急性冠脉综合症的早期介入治疗策略

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,*,NSTE 急性冠脉综合症的早期介入治疗策略,阜外医院 侯青,急性冠脉综合症,不稳定性心绞痛,非ST段抬高心肌梗塞,ST段抬高心肌梗塞,猝死,非ST段抬高的ACS,不稳定性心绞痛,非ST段抬高的心肌梗塞,非ST段抬高的ACS治疗策略,早期干预早期进行包括介入或CABG 的干预,早期保守给病人一个“cool pool”时期,早期干预的意义,不稳定性心绞痛病人急性事件发生多在第一小时和第一天,未进行血管重建的病人40%的新发事件在前两周；40%在2周到6个月；20%在6至12个月。,早期有创干预存在问题,早期有创干预造成围手术期手术相关并发症增加：例如急性、亚急性闭塞、no-reflow和slow-reflow的增加。,TIMI-IIIB,1,425例不稳定性心绞痛或非Q波心梗病人,早期干预组在随机进入后18-48小时内进行冠状动脉造影以决定PTCA或CABG。,早期保守组在随机进入后首先接受药物治疗。在药物治疗无效（静息下反复缺血发作）情况下接受造影和进一步的血管重建治疗。,TIMI IIIB 1年临床事件随访(1),死亡,早期干预（n=740),早期保守(n=733),p,住院期间,2.0%,1.9%,0.73,6周,2.3%,2.0%,0.74,1年,4.1%,4.4%,0.79,TIMI IIIB 1年临床事件随访(2),MI,早期干预,早期保守,P,住院期间,5.5%,4.9%,0.59,6周,5.8%,6.5%,0.67,1年,8.3%,9.3%,0.51,TIMI IIIB 1年临床事件随访(3),死亡和/或MI,早期干预,早期保守,P,住院期间,6.9%,6.1%,0.56,6周,7.2%,7.8%,0.69,1年,10.8%,12.2%,0.42,VANQWISH,920例不稳定性心绞痛或非Q波心梗病人,早期干预组住院后1-3天接受冠状动脉造影,早期保守组接受药物治疗，只有发生梗塞后心绞痛或运动试验异常的病人接受冠状动脉造影和血管重建。,VANQWISH住院期间临床事件随访,早期干预组,早期保守组,P,死亡,4.5%,1.3%,0.007,死亡和/或MI,7.7%,3.3%,0.004,VANQWISH1月临床事件随访,早期干预组,早期保守组,P,死亡,4.9%,1.9%,0.02,死亡和/或MI,10.3%,5.6%,0.012,VANQWISH1年临床事件随访,早期干预组,早期保守组,P,死亡,12.5%,7.8%,0.025,死亡和/或MI,24.0%,18.5%,0.05,FRISC II,2,247例不稳定性心绞痛或非ST段抬高的AMI病人,早期干预组7天内进行冠状动脉造影和血管重建,早期保守组首先接受药物治疗。运动试验异常的病人接受冠状动脉造影。出现严重心绞痛、心肌梗塞或运动试验前严重的心肌缺血的病人接受造影和血管重建。,FRISC II（1）,6个月结果,早期干预组（n=1222),早期保守组（n=1235),RR(95%CI),P值,死亡和/或MI,113(9.4%),148(12.1%),0.78(0.62-0.98),0.031,MI,94(7.8%),124(10.1%),0.77(0.60-0.99),0.045,死亡,23(1.9%),36(2.9%),0.65(0.39-1.09),0.10,FRISC II（2）,12个月结果,早期干预组,早期保守组,RR(95%CI),P,死亡和/或MI,127（10.4%),174(14.1%),0.74(0.60-0.92),0.005,MI,105(8.6%),143(11.6%),0.74(0.59-0.94),0.015,死亡,27(2.2%),48(3.9%),0.57(0.36-0.90),0.016,FRISC II（3）,24个月结果,早期干预组,早期保守组,RR(95%CI),P,死亡和/或MI,146（12.1%）,200(16.3%),0.74(0.61-0.90),0.003,MI,111(9.2%),156(12.7%),0.72(0.57-0.91),0.005,死亡,45(3.7%),67(5.4%),0.68(0.47-0.98),0.038,TACTICS TIMI 18,2,220例不稳定性心绞痛或非ST段抬高AMI病人,所有的病人使用tirofiban,早期干预组在4-48小时接受造影检查，有指征的病人接受血管重建。,早期保守组接受药物治疗。如果有缺血事件发作或运动试验检查阳性后接受造影和血管重建治疗,TACTICS TIMI 18 6个月随访结果,早期干预组（n=1106),早期保守组(n=1114),RR(95%CI),P,死亡和/或MI,7.3%,9.5%,0.74(0.54-1.00),3ULN,36(73),25(54),0.06,LDHQ,48,629503,432441,0.02,Which,When,How,WHICH,年龄：65岁,代谢功能障碍：,肾功能障碍,心功能不全：左心衰、BNP升高,冠状动脉病变严重：难以控制的心绞痛、ST段压低,既往心肌梗塞,冠脉内血栓形成：静息时发作心绞痛、肌钙蛋白升高,炎症：CRP、IL-6升高,ACC/AHA关于早期有创与保守措施的修订建议（1）,I级建议：UA/NSTEMI患者如有以下高危特征之一行早期有创策略（A）,尽管已接受强化抗缺血治疗，但仍出现静息或轻微运动复发心绞痛/心肌缺血,ACC/AHA关于早期有创与保守措施的修订建议（2）,b),TnT/I升高,c),新出现或可能出现ST段压低,ACC/AHA关于早期有创与保守措施的修订建议（3）,d) 复发心绞痛/心肌缺血合并心力衰竭症状、第3心音奔马律、肺水肿、加重的肺部罗音或新出现加重的二尖瓣关闭不全,e) 无创负荷试验发现高危征象,f) 左室收缩功能低下（LVEF40%),g) 血流动力学不稳定,ACC/AHA关于早期有创与保守措施的修订建议（4）,h) 持续性室性心动过速,i) 6个月内PCI,j) 既往CABG,哪些病人会从早期介入治疗获益？,Death/MI/Rehosp ACS-6 months,TIMI Risk Score,Low Risk T3,(TRS 0-2) T18,Intermed Risk T3,(TRS 3-4) * T18,High Risk T3,(TRS 5-7) * T18 *p0.05, *p=0.018,0.25 1,4,WHEN,最佳时机尚有争论,FRISCII早期干预组在3天内进行心导管检查，要7天才进行血管重建。,TACTICS-TIMI18早期干预组冠状动脉造影的时间是4-48小时（中值22小时），血管重建病人中2/3在中值25小时进行冠状动脉成形术；另外1/3在中值89小时CABG,HOW,完全的血管重建,冠状动脉支架、GPIIb/IIIa受体拮抗剂,充分的抗栓、抗血小板治疗：低分子肝素、氯吡格雷、阿司匹林、GPIIb/IIIa受体拮抗剂,问题,更理想的远端保护装置会进一步降低早期干预的风险？,更新的抗凝、抗血小板药物会进一步降低早期干预的风险？,有效的抗炎药物和二级预防药物会改善病人的远期预后？,是否可以更早的干预？,NSTE ACS,Risk stratification,Age 65岁 Recent severe angina,3 CAD risk factors cardiac maker ,Known CAD(stenosis 50%) ST deviation 0.5mm,ASA in past 7d,High risk,5-7,Intermediate risk,3-4,Low risk,0-2,ASA,Clopidogrel,LMWH or UFH,NTG,GPIIb/IIIa recetor blocker,-blocker,sttatin,PCI,Continue above therapies,Define coronary anatomy and,proceed to revascularzation if feasible,Continue risk-oriented Evaluation,ASA,Clopidogrel,LMWH or UFH,-blocker,sttatin,CABG,Secondary prevebtion,Inducible ischemia,No 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