稳定型冠心病的诊断和治疗从循证医学到临床指南课件_1

稳定型冠心病的诊断和治疗： 从循证医学到临床指南 陈纪言 广东省人民医院 SIHD：常见诊疗误区 诊断 推侧性诊断 过度使用CTA 过度使用冠脉造影 无创性缺血检查使用不足 治疗 介入治疗降低病人风险？死亡、心梗 强化药物治疗已经足够？ 冠心病的诊断 检查前冠心病可能性评估 病人是否有冠心病？ -缺血的客观依据 -可视性冠状动脉狭窄 严重症状 诊断流程 疑冠心病，PTP15-85% 思考： 病人适应证 设备条件/医生经验 PTP15-50%病人冠脉CTA检查 -如病人合适 -如有设备和足够的经验 病人是否有冠心病？ -缺血的客观依据 -可视性冠状动脉狭窄 严重症状 强化药物治疗 评估危险性（死亡率？) -缺血范围 -冠脉解剖 有创性冠脉造影 血运重建 冠心病的治疗 SIHD药物治疗:从经验到循证 -改善症状 硝酸甘油 B-阻断剂 钙离子拮抗剂 -改善预后 阿斯匹林 他丁类药物 ACEI CABG对死亡率的影响 0 20 40 60 80 100 CABG Year 5 Year 7 Year10 Medical Therapy Actual CABG Rate (%) Total 2649 stable CAD patients (not severe enough to necessitate surgery) between 1972-1884. 0 5 10 15 20 25 30 35 5 yrs7 yrs10 yrs Mortality Medical Therpay CABG (%) P=0.0001 P0.001 P=0.03 Yusuf, et al. Lancet 1994 Odds Ratios of Morality at 5 years (CABG over MT) 0 0.2 0.4 0.6 0.8 LM3VD1/2VD Total 2649 stable CAD patients (not severe enough to necessitate surgery) between 1972-1884. Yusuf, et al. Lancet 1994 不同亚组CABG 10年后对寿命延长 的影响 Yusuf, et al. Lancet 1994 COURAGE研究: PCI与药物治疗没有差异 Totally 2287 patients with stable CAD and those in whom initial CCS IV angina subsequently stabilized medically. 药物的使用 强化药物治疗对稳定性冠心病已经足够！ 结论对吗? COURAGE研究:OMT组1/3强的 病人接受血运重建 OMT Group PCI Group 25.5% PCI 7.1% CABG 4% No PCI Nagajoth, et al. NEJM 2007,357:416. The data were analyzed in a intend-to-treat style. COURAGE: 把很多重冠心病排除在外 ！ Meta 分析: 死亡率 7513 patients with stable IHD Schmig,et al. JACC2008 Shaw, et al. Circulation 2008 SPECT检查：负荷诱发心肌缺血 PCI+OMT (N=159)OMT (N=155) P=0.0004 P0.0001 Shaw, et al. Circulation 2008 心肌缺血面积减少对预后的影响 86.6% 75.3% Shaw, et al. Circulation 2008 残存缺血对预后影响 100% 84.4% 77.7% 60.7% Hachamovitch, et al. Circulation 2003 心肌缺血范围与疗效关系 10 627 patients who underwent stress Myocardial Perfusion Stress SPECT and had no prior MI or revascularization 心肌缺血对死亡危险性的影响 不是非常明确，也许与下述因素有关. 缺血的不良作用 Adverse effect of ischemia 严重狭窄病变闭塞 Occlusion of severe stenosis 恶性心律失常 Arrhythmia 严重缺血往往提示动脉硬化负荷较大、更可能 有更多不稳定斑块 More severe ischemia as a marker of atherosclerotic burden with more vulnerable plaques 单纯药物治疗对不同冠心病严重程 度预后影响 Non-Invasive Stratification (1) Non-Invasive Stratification (2) Indications for Revascularization in Stable Angina or Silent Ischemia 男性，48岁，下壁心梗3周，LCX 介入失败 DEFER FAME FAME OutcomeAngiography Guided FFR Guided Difference (95% CI) MACEs, %18.313.25.2 (0.79.7) MI, % (0.26.2) Death, %3.01.81.3 (0.63.2) MI or death, % (0.37.4) QALY0.8380.8530.015 (0.0080.037) $ of initial procedure60075332 $ of initial hospitalization14 87813 1821697 (2893510) $ of events during 12-mo f/(138325) Overall $16 70014 3152384 (38261011) 3-VD 14% 1-VD 34% 2-VD 43% 0-VD 9% Proportions of functionally diseased coronary arteries in patients with angiographic 3-vessel disease (n=115) FAME: Angiography versus FFR Tonino, et al. JACC 2010 FFR-guided SYNTAX Score (FSS) versus Conventional SYNTAX Score (SS) LOW risk LOW risk 33%33% MEDIUM risk MEDIUM risk 33%33% HIGH risk HIGH risk 33%33% LOW riskLOW risk 59 % 59 % MEDIUM MEDIUM risk 21%risk 21% HIGH risk HIGH risk 21%21% FSS SS 32% of patients moved to a lower-risk group 497 patients of the FFR-arm of FAME Nam, et al. JACC 2011 SYNTAX scoreFunctional SYNTAX score LowMediumHighp ValueLowMediumHighp Value Death1 (0.6)3 (1.8)5 (3.1)0.241 (0.3)5 (4.7)3 (3.0)0.01 MI8 (4.8)7 (4.2)15 (9.2)0.1113 (4.5) 4 (3.8)13 (12.9)0.005 Repeat PCI / CABG 6 (3.6)7 (4.2)17 (10.4)0.0213 (4.5) 4 (3.8)13 (12.9)0.005 Death / MI 9 (5.4)10 (6.0)19 (11.7)0.0614 (4.8) 8 (7.5)16 (15.8)0.005 MACE14 (8.4) 17 (10.2) 34 (20.9)0.00126 (9.0) 12 (11.3) 27 (26.7)0.001 FSS vs. SS and Clinical Outcome 497 patients of the FFR-arm of FAME Nam, et al. JACC 2011 FAME II: Inclusion Criteria Patients with stable angina or, stabilized angina pectoris or, atypical chest pain or no chest pain but with documented silent ischemia at least one stenosis is present of at least 50% in one major native epicardial coronary artery and supplying viable myocardium Eligible for PCI Signed written informed consent NCT01132495 FAME II: Study Flow Pts w/ stable agina or silent ischemia scheduled for 1, 2 or 3 vessel DES stenting OMTPCI + OMT Enrollment stopped due to more MACEs in OMT alone group interim analysis FFR in indicated stenoses 1 stenosis with an FFR 0.80No stenosis with an FFR 0.80 OMT NCT01132495 R N=1600N=200 Rate of Any Revascularisation International Study of Comparative Health Effectiveness With Medical & Invasive Approaches (ISCHEMIA) Population: 8000 patients with moderate/ high ischemia on stress imaging nuclear myocardial perfusion (10% myocardium) echo or cardiac magnetic resonance wall motion (3/16 segments with stress-induced severe hypo-/a-kinesis cardiac MR perfusion (12% myocardium). Verified February 2012 by NHLBI, not yet open for participant recruitment. Cath Revasc + OMTOMT 男性，48岁，下壁心梗3周，LCX 介入失败 FFR=0.80-0.82 小结 -诊断应按照规范流程 -SIHD包含着差异很大的各种病人 -不能用一种 方式治疗所有的病人 -药物治疗和二级预防是SIHD的基础 -了解病人的具体情况，评估死亡风险 症状 缺血的依据 心功能 SYNTAX评分STS评分 并存疾病 其他 -高危病人应选择血运重建治疗（PCI/CABG ） -了解循证依据/指南 -新的评价方式（FFR) 谢谢！ Summary 2 CABG saved more patients compared with MT PCI not definitely superior to OMT in CRTs, due to Under-representative High crossov