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,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,编辑课件,*,Is early invasive the answer for ACS,Dr. Ben He MD/PhD/FSCAI/FAPSIC,Director of Cardiology Department,Renji Hospital Affiliated to Shanghai Jiaotong university,编辑课件,Is early invasive the answer f,1,Pathophysiology of Acute Coronary Syndrome,编辑课件,Pathophysiology of Acute Coron,2,ACS is an Important Manifestation of Atherothrombosis,1,1. Cannon CP.,J Thromb Thrombolysis,1995; 2: 205,218.,Antithrombotic,therapy,Stable,angina,UA,Non-Q-wave MI,Thrombolysis,primary PCI,Q-wave,MI,Minutes,hours,Days,weeks,STEMI,UA/NSTEMI,Atherothrombosis,New term,Old term,Plaquerupture,编辑课件,ACS is an Important Manifestat,3,编辑课件,编辑课件,4,Relation of TIMI risk score and MACE rate,编辑课件,Relation of TIMI risk score an,5,Hot topic in ACS,Is early invasive superior to conservative strategy in ACS?,Should invasive be deferred for cooling off?,What is the optimal time for invasive?,编辑课件,Hot topic in ACS编辑课件,6,编辑课件,编辑课件,7,Optimal Strategy for UA/NSTEMI,TIMI IIIB,2005,Conservative,Invasive,VANQWISH,FRISC II,TACTICS-TIMI 18,RITA-3,编辑课件,Optimal Strategy for UA/NSTEMI,8,FRICS-II: high risk get more,编辑课件,FRICS-II: high risk get more编辑,9,TIMI-18: high risk get more,编辑课件,TIMI-18: high risk get more编辑课,10,RITA-3: 1&3 yrs outcome,编辑课件,RITA-3: 1&3 yrs outcome编辑课件,11,RITA-3: 5yrs outcome,编辑课件,RITA-3: 5yrs outcome编辑课件,12,编辑课件,编辑课件,13,编辑课件,编辑课件,14,编辑课件,编辑课件,15,In 2005,It seems we found answer,In ACS, early invasive superior to early conservative,This is particular true in high risk patients,编辑课件,In 2005,It seems we found answ,16,ESC Guideline 2005,编辑课件,ESC Guideline 2005编辑课件,17,编辑课件,编辑课件,18,Is the problem settled?,编辑课件,Is the problem settled?编辑课件,19,ICTUS Designed,编辑课件,ICTUS Designed编辑课件,20,编辑课件,编辑课件,21,编辑课件,编辑课件,22,编辑课件,编辑课件,23,编辑课件,编辑课件,24,编辑课件,编辑课件,25,编辑课件,编辑课件,26,4 yrs ICTUS Lancet 2007;369:827-835,However, most of selective pts were performed PCI,So, the long-term f/u results do not inflect Inv/Cons strategy,编辑课件,4 yrs ICTUS Lancet 2007;369:,27,4 yrs ICTUS Lancet 2007;369:827-835,编辑课件,4 yrs ICTUS Lancet 2007;369:,28,ICTUSs criticism,Liberty definition of MI (only 1*ULN) causing the early MI increase in early invasive group,3yrs revascularization rate was equal in 2 group(81%PCI),1year mortality rate in ACS in both arm are very low(2.5%),Is it a real high risk?,编辑课件,ICTUSs criticism Liberty defi,29,Even put ICTUS into pool, Inv Cons,编辑课件,Even put ICTUS into pool, Inv,30,Inv vs Cons/All cause death,High risk?,编辑课件,Inv vs Cons/All cause death Hi,31,编辑课件,编辑课件,32,编辑课件,编辑课件,33,2007 ESC Guideline,Urgent,Coronary angiography is recommended in Pts with refractory or recurrent angina associated with dynamic ST deviation, heart failure, life threatening arrhythmias, or haemodynamic instability,(I-C),Early(72h),angiography followed by revascularization (PCI or CABG) in patients with intermediate to high risk features is recommended (I-A),编辑课件,2007 ESC GuidelineUrgent Coron,34,Monocyte,LDL-C,Adhesion molecule,Macrophage,Foam cell,OxidizedLDL-C,Plaque rupture,Smooth muscle cells,CRP,2,编辑课件,MonocyteLDL-CAdhesion molecul,35,ISAR-COOL Trial,编辑课件,ISAR-COOL Trial编辑课件,36,ISAR-COOL Antithrombotic Regimen,编辑课件,ISAR-COOL Antithrombotic Regim,37,编辑课件,编辑课件,38,ISAR-COOL,编辑课件,ISAR-COOL编辑课件,39,编辑课件,编辑课件,40,编辑课件,编辑课件,41,编辑课件,编辑课件,42,What is the optimal time for PCI?,编辑课件,What is the optimal time for P,43,编辑课件,编辑课件,44,Methods for Optimal trial,编辑课件,Methods for Optimal trial编辑课件,45,Results of Optimal trial,编辑课件,Results of Optimal trial编辑课件,46,Conclusion from Optimal trial,编辑课件,Conclusion from Optimal trial编,47,Whats the difference between ISAR-Cool & Optimal?,2.5 vs 84 +,0.5 vs 25 -,编辑课件,Whats the difference between,48,Time to Coronary Angiography and Outcomes Among Patients With High-Risk NonST-SegmentElevation Acute Coronary Syndromes: Results From the,SYNERGY Trial,Pierluigi Tricoci, MD, MHS, PhD; Yuliya Lokhnygina, PhD; Lisa G. Berdan, PA-C, MHS; Steven R. Steinhubl, MD; Dietrich C. Gulba, MD; Harvey D. White, MD; Neal S. Kleiman, MD; Philip E. Aylward, MD; Anatoly Langer, MD; Robert M. Califf, MD; James J. Ferguson, MD; Elliott M. Antman, MD; L. Kristin Newby, MD, MHS; Robert A. Harrington, MD; Shaun G. Goodman, MD; Kenneth W. Mahaffey, MD,Division of Cardiology, Duke Clinical Research Institute, Durham, NC,编辑课件,Time to Coronary Angiography a,49,Background,2007 ACC/AHA Guidelines for NSTE ACS recommend the use of an early invasive strategy for high-risk patients,Randomized clinical trials on,early vs. conservative,strategy used different timing of cardiac catheterization,Optimal timing of cardiac catheterization in NSTE ACS not yet established (,expedited vs. deferred,),Expedited catheterization increasingly adopted in the US,编辑课件,Background2007 ACC/AHA Guideli,50,Study Objective,To evaluate the association between time from hospital admission to cardiac catheterization and adverse outcomes among high-risk patients with NSTE ACS treated with an early invasive strategy (cardiac catheterization,48h of hospital admission),编辑课件,Study ObjectiveTo evaluate the,51,Study Population,Patients randomized in the SYNERGY trial,Ischemic symptoms,60 years,ST-segment depression or transient elevation,Positive troponin and/or CK-MB,Use of coronary angiography in SYNERGY,10,027 pts randomized in the SYNERGY trial,9,188 pts underwent cardiac catheterization,6,352 pts underwent cardiac catheterization,48h,编辑课件,Study PopulationPatients rando,52,Adjusted Estimates of 30-day Death/MI Rates (with 95% CI),.0,.0,编辑课件,Adjusted Estimates of 30-day D,53,Landmark Analysis: Adjusted OR of 30-day Death/MI (with 95% CI),编辑课件,Landmark Analysis: Adjusted OR,54,Adjusted Estimates of In-hospital Transfusion Rates (with 95% CI),编辑课件,Adjusted Estimates of In-hospi,55,Study Limitations,Non-randomized observational analysis,Propensity-based models used to deal with lack of randomization,Time to cath is a post-baseline and “dynamic” variable,Statistical methodologies attempted to address these issues,Events from hospital admission to randomization not available,Events unlikely prior to randomization,Myocardial infarction in the first hours following the hospitalization is more difficult to adjudicate,编辑课件,Study LimitationsNon-randomize,56,Conclusions from Synergy- 1,Observational analysis among high-risk NSTE ACS patients enrolled in the SYNERGY trial treated with an early invasive strategy,Reduced time to cardiac catheterization was associated with decreased probability of 30-day death/MI and no changes in bleeding,No signals suggesting benefits of delaying the cardiac catheterization were observed,编辑课件,Conclusions from Synergy- 1Obs,57,Conclusions from Synergy- 2,Randomized clinical trials to establish optimal timing of catheterization in NSTE ACS are needed but challenging,Delaying cath is problematic for hospital adopting expedited cath strategy,Lag from hospitalization to randomization may confound actual time to catheterization intervals,Early re-MI adjudication complex,Well-designed observational studies may be of value in the debate on optimal timing of cardiac catheterization among NSTE ACS patients,编辑课件,Conclusions from Synergy- 2Ran,58,Conclusion & Prospective,ACS, early invasive is superior to early conservative in most Pts especially high risk,Immediate invasive strategy is recommended in very high risk (instability of hemodynamic or electricity),In high risk pts, short-term(24hrs) cooling-off may be benefited (but no more than 48hs ),In low risk ,esp in women, early conservative can be chosen,New antiplatelet drug may change practice,编辑课件,Conclusion & ProspectiveACS, e,59,Thank you for your attention,编辑课件,Thank you for your attention编辑,60,
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