从指南到临床实践 看ACS的抗栓治疗

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,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,从指南到临床实践,看,ACS,的抗栓治疗,CRUSADE,研究结果与临床试验比较实际的,ACS,早期死亡率更高,PURSUIT,1,(n=9,461),PRISM-PLUS,2,(n=1,915),SYNERGY,3,(n=9,975),CRUSADE(n=165,498),1.8%,1.9%,1.5%,4.5%,7,天死亡率,院内死亡率,1.The PURSUIT Trial Investigators.N Engl J Med 1998,2.The PRISM-PLUS Study Investigators.N Engl J Med 1998,3.The Synergy Study JAMA 2004,CRUSADE cumulative data through 12/31/2005,ACS,患者,6,个月死亡率,ACS,患者需要更强化的院内和出院后治疗,ST,段压低,ST,段抬高,T,波倒置,10%,8%,6%,4%,2%,0%,0,30,60,90,120,150,180,从随机分组开始的天数,6,个月死亡率,Savonitto S.JAMA.1999 24;281(8):707-13,8.9%,6.8%,3.4%,GUSTO-IIb,研究结果,ACS,的长期风险,UA/NSTEMI,的累积年死亡率,UA/NSTEMI 4,年内的死亡原因,Toneja AK.Eur Heart J 2004;25:20:2013-18,70%,的死亡属于心血管疾病,16,15,19,50,再发心梗,其他心血管疾病,肿瘤,非心血管疾病,10.2,14.4,19.1,22.6,1,2,3,4,4,年份,25,20,10,15,5,0,%,死亡率,抗血栓协作组荟萃分析,*,抗血小板治疗对各心脑血管患者亚组均有降低心血管事件的作用,*,包括心肌梗死（,MI,）脑血管意外（,CVA,），血管性死亡,BMJ 2002;324:71-86,20,10,0,既往,MI,急性,MI,急性,CVA,既往,C,VA/TIA,其他高风险,全部,13.5,17,10.4,14.2,17.8,8.2,21.4,9.1,8,10.2,10.7,13.2,抗血小板,对照,心血管事件*,%,P0.0001,P0.0001,P0.0001,P0.0001,P0.0001,P0.0001,*,涵盖了至,97,年,9,月的所有临床研究（,n=135,000,287,项随机对照试验）,无风险,氯吡格雷,75mg62595145607060205990598154814742400431802418,安慰剂,63035158604859935965595453904639392931592388,CURE,研究结果,氯吡格雷,75mg,用于非,ST,段抬高,ACS,的早期和长期疗效,The CURE Trial Investigators.N Engl J Med 2001;345:494,502.,100,0.98,0.96,0.94,0.92,0.90,无事件患者比例,%,1.00,0.98,0.96,0.94,0.92,0.90,0-30,天,31,天至,12,个月,氯吡格雷,75mg,安慰剂,安慰剂,RR,：,0.79(0.87-0.92),P=0.003,RR,：,0.82(0.75-0.95),P=0.003,0,1,2,3,4,1,4,6,8,10,12,周,月,氯吡格雷,75mg,在采用不同治疗策略的,NSTEMI/UA,患者中氯吡格雷,75mg,治疗的,1,年终点事件,*,发生率均明显降低,Fox et al.Circulation 2004;,110(10):1202-8.,0.20,0.15,0.10,0.05,0.0,0100200300,Placebo,Clopidogrel,RR:0.80(0.69-0.92),药物治疗患者,随访时间,(,天,),累积风险,(%),0.20,0.15,0.10,0.05,0.0,0100200300,Placebo,Clopidogrel,RR:0.82(0.69-0.96),血运重建,0.20,0.15,0.10,0.05,0.0,0100200300,Placebo,Clopidogrel,RR:0.72(0.57-0.90),PCI,0.20,0.15,0.10,0.05,0.0,0100200300,Placebo,Clopidogrel,RR:0.89(0.71-1.11),CABG,随访时间,(,天,),累积风险,(%),*,主要终点事件,:,死亡,/MI/,卒中,CLARITY,研究结果,在包括溶栓和,ASA,标准治疗的基础上氯吡格雷,75mg,可使,STEMI,患者,30,天临床事件,*,的风险相对降低,20%,*,心血管事件,/MI/,再发缺血性事件导致紧急血运重建,入组时间,(,天,),终点事件发生率,(%),0,5,10,15,0,5,10,15,20,25,30,标准治疗,标准治疗,+,氯吡格雷,75mg,20%*,p=0.03,1.Sabatine MS et al.,New Engl J Med 2005;352(available at,www.nejm.org),Sabatine et al.N Engl J Med 2005;352:1179-1189,2007,年,ESC,非,ST,段抬高,ACS,指南,急性期,/,长期抗血小板治疗,I IIa IIb III,如无禁忌，所有患者阿司匹林起始负荷剂量,160325 mg(,非肠溶,),，长期维持剂量为,75100 mg,所有患者立即给予,300mg,负荷剂量氯吡格雷，再以每天,75mg,维持剂量治疗。除非有极高出血风险，否则氯吡格雷应维持使用,12,个月,阿司匹林禁忌，改用氯吡格雷,考虑进行介入或,PCI,治疗的患者，可采用,600mg,负荷剂量以更快达到抑制血小板功能,如需行,CABG,，手术应在停用氯吡格雷,5,天后进行,不主张症状初现后,12,个月,内暂停双重抗血小板治疗（阿司匹林氯吡格雷）,不主张长期或永久停用阿司匹林和（或）氯吡格雷，除非有临床停药指征。,A,A,C,Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes.The European Society of Cardiology 2007.European Heart Journal doi:10.1093/eurheartj/ehm161,B,B,C,C,确诊,ACS,伴插管和,PCI,或,高危(IIa),低危,ACS,可能有,ACS,阿司匹林,+,IV 肝素/LMWH*,+,IV,血小板,GP IIb/IIIa,抑制剂,氯吡格雷75mg,阿司匹林,+,SC LMWH*,或,IV 肝素,氯吡格雷75mg,阿司匹林,抗栓治疗的,I,级建议,1,1,IIa,类,:依诺肝素,优于,IV 肝素.,ACC/AHA Braunwald E,等,.,可以在如下地址下载,:,http:/www.acc.org/clinical/guidelines/unstable/unstable.pdf.,2004,年,12,月,9,日,.,*,无肾衰时使用,依诺肝素,，除非计划在,24,小时内行,CABG,ACC/AHA,处理,UA/NESTEMI,的指南,临床实践与指南的差距,ACS,患者急性期药物使用情况,在最初的,24,小时内，无禁忌症的患者中的比例,CRUSADE DATA:January 1,2005 December 31,2005(n=34,408),ACS,患者出院时的氯吡格雷,75mg,处方,73,53,97,34,CABG,患者,PCI,患者,药物治疗的患者,合计,100,80,60,40,20,0,氯吡格雷,75mg,使用,%,CRUSADE DATA:Quarter 4,2004-Quarter 3,2005(n=35,897),Arch Intern Med 2006;166:806-811,ACS,患者出院时药物治疗在医院间存在很大差别,Peterson et al,ACC 2004,#LVEF 40%,*Known hyperlipidemia,老年患者出院时处方率较低,（在无禁忌症的患者中）,100%,90%,80%,70%,60%,50%,40%,30%,20%,50,60,70,80,90,年龄（年）,比例,阿司匹林,-,受体阻滞药,降脂药物,ACE,抑制剂,氯吡格雷,75mg,Alexander KA,J Am coll Cardiol 2005;46:1479-87,心脑血管患者院外治疗的差距,NCEP=National Cholesterol Education Program.Pearson TA et al.,Arch Intern Med.,2000;160:459-467.,18,Provider awareness does not equal successful implementation,95,医生对指南,(NCEP),的了解率,病人治疗的达标率,百分比,(%),0,20,40,60,80,100,入院时或住院期间,出院时,出院后,6,个月随访时,3,级医院,2,级医院,我国,ACS,患者抗血小板和调脂药治疗情况,患者出院后治疗率下降,二级医院治疗率较三级医院低,高润霖等,.,中国,ACS,登记研究,CPACS,98%,96%,ASA,氯吡格雷,75mg,他汀类,100%,80%,60%,40%,20%,0%,93%,88%,94%,89%,63%,54%,43%,37%,31%,21%,89%,71%,84%,79%,57%,78%,接受侵入性治疗的患者出院时的用药,Aspirin,Clopidogrel,B-Blocker,ACE-l,Statin,Smoking,Cessation,Cardiac,Rehab,Bhatt DL.,JAMA,2004;292:2096-104.,Percentage Use,0,10,20,30,40,50,60,70,80,90,100,92.6,85.2,63.4,38.9,82.3,Early Cath,59.5,58.5,76,70.2,64.8,50.1,47.5,27.8,No Early Cath,遵循指南对临床结果的影响,0%,25%,50%,75%,100%,接受到,100%,指南推荐的药物治疗的患者比率,Overall 100%Correct,Medication,Acute 100%Correct,Medication,Discharge 100%,Correct Medication,16%,21%,31%,33%,30%,36%,46%,48%,30%,34%,47%,50%,Q1,Q4,Q8,Q11,Mehta et al,AHA 2005.,*In patients without contraindications.,Hospital Link Between Overall,Guidelines Adherence and Mortality,5.95,6.31,5.16,5.06,4.97,4.63,4.16,4.15,7,6,5,4,3,2,1,0,%,In-Hosp Mortality,=75%,Hospital Composite Quality Quartiles,Peters