ሗ࿌
ෙື⬦
CT ࠾࠸࡚ positive-remodeling
low attenuation ࢆ♧ࡋࡓ㒊ࡀ
2 ᖺᚋᛴᛶෙೃ⩌ࡢ culprit region ࡞ࡗࡓ 1
୰᰿┿࿃1)ࠊబ⸨ᶞ2)ࠊ⸨⏣ኸ2)ࠊᒣཱྀᒎᐶ2)ࠊᑿୖ⣖Ꮚ2)ࠊ▼ሯ2)ࠊ⠛ᓮẎ2) 1) ྎ་⒪ࢭࣥࢱ࣮ ◊ಟ་ ᚠ⎔ჾෆ⛉ 2) ྎ་⒪ࢭࣥࢱ࣮ ᚠ⎔ჾෆ⛉ Ӑᢒ㘓ӑ ࡣ78 ṓ⏨ᛶࠋᖹᡂ 23 ᖺ 6 ᭶ព㆑ᾘኻⓎసࡢࡓࡵᙜ㝔⚄⤒ෆ⛉ධ㝔࡞ࡗࡓࠋཎᅉ⢭ᰝࡢࡓࡵ 256 ิෙື⬦ CT ࢆ⏝࠸࡚ෙື⬦ࢆホ౯ࡋࡓࡀࠊ᭷ព⊃✽ࢆㄆࡵ࡞ࡗࡓࠋෙື⬦ᝈ࡛ࡣ࡞࠸デ᩿ࡉࢀ ࡓࠋLDL ࢥࣞࢫࢸ࣮ࣟࣝࡶṇᖖ⠊ᅖ࡛࠶ࡗࡓࡓࡵࢫࢱࢳࣥࡣᢞࡉࢀ࡞ࡗࡓࠋ2 ᖺᚋ⬚③ࢆッᙜ 㝔ࢆཷデࡋࡓࠋᚰ㟁ᅗᕥ༶⯆㒊ㄏᑟࡢST ୖ᪼ࢺ࣏ࣟࢽࣥ T ࡢୖ᪼ࢆㄆࡵࠊᛴᛶෙೃ⩌デ᩿ࡋࡓࠋ ⥭ᛴෙື⬦㐀ᙳ࡚ᕥෙື⬦ᖿ㒊㉳ጞ㒊90%⊃✽ࢆㄆࡵࠊෙື⬦ࢫࢸࣥࢺ␃⨨⾡ࢆ⾜ࡋࡓࠋ ึᅇධ㝔ࡢෙື⬦CT ⏬ീࢆᨵࡵ࡚ヲ⣽ 3 ḟඖᵓᡂࡋࡓࡇࢁࠊᕥෙື⬦㉳ጞ㒊 culprit region positive remodeling low attenuation ࢆ᭷ࡍࡿࣉ࣮ࣛࢡࢆㄆࡵࡓࠋෙື⬦ CT ࠾࠸࡚ࠊࡇࡢ 2 ࡘࡢ≉ ᚩࢆ᭷ࡍࡿࣉ࣮ࣛࢡࡀᛴᛶෙೃ⩌ࡢⓎࢆண▱ࡍࡿ࠸࠺௬ㄝྜ⮴ࡍࡿ࡛࠶ࡗࡓࠋ
࣮࣮࢟࣡ࢻ㸸ᛴᛶෙೃ⩌ࠊpositive remodelingࠊlow attenuationࠊࣉ࣮ࣛࢡ◚ࠊෙື⬦ CT
㸦2013 ᖺ 12 ᭶ 1 ᪥ཷ㡿ࠊ2014 ᖺ 2 ᭶ 14 ᪥᥇⏝㸧 㸯 ึࡵ ᛴᛶෙೃ⩌ࡣ⬤ᙅࣉ࣮ࣛࢡࡢ◚⥢ࡼࡗ࡚Ⓨ ⏕ࡍࡿࠋࡋࡋࠊ◚⥢ࣜࢫࢡࡢ㧗࠸⬤ᙅࣉ࣮ࣛࢡࢆ 㠀くⓗデ᩿ࡍࡿ᪉ἲࡀ࡞࠸ࡇࡀࡁ࡞⮫ᗋ ⓗၥ㢟࡞ࡗ࡚࠸ࡿࠋ㏆ᖺࠊෙື⬦CT ࠾ࡅࡿ
positive remodeling low attenuation ࡀࣉ࣮ࣛࢡ ◚⥢ࡢண▱ᅉᏊ࡛࠶ࡿሗ࿌ࡉࢀ࡚࠸ࡿࠋᡃࠎࡣ 256 ิෙື⬦ CT ࢆ⏝࠸࡚ࠊୖグࡢ௬ㄝྜ⮴ࡋࡓ ࢆ⤒㦂ࡋࡓࡢ࡛ሗ࿌ࡍࡿࠋ 㸰 ᝈ⪅㸸78 ṓ ⏨ᛶ ッ㸸⬚③ ᪤ Ṕ㸸๓❧⭢⒴ࠊᑠ⬻ฟ⾑ࠊ㧗⾑ᅽࠊ㛢ሰᆺ╧╀ ↓྾ೃ⩌ࠊࣛࢡࢼ᱾ሰ ➨୍ᅇධ㝔 ⌧Ṕ ᖹᡂ23 ᖺ 6 ᭶ࠊṑࢆ☻࠸࡚࠸ࡿ✺↛ࠊព㆑ ᾘኻࢆࡁࡓࡋࡓࠋ2-3 ศ࡛ぬ㓰ࡋࡓࠋ⬚③ࡣඛ⾜ࡋ ࡚࠸࡞ࡗࡓࠋᙜ㝔ᩆᛴᦙ㏦ࡉࢀ⚄⤒ෆ⛉ධ㝔 ࡞ࡗࡓࠋ
62
ධ㝔⌧
⾑ᅽ121/72, ⬦ᢿ 92, SpO2 95% (room air) ࠊᚰ
㞧㡢ࣛ㡢ࡣ⫈ྲྀࡏࡎࠊ⚄⤒Ꮫⓗᡤぢࡣṇᖖ࡛࠶ࡗ ࡓࠋ ධ㝔᳨ᰝᡤぢ ⾑ᾮ⏕Ꮫ᳨ᰝ㸦⾲1㸧 ࢺ࣏ࣟࢽࣥI ࡢ୍㐣ᛶୖ᪼ࢆㄆࡵࡓࠋ ⾲㸯 ➨୍ᅇධ㝔➨ᅇධ㝔ࡢ⏕Ꮫ᳨ᰝࠋH: ␗ᖖ 㧗್ࠊn/a: ィ ್࡞ࡋࠋ ⤒㐣 ⬚㒊X ⥺┿ࠊᚰ㟁ᅗࠊᚰ⮚㉸㡢Ἴ᳨ᰝࠊ࣍ࣝࢱ ࣮ᚰ㟁ᅗࠊᚰᐊ㐜ᘏ㟁᳨ᰝࠊ㢕ື⬦㉸㡢Ἴ᳨ᰝࠊ 㢌㒊MR ⾑⟶㐀ᙳἲ࡚ព㆑ᾘኻࡢཎᅉࢆㄝ࡛᫂ ࡁࡿᡤぢࢆㄆࡵ࡞ࡗࡓࠋෙື⬦CT㸦ᅗ㸯㸪128
ิ2 ⟶⌫, SOMATOM Definition Flash,
Siemens㸧ࢆ⾜ࡋࡓࠋᕥෙື⬦ᖿ㒊ࣉ࣮ࣛ ࢡࢆㄆࡵࡓࡀࠊ᭷ព⊃✽ࡣㄆࡵ࡞ࡗࡓ㸦ᅗ㸯㸧ࠋ ࢺ࣏ࣟࢽࣥI ࡢ୍㐣ᛶୖ᪼ࡢཎᅉࡣ࡛᫂࠶ࡿࡀࠊ ㏞㉮⚄⤒ᑕࡼࡿព㆑ᾘኻࢆᙉࡃࡗࡓࠋLDL ࢥࣞࢫࢸ࣮ࣟࣝࡣṇᖖ್࡛࠶ࡗࡓࡓࡵࠊࢫࢱࢳࣥࡀ ᢞࡉࢀࡿࡇ࡞ࡃ㏥㝔࡞ࡗࡓࠋ ᅗ㸯 ➨୍ᅇධ㝔⾜ࡉࢀࡓᕥෙື⬦ᖿ㒊ᅇ᪕ᯞ ࡢෙື⬦CT ⏬ീࠋ᭷ព⊃✽ࢆㄆࡵ࡞࠸ࠋᕥෙື⬦ᖿ㒊㉳ ጞ㒊ࣉ࣮ࣛࢡࢆㄆࡵࡿ㸦▮༳㸧ࠋ ➨ᅇධ㝔 ➨୍ᅇ┠ධ㝔ࡢ2 ᖺᚋࠊᖹᡂ 25 ᖺ 5 ᭶ᮎ㡭ࡼࡾ ປసࡸᒀ⬚③࣭ື࣭෭ờࢆឤࡌࡿࡼ࠺ ࡞ࡗࡓࠋྠᖺ6 ᭶ 5 ᪥ṑ☻ࡁ୰ᙉ࠸⬚③෭ờ࠶ ࡾࠋྠ᪥ᙜ㝔ᚠ⎔ჾෆ⛉ཷデ࡞ࡗࡓࠋᛴᛶෙೃ ⩌ࢆࢃࢀධ㝔࡞ࡗࡓࠋ ᅗ㸰 ➨ᅇධ㝔ࡢ⬚㒊༢⣧ࣞࣥࢺࢤࣥ┿ࠋᚰ⬚㒌 ẚ54.0㸣ࠊ⫵㔝␗ᖖࢆㄆࡵ࡞࠸ࠋ
63
ධ㝔⌧
⾑ᅽ 151/61ࠊ⬦ᢿ 85, SpO2 98% (room air)ࠊ ᚰ㞧㡢ࣛ㡢ࡣ⫈ྲྀࡏࡎࠊ⚄⤒Ꮫⓗᡤぢ↓ࡋ ධ㝔᳨ᰝᡤぢ ⬚㒊X ⥺┿㸦ᅗ㸰㸧 ᚰ⬚㒌ẚ54.0㸣ࠊ⫵㔝௨ୖࢆㄆࡵ࡞࠸ࠋ ᚰ㟁ᅗ㸦ᅗ㸱㸧 ᕥഃ⬚㒊ㄏᑟST పୗࢆㄆࡵࡓࠋ ᅗ㸱 ➨ᅇධ㝔ࡢ12 ㄏᑟᚰ㟁ᅗ㸸ධ㝔ᕥഃ⬚㒊ㄏᑟ ࡢST పୗࢆㄆࡵࡓࠋ ⾑ᾮ⏕Ꮫ᳨ᰝ㸦⾲㸯㸧㸸 ࢺ࣏ࣟࢽࣥT ࡢୖ᪼ㄆࡵࡓࠋ ᅗ㸲 ➨ᅇධ㝔ࡢ⥭ᛴෙື⬦㐀ᙳ㸦ྑ๓ᩳ30 ᗘࠊ㢌ഃ 30 ᗘ㸧ࠋᕥෙື⬦ᖿ㒊 90%⊃✽ࢆㄆࡵࡿ㸦▮༳㸧ࠋ ⤒㐣 ᛴᛶෙೃ⩌デ᩿ࡋࠊ⥭ᛴෙື⬦㐀ᙳ᳨ᰝࢆ ⾜ࡗࡓࠋᕥᶨ㦵ື⬦ࣉ࣮ࣟࢳ࡚ෙື⬦㐀ᙳࢆ⾜ ࠸ࠊᕥෙື⬦ᖿ㒊90%⊃✽ࢆㄆࡵࡓ㸦ᅗ㸲㸧ࠋ
⾑⟶ෆ㉸㡢Ἴἲ㸦IVUS㸧ࡼࡗ࡚ culprit region
ࢆほᐹࡋࡓࡀࠊ᫂ࡽ࡞low attenuation ࢆక࠺ࣉ ࣮ࣛࢡࢆㄆࡵ࡞ࡗࡓࠋ1 㐌㛫ᚋࢺ࣏ࣟࢽࣥ T ࡣ ṇᖖࡋࡓࠋᚋ᪥ࠊኚ㒊⸆⁐ฟᛶࢫࢸࣥࢺ Noboriࢆ␃⨨ࡋࡓࠋࢫࣆࣜࣥ⭠⁐㘄 100mg ࣅࢱࣂࢫࢱࢳࣥ2mg ࡀᢞࡉࢀࠊධ㝔 24 ᪥┠㏥ 㝔࡞ࡗࡓࠋ ᨵࡵ࡚➨୍ᅇ┠㸦ᖹᡂ23 ᖺ 6 ᭶㸧ධ㝔ࡢෙື ⬦CT ⏬ീࢆヲ⣽ 3 ḟඖᵓᡂࡋࡓࡇࢁࠊᕥෙ ື⬦ᖿ㒊ࡢ⊃✽ࢆㄆࡵࡓculprit region ୍⮴ࡋ
࡚ࠊ⾑⟶ࡢpositive remodeling 㤿㋟ᙧࡢ low
attenuation㸦CT ್: 20 HU㹼40HU㸧㡿ᇦࢆྵࡴ ࣉ࣮ࣛࢡࢆㄆࡵࡓ㸦ᅗ㸳㸧ࠋෙື⬦ࡢࡢ㒊ࡣࠊ ࡇࡢࡼ࠺࡞ᡤぢࡣㄆࡵ࡞ࡗࡓࠋ
ᅗ㸳 ➨୍ᅇධ㝔⾜ࡉࢀࡓෙື⬦CT ࡢᵓᡂ⏬ീࠋ
A): ື⬦ࡽᕥෙື⬦ᖿ㒊ࠋࣉ࣮ࣛࢡෆ low attenuation 㡿ᇦ㸦CT ್㸸20 HU㹼40 HUࠊ୕ゅ㸧ࢆㄆࡵ ࡿࠋB): A)࠾ࡅࡿኴᐇ⥺▮༳㸦B㸧ࡢ⨨࡛ࡢᶓ᩿㠃ࠋእ
ഃ✺ฟࡋࡓࣉ࣮ࣛࢡࠊࡑࡢෆ㒊ࡢ㤿㋟ᙧࡢlow
attenuation 㡿ᇦ㸦CT ್㸸20 HU㹼40 HU㸧ࢆㄆࡵࡿ㸦୕ ゅ㸧ࠋC)㸸A)࠾ࡅࡿኴⅬ⥺▮༳㸦C㸧ࡢ⨨࡛ࡢᶓ᩿㠃ࠋ ࣉ࣮ࣛࢡࢆㄆࡵ࡞࠸ࠋ
㸱 ⪃ᐹ
ᛴᛶෙೃ⩌ࡣ⾑⟶ෆᚄࡀ㍍ᗘࡽ୰➼ᗘ⊃ ✽ࡋࡓ㒊Ꮡᅾࡍࡿ⬤ᙅࣉ࣮ࣛࢡࡽⓎ⏕ࡍࡿ ⪃࠼ࡽࢀ࡚࠸ࡿ1)ࠋࡋࡋࠊෙື⬦ࡢ⊃✽ᗘࣉ ࣮ࣛࢡࡢ⬤ᙅᛶࡣ┦㛵ࡋ࡞࠸ࡓࡵࠊෙື⬦㐀ᙳ᳨ᰝ ࡼࡗ࡚⬤ᙅࣉ࣮ࣛࢡࢆデ᩿ࡍࡿࡇࡣ࡛ࡁ࡞࠸ࠋ ࡇࡢࡓࡵࠊᵝࠎ࡞⬤ᙅࣉ࣮ࣛࢡデ᩿ἲࡀヨࡳࡽࢀ࡚ ࡁࡓࠋෙື⬦CT ⏬ീࡣࠊࡑࡢゎീᗘࡀ᱁ẁྥୖ ࡋ࡚ࡁࡓࡓࡵࠊ㠀くⓗࣉ࣮ࣛࢡࡢ㉁ࢆデ᩿࡛ࡁ ࡿᙉຊ࡞ࢶ࣮ࣝ࡞ࡗ࡚࠸ࡿࠋ㏆ᖺࠊෙື⬦CT ⏬
ീ࠾ࡅࡿpositive remodeling ࠊlipid core ᑐ
ᛂࡍࡿࣉ࣮ࣛࢡෆlow attenuation 㡿ᇦࡀ⬤ᙅࣉࣛ
࣮ࢡࡢ≉ᚩࡶࡋࢀ࡞࠸ࡇࠊࡑࡋ࡚ࠊࡇࡢ2 ࡘࡢ
≉ᚩࡢᏑᅾࡀᛴᛶෙೃ⩌ࡢⓎࢆண▱ࡍࡿྍ⬟
ᛶࡀ࠶ࡿࡇࡀሗ࿌ࡉࢀ࡚࠸ࡿ2, 3)ࠋ
ᮏ࠾࠸࡚ࠊ1 ᅇ┠ධ㝔࡛ㄆࡵࡽࢀࡓ positive remodeling low attenuation 㡿ᇦࡀ 2
ᖺᚋᛴᛶෙೃ⩌ࡢculprit lesion ࡞ࡗࡓࡇ
ࡣୖグࡢ௬ㄝྜ⮴ࡍࡿࠋࡲࡓࠊlow attenuation
㡿ᇦࡢCT ್ࡣ 20 HU㹼40HU ࡛࠶ࡗࡓࡇࡶࠊࡇ
ࢀࡲ࡛ࡢሗ࿌୍⮴ࡍࡿ3)ࠋ୍᪉ࠊPohle ࡽࡣࠊIVUS
ࡼࡗ࡚デ᩿ࡉࢀࡓlipid rich ࣉ࣮ࣛࢡ fibrous
ࣉ࣮ࣛࢡࡢCT ್ࡢ㛫ࡣࡁ࡞ over lap ࡀ࠶ࡿ
ሗ࿌ࡋ࡚࠸ࡿ㸦lipid rich ࣉ࣮ࣛࢡ: 58s43HU,
fibrous ࣉ࣮ࣛࢡ: 121s34㸧㸲)ࠋᮏࡢlow attenuation ࡣࠊࡇࡢ overlap ࡢ㡿ᇦࢆศୗᅇ ࡗ࡚࠸ࡿࡇࡽࠊlipid rich ࡞ᛶ≧࡛࠶ࡗࡓ⪃ ࠼ࡽࢀࡿࠋ ࡲࡓࠊ㐀ᙳࡼࡿࣉ࣮ࣛࢡࡢ㐀ᙳຠᯝࡀlow attenuation ࡢྠᐃᙳ㡪ࢆ࠼ࡿྍ⬟ᛶࡶ࠶ࡿࠋ low attenuation 㡿ᇦࡢ㎶⦕㒊ࡣ⾑ὶࢆ᭷ࡍࡿྍ⬟ ᛶࡀ࠶ࡿࡓࡵࠊタࡼࡗ࡚␗࡞ࡿ㐀ᙳࣉࣟࢺࢥ࣮ ࣝࡀlow attenuation ࡢࢧࢬࢆつᐃࡍࡿࡶࡋࢀ ࡞࠸ࠋ≉ࠊప⏬ീゎീᗘࡢሙྜࡣ㐀ᙳຠᯝࡼ ࡗ࡚low attenuation ࡀᾘኻࡋ࡚ぢ࠼ࡿྍ⬟ᛶࡀ࠶ ࡿࠋ୍᪉ࠊゎീᗘࡢ㧗࠸⏬ീ㸦ᅗ5㸧࡛࠶ࢀࡤࠊ㐀 ᙳຠᯝࡣlow attenuation ࡢቃ⏺㒊ࢆ᫂☜ࡍࡿࡓ ࡵࠊࡑࡢᏑᅾデ᩿ࡢࡓࡵ᭷┈࡛࠶ࡿࠋ 2 ᅇ┠ධ㝔⾜ࡗࡓ IVUS ⏬ീࡣ low attenuation ࣉ࣮ࣛࢡࢆㄆࡵ࡞ࡗࡓࠋࡑࡢ⌮⏤ࡣ IVUS ⏬ീࡀ◚ᚋࡢࣉ࣮ࣛࢡ⏬ീ࡛࠶ࡗࡓࡓࡵ ᛮࢃࢀࡿࠋ2 ᅇ┠ධ㝔ෙື⬦ CT ࢆ⾜ࡋ࡚࠸ ࡞࠸ࡓࡵࠊࣉ࣮ࣛࢡᛶ≧ࡀ⤒ⓗࡢࡼ࠺ኚ ࡋࡓࡣ࡛᫂࠶ࡿࠋ ᮏ࠾࠸࡚ࠊ㸯ᅇ┠ධ㝔ࡽ2 ᅇ┠ධ㝔ࡲ࡛ ࡢᮇ㛫ࠊࢫࢱࢳࣥࡀᢞࡉࢀ࡚࠸࡞ࡗࡓࡇࡀ ᛴᛶෙೃ⩌Ⓨ㛵㐃ࡋ࡚࠸ࡓྍ⬟ᛶࡀ࠶ࡿࠋࢫ ࢱࢳࣥࡣࣉ࣮ࣛࢡ⦰ᑠຠᯝࡸ⓶⭷Ᏻᐃຠᯝ5. 6)ࡀ ࠶ࡿࡓࡵࠊෙື⬦ᝈࡢ1 ḟண㜵㔜せ࡛࠶ࡿࠋࡋ ࡋࠊ1 ᅇ┠ධ㝔ࡢ⬡㉁᳨ᰝࢹ࣮ࢱࡣṇᖖ⠊ᅖ࡛ ࠶ࡾࠊ᪥ᮏື⬦◳Ꮫࡢື⬦◳ᛶᝈண㜵࢞ ࢻࣛࣥ2012 ᖺ∧ᚑࡗ࡚ࡶࠊࢫࢱࢳࣥᢞࡢ㐺 ᛂࡣ࡞ࡽ࡞࠸ࠋࡲࡓࠊ2 ᅇ┠ධ㝔ࡢ LDL ࢥࣞ ࢫࢸ࣮ࣟࣝࡶྠᵝṇᖖ್࡛࠶ࡗࡓࠋෙື⬦CT
ࡼࡗ࡚positive remodeling low attenuation ࡀ
ほᐹࡉࢀࡓࠊࢫࢱࢳࣥࡀᛴᛶෙೃ⩌1 ḟண㜵
᭷ຠ࡛࠶ࡿྰࡣᮍࡔ࡛᫂࠶ࡿࠋࡉࡽ࡞ࡿ ࡢ㞟✚◊✲ࡀᚲせ࡛࠶ࡿࠋ
㸲
㸲 ⤖ㄒ
Positive remodeling low attenuation ࢆㄆࡵ
ࡿෙື⬦ࣉ࣮ࣛࢡ㒊ࡀᛴᛶෙೃ⩌ࡢculprit
lesion ࡞ࡗࡓࢆ⤒㦂ࡋࡓࠋ⬤ᙅࣉ࣮ࣛࢡࡢデ
᩿ෙື⬦CT ࡣ᭷⏝࡛࠶ࡿࠋ
㸳 ᩥ⊩
1㸧 Higashi M: Noninvasive Assessment of Coronary Plaque Using Multidetector Row Computed Tomography : Circ J 2011;75: 1522-1528
2㸧 Motoyama S, Kondo T, Sarai M, et al : Multislice Computed Tomographic
Characteristics of Coronary Lesions in Acute Coronary Syndromes : J Am Coll Cardiol 2007; 50:319-326
3㸧 Motoyama S, Sarai M, Harigaya H, et al: Computed Tomographic Angiography Characteristics of Atherosclerotic Plaques Subsequently Resulting in Acute Coronary Syndrome : J Am Coll Cardiol 2009; 54: 49-57 4㸧 Pohle K, Achenbach S, MacNeill B, et al:
Characterization of non-calcified coronary atherosclerotic plaque by multi-detector row CT: Comparison to IVUS. Atherosclerosis 2007;190:174-180
5㸧 Nissen SE, Nicholls SJ, Sipahi I, et al.: Effect of very high-intensity statin therapy on regression of coronary atherosclerosis: the ASTEROID trial. JAMA 2006;295: 1556-65 6㸧 Okazaki S, Yokoyama T, Miyauchi K, et al.
Early statin treatment in patients with acute coronary syndrome: demonstration of the beneficial effect on atherosclerotic lesions by serial volumetric intravascular ultrasound analysis during half a year after coronary event: the ESTABLISH Study. Circulation 2004;110:1061-1068
