joint Working Groups performed in 2018.(Website:http:/www.j-circ.or.jp/guideline/pdf/JCS2018_kimura.pdf).*Chairperson.Refer to Appendix 1 for the details of membe
3、rs.Joint Working Groups:The Japanese Circulation Society,the Japanese Association for Thoracic Surgery,the Japanese Association of Cardiac Rehabilitation,the Japanese Association of Cardiovascular Intervention and Therapeutics,the Japanese College of Cardiology,the Japanese Coronary Association,the
4、Japanese Heart Rhythm Society,the Japanese Society for Cardiovascular Surgery,the Japanese Society of Intensive Care MedicineISSN-1346-9843 All rights are reserved to the Japanese Circulation Society.For permissions,please e-mail:cjj-circ.or.jpJCS 2018 Guideline on Diagnosis and Treatment of Acute C
5、oronary SyndromeTable of ContentsI.Introduction 3 1.Regarding the Revision 3 2.Classifications and Evidence Levels 4 3.Abbreviations Used in the Guidelines 4II.Concept and Epidemiology 4 1.Concept and Definition 4 2.Epidemiology 6III.Prehospital Care 7 1.Emergency Medical Dispatchers 7 2.Initial Man
6、agement of Physician on Scene 7 3.Management of Emergency Medical Service Personnel 7 4.Emergency Medical System 8IV.Initial Diagnosis and Treatment 8 1.Initial Patient Evaluation 8 2.Initial Therapy 19V.STEMI 21 1.Primary PCI 21 2.Fibrinolysis 27 3.Emergent CABG 27 4.Assessment of Reperfusion 28 5.
7、Adjuncts to Reperfusion Therapy 28VI.NSTE-ACS 29 1.Risk Assessment 29 2.Conservative Strategy and Invasive Strategy 30 3.Coronary Revascularization 32VII.Evaluation and Management During Hospitalization 33 1.The Role of CCU 33 2.General Early-Phase Treatments 34 3.Pharmacological Therapy 36 4.Assist
8、ed Circulation 39 5.Management of Arrhythmias 42 6.Heart Failure Evaluation and Treatment 45 7.RV Infarction 47 8.Diagnosis and Treatment of Mechanical Complications After AMI 47 9.Prevention of Acute Kidney Injury(AKI)(Including CIN)After CAG and PCI 50 10.Bleeding Complication 52 11.Other Complica
9、tions 52 12.Assessment of Infarct Size 53 13.Cardiac Rehabilitation 56VIII.Conditions Requiring Special Consideration 59 1.The Elderly 59 2.Women 59 3.Coronary Spasm 60 4.Others 61IX.Secondary Prevention 62 1.General Therapy 62 2.Pharmacotherapy 63 3.Cardiac Rehabilitation 70 4.Regional Clinical All
10、iance 73X.Measurement and Assessment of the Quality of Diagnosis and Treatment 73 1.Approach by the PCI Registry(NCD)74 2.Approach Using the DPC Data(JROAD)74(Table of Contents continued the next page.)JCS GUIDELINESAdvance PublicationBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
11、BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB2KIMURA K et al.AbbreviationsXI.Recommendations for Social Activities Required to Prevent ACS and Improve Prognosis 74 1
12、.Enhancement of ECC System 74 2.Primary and Secondary Prevention for ACS 75XII.Future Challenges:Based on Differences Compared to European and NorthAmerican Clinical Practice Guidelines 75References 76Appendix 1 105Appendix 2 106AIVRaccelerated idioventricular rhythmACTactivated coagulation timeAPTT
13、activated partial thromboplastin timeAADacute aortic dissection ACSacute coronary syndromeAKIacute kidney injuryAMIacute myocardial infarctionADPadenosine diphosphateATPadenosine triphosphateACCAmerican College of CardiologyAHAAmerican Heart AssociationACEangiotensin converting enzyme ARBangiotensin
14、 II receptor blockerALPManterolateral papillary muscleANPatrial natriuretic peptideAVatrioventricularAEDautomated external defibrillatorBMSbare metal stentBLSbasic life supportBiPAPbiphasic positive airway pressureBMIbody mass indexBNPbrain natriuretic peptideCCBcalcium channel blockerCANVASCANaglif
15、lozin cardioVascular Assessment StudyCIcardiac indexCMRcardiac magnetic resonanceCVDcardiovascular diseaseCKDchronic kidney diseaseCTcomputed tomographyCPAPcontinuous positive airway pressureCINcontrast-induced nephropathyCAGcoronary angiographyCABGcoronary artery bypass grafting CADcoronary artery
16、diseaseCEcoronary artery embolismCCUcoronary care unitCKcreatine kinaseCK-MBcreatine kinase MBCRPC-reactive proteinDPCthe Diagnosis Procedure CombinationDPP-4dipeptidyl peptidase 4DOACdirect oral anticoagulantsDHAdocosahexaenoic acidDESdrug-eluting stentDAPTdual antiplatelet therapyEPA/AAeicosapenta
17、enoic/arachidonic acids ratioEPAeicosapentanoic acidECGelectrocardiogramECCemergency cardiovascular careEMSemergency medical serviceERemergency roomeGFRestimated glomerular filtration rateESCEuropean Society of CardiologyELIXAEvaluation of LIXisenatide in Acute Coronary SyndromeEXAMINEEXamination of
18、 CArdiovascular OutcoMes with AlogliptIN versus Standard of CarE in Patients with Type 2 Diabetes Mellitus and Acute Coronary SyndromeEXSCELExenatide Study of Cardiovascular Event LoweringFHfamilial hypercholesterolemiaFIELDFenofibrate Intervention and Event Lowering in DiabetesFDGfluorodeoxyglucose
19、FFRfractional flow reserveFOURIERFurther Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated RiskGIBgastrointestinal bleedingGLAGOVGlobal Assessment of Plaque Regression With a PCSK9 Antibody as Measured by Intravascular UltrasoundGRACEGlobal Registry of Acute Coronary E
20、ventsGLP-1glucagon-like peptide 1GIPglucose-dependent insulinotropic peptideH-FABPheart type fatty acid-binding proteinHbA1cHemoglobin A1cHITheparin-induced thrombocytopeniaHDL-Chigh-density lipoprotein cholesterolhANPhuman atrial natriuretic polypeptideICU-AWICU acquired weaknessICDimplantable card
21、ioverter defibrillatorIMPROVE-IT IMProved Reduction of Outcomes:Vytorin Efficacy International TrialICUintensive care unitIABPintra-aortic balloon pumpingIVUSIntravascular ultrasoundJCSthe Japanese Circulation SocietyJSICMthe Japanese Society of Intensive Care Medicine KPNCKaiser Permanente Northern
22、 CaliforniaLGElate gadolinium enhancementLADleft anterior descending coronary arteryLCXleft circumflex coronary arteryLVleft ventricularLVADleft ventricular assist deviceLVEFleft ventricular ejection fractionAdvance PublicationBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
23、BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB3JCS 2018 Guideline on Diagnosis and Treatment of Acute Coronary SyndromeI.Introduction1.Regarding the RevisionAcute coronary sy
24、ndromes(ACS)are a comprehensive disease concept characterized by acute myocardial isch-emia caused by disruption of coronary artery plaque and consequent thrombosis-induced severe coronary artery stenosis or occlusion,leading to unstable angina(UA),acute myocardial infarction(AMI)or sudden cardiac d
25、eath.However,these diagnoses cannot be established without evaluation of the time course of myocardial markers and were thus unsuitable for rapid diagnosis and establish-ment of the treatment policy in the emergency room.In addition,the prognosis of ACS with coronary artery thrombosis is considerabl
26、y different from that of stable coronary artery disease(CAD)with organic stenosis of the coronary arteries.In 1992,Fuster et al.proposed that unstable angina pectoris and AMI caused by coronary artery thrombosis are the same disease states and should therefore be included in the category of ACS.The
27、initial diagnosis and decision of management in the clinical setting thus changed considerably after introduction of the concept of ACS based on the underlying mechanism.In recent years,the introduction of cardiac troponin,which can detect even minor myocardial damage unable to be detected by creati
28、ne kinase(CK)or CK-MB,has also contributed substantially to the clinical diagnosis and risk stratification of ACS.Five years have passed,since the guidelines for the management of patients with ST-eleva-tion acute myocardial infarction(Chairperson:Kazuo Kimura)was issued by the Japanese Circulation
29、Society(JCS).However,revision of this guideline independently of the guidelines for management of acute coronary syndrome without persistent ST segment elevation(Chairperson:Takeshi Kimura)may not match the present conditions.LVFWRleft ventricular free wall ruptureLEADERLiraglutide Effect and Action
30、 in Diabetes:Evaluation of Cardiovascular Outcome ResultsLDL-Clow-density lipoprotein cholesterolMACEmajor adverse cardiovascular eventMVOmicrovascular obstructionMINOCAmyocardial infarction with non-obstructive coronary arteriesNACN-acetyl cysteineNCDthe National Clinical DatabaseNMESneuro muscular
31、 electrical stimulationNYHANew York Heart AssociationNPPVnon-invasive positive pressure ventilationNSAIDsnon-steroidal anti-inflammatory drugsNSTE-ACSnon-ST-segment elevation ACSNSTEMInon-ST-segment elevation myocardial infarctionNT-proBNPN-terminal pro B-type natriuretic peptideNNTnumber needed to
32、treatOGTToral glucose tolerance testPMpapillary musclePMRpapillary muscle rupturePCPSpercutaneous cardiopulmonary support PCIpercutaneous coronary interventionPADperipheral arterial diseasePDEphosphodiesterase PRECISE-IVUSPlaque Regression With Cholesterol Absorption Inhibitor or Synthesis Inhibitor
33、 Evaluated by Intravascular UltrasoundPEEPpositive end-expiratory pressurePETpositron emission tomographyPMPMposteromedian papillary musclePVCpremature ventricular contractionsPSVpressure support ventilationPACIFICPrevention of AtherothrombotiC Incidents Following Ischemic Coronary attackPCSK9propro
34、tein convertase subtilisin/kexin type 9PROactive PROspective pioglitAzone Clinical Trial In macroVascular EventsPPIproton-pump inhibitorpro-UKprourokinasePCWPpulmonary capillary wedge pressureQOLquality of lifeQIquality indicatorRCTrandomized clinical trial/randomized controlled trialREAL-CAD Random
35、ized Evaluation of Aggressive or Moderate Lipid Lowering Therapy With Pitavastatin in Coronary Artery DiseaseRICremote ischemic conditioningRCAright coronary arteryRVright ventricular SAVOR-TIMI53Saxagliptin Assessment of Vascular Outcomes Recorded in patients with diabetes mellitus Thrombolysis in
36、Myocardial Infarction-53SCrserum creatinineSPECTsingle photon emission computed tomographySGLT-2sodium glucose co-transporter 2SCADspontaneous coronary artery dissectionSTEMIST-segment elevation myocardial infarctionSTOP-NIDDMStudy to Prevent NIDDMTIMIThrombolysis in Myocardial InfarctiontPAtissue p
37、lasminogen activatorTECOSTrial Evaluating Cardiovascular Outcomes with SitagliptinSUSTAIN-6 Trial to Evaluate Cardiovascular and Other Long-term Outcomes with Semaglutide in Subjects with Type 2 DiabetesTAPTtriple antiplatelet therapyUFHunfractionated heparinUKPDSUnited Kingdom Prospective Diabetes
38、StudyUAunstable anginaVA-ECMOveno-arterial extracorporeal membrane oxygenationVFventricular fibrillationVSPventricular septal perforationVSRventricular septal ruptureVTventricular tachycardiaWCDwearable cardioverter defibrillator95%CI95%confidence intervalAdvance PublicationBBBBBBBBBBBBBBBBBBBBBBBBB
39、BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB4KIMURA K et al.Although the short-term outcomes of patients with ACS have impro
40、ved,the long-term outcomes,which can be negatively affected by heart failure,must be further improved.Guidelines for secondary prevention of myocar-dial infarction(Chairperson:Hisao Ogawa)were issued 7 years ago,and remarkable progress has been made in this field.We therefore comprehensively integra
41、ted the 3 guidelines consisting of the guidelines for the management of patients with ST-elevation acute myocardial infarction,the guidelines for management of acute coronary syndrome without persistent ST segment elevation,and the guidelines for secondary prevention of myocardial infarction into“JC
42、S 2018 guideline on diagnosis and treatment of acute coronary syndrome.”At present,ACS guideline including ST-segment elevation acute myocardial infarction(STEMI)and non-ST-segment elevation acute coronary syndrome(NSTE-ACS)is not available as American College of Cardiology(ACC)/American Heart Assoc
43、iation(AHA)guidelines or European Society of Cardiology(ESC)guidelines.We therefore attempted to avoid short-comings and duplication of the contents from the stage of chapter preparation.However,similar descriptions were found in parts of the manuscript.In the present guidelines,recommendation level
44、s and evidence levels were stated similarly to the conventional Japanese Circulation Society guidelines,ACC/AHA guidelines,and ESC guidelines.In addition,class III recommendations were classified as“no benefit”and“harm”in accordance with the ACC/AHA guidelines.The present guidelines were designed to
45、 be used as a reference in Asian countries,not only in Japan,and new efforts were incorporated during the preparation.Guidelines for diagnosis and treatment should be reviewed by all members of group meetings to avoid biased opinions and ways of thinking.However,owing to the extensive contents and m
46、any committee members involved in con-solidation of the 3 guidelines,it is difficult to hold the meet-ings of the committee members many times over a long period.Working groups consisting of members who wanted to participate were therefore established to discuss manuscript revisions in a training ca
47、mp format and hold multiple mail discussions.In particular,we extensively discussed classifications and evidence levels for which opinions were divided,spending as much time on discus-sion as possible.Guidelines are prepared on the basis of a critical appraisal of evidence obtained from large clinic
48、al trials and observation studies of patients with the diseases covered by the guidelines and are designed to standardize and improve the quality of medical treatment.Guideline recommendations are designed for average patients with disease.Guidelines should not be followed uniformly in a medical car
49、e setting.Patients for whom the guidelines are indicated as well as differences among individual patients should be considered,and it is important to indicate treat-ment best suited to the individual patient.The results of diagnosis and treatment performed according to the guide-lines as well as pro
50、blems should be clarified,and improved guidelines should be prepared after several years to con-tribute to enhancing the levels of diagnosis and treatment provided to patients.2.Classifications and Evidence LevelsUnapproved techniques,treatments,and drugs not yet approved in Japan or for which adequ