心血管急症（asc）课件

Charles V. Pollack Jr, MA, MD, FACEP, FAAEMCharles V. Pollack Jr, MA, MD, FACEP, FAAEM Program ChairmanProgram Chairman Chairman, Department of Emergency MedicineChairman, Department of Emergency Medicine Pennsylvania HospitalPennsylvania Hospital Professor of Emergency MedicineProfessor of Emergency Medicine University of PennsylvaniaUniversity of Pennsylvania School of MedicineSchool of Medicine Philadelphia, PennsylvaniaPhiladelphia, Pennsylvania Cardiovascular Emergencies New Dimensions and Critical Practice Advances Evidence-Based Management of Acute Coronary Syndromes: Optimizing Patient Outcomes in the Complex and Challenging Sphere of Cardiovascular Emergency Care Getting in the Stream of ThingsGetting in the Stream of Things CME-accredited symposium jointly sponsored by the University of Massachusetts Medical School and CMEducation Resources, LLC Commercial Support: Sponsored by an independent educational grant from The Medicines Company Mission statement: Improve patient care through evidence-based education, expert analysis, and case study-based management Processes: Strives for fair balance and clinical relevance; stresses on-label indications for agents discussed, and emerging evidence and information from recent studies COI: Full faculty disclosures provided in syllabus and at the beginning of the program Welcome and Program OverviewWelcome and Program Overview Program Educational Objectives As a result of this session, emergency physicians will: As a result of this session, emergency physicians will: Learn to identify signs, symptoms, and prognostic features of Learn to identify signs, symptoms, and prognostic features of acute coronary syndromes and related cardiovascular acute coronary syndromes and related cardiovascular emergencies.emergencies. Learn to assess and implement optimal pharmacologic Learn to assess and implement optimal pharmacologic interventions, especially antithrombotic therapy in the interventions, especially antithrombotic therapy in the upstream setting, for patients presenting with manifestations of upstream setting, for patients presenting with manifestations of ACS and related cardiovascular disease emergencies.ACS and related cardiovascular disease emergencies. Learn to characterize, identify, and evaluate the safety, efficacy, Learn to characterize, identify, and evaluate the safety, efficacy, and side effects of myriad therapeutic options used for acute and side effects of myriad therapeutic options used for acute ischemic coronary syndromes including, aspirin, ischemic coronary syndromes including, aspirin, antiplateletantiplatelet agents, direct thrombin inhibitors, UFH, agents, direct thrombin inhibitors, UFH, LMWHsLMWHs, and factor , and factor XaXa inhibitors with a focus on new 2007 ACC/AHA UA/NSTEMI inhibitors with a focus on new 2007 ACC/AHA UA/NSTEMI GuidelinesGuidelines Program FacultyProgram Faculty Program ChairmanProgram Chairman Charles V. Pollack Jr, MA, Charles V. Pollack Jr, MA, MD, FACEP, FAAEMMD, FACEP, FAAEM Chairman, Department of Chairman, Department of Emergency Medicine Emergency Medicine Pennsylvania HospitalPennsylvania Hospital Professor of Emergency MedicineProfessor of Emergency Medicine University of Pennsylvania School University of Pennsylvania School of Medicine of Medicine Philadelphia, PennsylvaniaPhiladelphia, Pennsylvania Distinguished PresentersDistinguished Presenters Judd E. Hollander, MDJudd E. Hollander, MD Professor and Clinical Research DirectorProfessor and Clinical Research Director Department of Emergency MedicineDepartment of Emergency Medicine University of PennsylvaniaUniversity of Pennsylvania Philadelphia, PennsylvaniaPhiladelphia, Pennsylvania Sunil Rao, MD, FACCSunil Rao, MD, FACC Director of Interventional CardiologyDirector of Interventional Cardiology Veterans Administration Medical CenterVeterans Administration Medical Center Assistant ProfessorAssistant Professor Division of Cardiovascular MedicineDivision of Cardiovascular Medicine Duke University Medical CenterDuke University Medical Center Durham, North Carolina Durham, North Carolina COI Faculty DisclosuresCOI Faculty Disclosures Charles V. Pollack Jr, MA, MD, FACEP, FAAEMCharles V. Pollack Jr, MA, MD, FACEP, FAAEM Grant/Research Support: GlaxoSmithKline Consultant: The Medicines Co., Schering-Plough, Sanofi-Aventis, BMS, Genentech Speakers Bureau: Schering-Plough, Sanofi-Aventis, BMS, Genentech Judd E. Hollander, MDJudd E. Hollander, MD Grant/Research Support: Grant/Research Support: SanofiSanofi-Aventis, -Aventis, BiositeBiosite, , SciosScios, The Medicines Company, The Medicines Company Consultant: Consultant: SanofiSanofi-Aventis, -Aventis, BiositeBiosite, , SciosScios, The Medicines Company, The Medicines Company Speakers Bureau: Speakers Bureau: SanofiSanofi-Aventis, -Aventis, BiositeBiosite, , SciosScios, The Medicines Company, The Medicines Company Sunil Rao, MD, FACCSunil Rao, MD, FACC Grant/Research Support: Grant/Research Support: CordisCordis Consultant: Consultant: SanofiSanofi-Aventis, The Medicines Company-Aventis, The Medicines Company Speakers Bureau: Speakers Bureau: SanofiSanofi-Aventis, The Medicines Company, -Aventis, The Medicines Company, CordisCordis Acute Coronary Syndrome The 2007 ACC/AHA UA/NSTEMI Guidelines From the ED to CCU and Cath Lab Adherence Yields Better Outcomes Charles V. Pollack Jr, MA, MD, FACEP, FAAEMCharles V. Pollack Jr, MA, MD, FACEP, FAAEM Program ChairmanProgram Chairman Chairman, Department of Emergency MedicineChairman, Department of Emergency Medicine Pennsylvania HospitalPennsylvania Hospital Professor of Emergency MedicineProfessor of Emergency Medicine University of PennsylvaniaUniversity of Pennsylvania School of MedicineSchool of Medicine Philadelphia, PennsylvaniaPhiladelphia, Pennsylvania Getting in the (Up)Stream of ThingsGetting in the (Up)Stream of Things Changing the Calculation Assessing Adherence to Guidelines Anderson HV, Bach RG, J Am Coll Cardiol 2005;46:1488-9. “We need to invert the current equation to calculate an opportunity score for ACS patients rather than a risk score. Patients with higher baseline risks, such as the elderly, would have higher opportunity scores for benefit, even allowing for some of the greater risks from the treatment.” + + + + Ischemic Discomfort at Rest No ST-segment Elevation Non-Q-wave MIUnstable Angina Q-wave MI ST-segment Elevation + + ( : positive cardiac biomarker) EmergencyEmergency DepartmentDepartment In-hospitalIn-hospital 6-24hrs6-24hrs PresentationPresentation Acute Coronary Syndromes Clinical Spectrum and Presentation NSTEMI SYNERGY LMWHLMWH ESSENCEESSENCE 1994199419951995199619961997199719981998 1999199920002000200220022003200320042004200520052006200620012001 CURECURE ClopidogrelClopidogrel Bleeding riskBleeding risk Ischemic riskIschemic risk GP IIb/IIIa GP IIb/IIIa blockersblockers PRISM-PLUSPRISM-PLUS PURSUITPURSUIT ACUITY TACTICS TIMI-18TACTICS TIMI-18 Early invasiveEarly invasive PCIPCI 5% stents 5% stents85% stents85% stentsDrug-eluting stentsDrug-eluting stents ISAR-REACT 2 Milestones in ACS Management OASIS-5 Fondaparinux Fondaparinux Anti-Thrombin RxAnti-Thrombin Rx Anti-Platelet RxAnti-Platelet Rx Treatment StrategyTreatment Strategy HeparinHeparin AspirinAspirin ConservativeConservative ICTUS BivalirudinBivalirudin REPLACE 2REPLACE 2 Adapted from and with the courtesy of Steven Manoukian, MDAdapted from and with the courtesy of Steven Manoukian, MD We Must Risk Stratify Patients with Chest Pain Three levels of risk stratification are pertinent to Emergency Department Management Low, intermediate, or high risk that ischemic symptoms are a result of CAD Low, intermediate, or high risk of short-term death or nonfatal MI from ACS Dynamic, ongoing risk-oriented evaluation of low - or intermediate-risk patients for “conversion” to high- risk status that is linked to intensity of treatment “Dynamic Risk Stratification” Tools History and Physical Standard EKG and non-standard EKG leads 15-lead ECGs should, perhaps, be “standard” in all but very-low-risk patients Biomarkers CPK-MB, Troponins I and T, Myoglobin Ischemia-Modified Albumin Non-Invasive Imaging Echocardiogram Stress testing Technetium-99m-sestamibi Predictive Indices/Schemes Better as research tools than for real-time clinical decision-making BraunwaldBraunwald E, Antman EM, Beasley JW, et al: ACC/AHA E, Antman EM, Beasley JW, et al: ACC/AHA guidelines for the management of patients with guidelines for the management of patients with unstable angina and non-ST-segment elevation unstable angina and non-ST-segment elevation myocardial infarction: a report of the American College myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management on Practice Guidelines (Committee on the Management of Patients with Unstable Angina). of Patients with Unstable Angina). J Am Coll CardiolJ Am Coll Cardiol 2000;36:970-1062 (2002 update at 2000;36:970-1062 (2002 update at ; ; summary in summary in CirculationCirculation 2002;106:1893-1900) 2002;106:1893-1900) Pollack CV, Roe MT, Peterson ED: 2002 Update to the Pollack CV, Roe MT, Peterson ED: 2002 Update to the ACC/AHA guidelines for the management of patients ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation with unstable angina and non-ST-segment elevation myocardial infarction: Implications for emergency myocardial infarction: Implications for emergency department practice. department practice. Ann Ann EmergEmerg Med Med 2003;41:355-69 2003;41:355-69 NSTE ACS Optimal Therapy: 2002NSTE ACS Optimal Therapy: 2002 Anderson JL, Adams CD, Antman EM, et al. 2007 Anderson JL, Adams CD, Antman EM, et al. 2007 guidelines for the management of patients with unstable guidelines for the management of patients with unstable angina/non-ST-segment-elevation myocardial infarction: a angina/non-ST-segment-elevation myocardial infarction: a report of the American College of Cardiology/American report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Heart Association Task Force on Practice Guidelines. J J Am Am CollColl CardiolCardiol 2007;50:e1-e157, and 2007;50:e1-e157, and CirculationCirculation 2007;116:e148-e304, and at 2007;116:e148-e304, and at and at and at . . Pollack CV, Pollack CV, BraunwaldBraunwald E: 2007 Update to the ACC/AHA E: 2007 Update to the ACC/AHA guidelines for the management of patients with unstable guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial angina and non-ST-segment elevation myocardial infarction: Implications for emergency department infarction: Implications for emergency department practice. practice. Ann Ann EmergEmerg Med Med 2007, in press. 2007, in press. NSTE ACS Optimal Therapy, 2007NSTE ACS Optimal Therapy, 2007 I IIa IIb III “The Guidelines” Classes of Recommendations Intervention is useful and effective Evidence supportive; awaiting confirming data Evidence conflicts/opinions differ; neutral statement Intervention is not useful/effective and may be harmful Evidence-Based Approach to ACS Weighing the Evidence Class I: Benefit Risk Class IIa: Benefit Risk Class IIb: Benefit Risk Class III: Risk Benefit “The Guidelines” Weighing the Evidence Weight of Evidence Grades = Data from many large, randomized trials =Data from fewer, smaller randomized trials, careful analyses of nonrandomized studies, observational registries =Expert consensus What Do The Guidelines Mean for Emergency Medicine Practice? Objective approach to risk stratification and treatment Driven by risk, not patient geography Multidisciplinary Provides a foundation for communication, collaboration, and continuum of care from ED to cardiology service 2007 Guidelines push for that continuum to be compressed in duration Acute Coronary Syndrome What Do The Guidelines Mean for Emergency Medicine Practice? Acute Controversy Syndrome What Do The Guidelines Mean for Emergency Medicine Practice? Acute Confusional Syndrome What Do The Guidelines Mean for Emergency Medicine Practice? Acute Confounded Syndrome “The Writing Committee believes that inadequate unconfounded, comparative information is available to recommend a preferred anticoagulation regimen when an early, invasive strategy is used for UA/NSTEMI, and physician and health care system preference, together with individualized patient application, is advised.” UA/NSTEMI UA/NSTEMI Strategy OverviewStrategy Overview ACC/AHA 2007 Guidelines for the Management of UA/NSTEMI. August 6, 2007, Circulation. Acute Contentiousness Syndrome What Do The Guidelines Mean for Emergency Medicine Practice? Acute Collaboration Syndrome What Do The Guidelines Mean for Emergency Medicine Practice? Big Picture: Early Invasive Vs. Initial Conservative Therapy “An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is indicated in initially stabilized UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events.” “In initially stabilized patients, an initially conservative (i.e., a selectively invasive) strategy may be considered as a treatment strategy for UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events, including those who are troponin positive.” “The decision to implement an initial conservative (vs. initial invasive) strategy in these patients may be made by considering physician and patient preference.” UA/NSTEMI UA/NSTEMI Strategy OverviewStrategy Overview ACC/AHA 2007 Guidelines for the Management of UA/NSTEMI. August 6, 2007, ACC/AHA 2007 Guidelines for the Management of UA/NSTEMI. August 6, 2007, Circulation.Circulation. Algorithm for Evaluation and Management of Patients Suspected of Having ACS ACC/AHA 2007 Guidelines for the Management of UA/NSTEMI. August 6, 2007, Circulation. A Symptoms Suggestive Symptoms Suggestive of ACSof ACS NoncardiacNoncardiac DiagnosisDiagnosis UnstableUnstable AnginaAngina Treatment as Treatment as indicated by indicated by alternative alternative diagnosisdiagnosis See ACC/AHA See ACC/AHA Guidelines for Guidelines for Chronic Stable Chronic Stable AnginaAngina BIB2 Possible Possible ACSACS DefiniteDefinite ACSACS B3B4 Algorithm for Evaluation and Management of Patients Suspected of Having ACS Possible ACSPossible ACS NondiagnosticNondiagnostic ECG ECG Normal initial serum cardiac biomarkersNormal initial serum cardiac biomarkers OBSERVEOBSERVE 12 hours or more 12 hours or more from symptom onsetfrom symptom onset No recurrent pain, No recurrent pain, negative follow-up negative follow-up studiesstudies Recurrent pain, positive Recurrent pain, positive follow-up studiesfollow-up studies Diagnosis OF ACS Diagnosis OF ACS confirmedconfirmed Admit to hospitalAdmit to hospital Manage via acute Manage via acute ischemia pathwayischemia pathway Stress study to provoke ischemiaStress study to provoke ischemia Consider evaluation of LV function if Consider evaluation of LV function if ischemia is present (tests may be ischemia is present (tests may be performed either prior to discharge performed either prior to discharge or as outpatientor as outpatient D1 E1 F2F1 G1 H3 ACC/AHA 2007 Guidelines for the Management of UA/NSTEMI. August 6, 2007, Circulation. Algorithm for Evaluation and Management of Patients Suspected of Having ACS PositivePositive Diagnosis of ACS Diagnosis of ACS confirmed or highly confirmed or highly likelylikely Admin to hospitalAdmin to hospital Manage via Manage via acute ischemia acute ischemia pathwaypathway H2H3 Stress study to provoke ischemiaStress study to provoke ischemia Consider evaluation of LV function if Consider evaluation of LV function if ischemia is present (tests may be ischemia is present (tests may be performed either prior to discharge performed either prior to discharge or as outpatientor as outpatient G1 NegativeNegative Potential diagnoses:Potential diagnoses: NonischemicNonischemic discomfort; low-risk discomfort; low-risk ACSACS Arrangements for Arrangements for outpatient follow-upoutpatient follow-up H1 I1 ACC/AHA 2007 Guidelines for the Management of UA/NSTEMI. August 6, 2007, Circulation. Specific Recommendations, Class Designation, and Levels Of Evidence Initial Invasive Strategy: Whats New? UA/NSTEMI Strategy Overview New Strategies: Anticoagulants “Two new anticoagulants, fondaparinux and bivalirudin, have undergone favorable testing in clinical trials and are recommended as alternatives to unfractionated heparin (UFH) and low-molecular- weight heparins (LMWHs) for specific or more general applications.” UA/NSTEMI Strategy Overview ACC/AHA 2007 Guidelines for the Management of UA/NSTEMI. August 6, 2007, Circulation. Algorithm for Patients With UA/NSTEMI Managed by an Initial Invasive Strategy Diagnosis of UA/NSTEMI is Likely or DefiniteDiagnosis of UA/NSTEMI is Likely or Definite ASA (Class I, LOE:A)* ASA (Class I, LOE:A)* Clopidogrel if ASA intolerant (Class I, LOE: A)Clopidogrel if ASA intolerant (Class I, LOE: A) Select Management StrategySelect Management Strategy Invasive StrategyInvasive Strategy Initiate anticoagulant therapy (Class I, LOE: A): Initiate anticoagulant therapy (Class I, LOE: A): Acceptable options*: enoxaparin or UFH (Class Acceptable options*: enoxaparin or UFH (Class I, LOE: A), bivalirudin or fondaparinux are I, LOE: A), bivalirudin or fondaparinux are preferable (Class I, LOE: B)preferable (Class I, LOE: B) InitialInitial Conservative Conservative StrategyStrategy A A B1B1 ACC/AHA