非st段抬高急性冠脉综合征诊治精品课件

非ST段抬高急性冠脉综合征诊治 -策略与选择 阜外心血管病医院 乔树宾 ACS住院患者（NSTE-ACS vs STEMI） National Center for Health Statistics. 2001. ACS 2.3 million hospital admissions ACS ( 230万/年 ACS住院患者） UA / NSTEMIUA / NSTEMI 1.43 million admissions per year （143万/年患者占63%） STEMISTEMI 829,000 admissions per year （82.9万/年患者占36%） ACS主要发病机理 动脉粥样硬化斑块-不稳定或破裂 血栓形成 炎症炎症 细胞细胞 少量平滑肌少量平滑肌 细胞细胞 激活的巨噬细胞激活的巨噬细胞 血栓 The “Vulnerable Plaque” Paradigm （易损斑块的特征） Non-vulnerable plaque (非易损斑块) 纤维组织部分阻塞血流，但不易引起血凝块 及心脏事件。 Vulnerable Plaque（易损斑块） 富含脂质核、纤维帽薄、边缘炎症反应明 显，易于破裂。 ACS的病理生理基础 CK- MB or Troponin Troponin elevated or not Adapted from Michael Davies Adapted from Michael Davies ACS 无持续ST段抬高 ACS 伴持续ST段抬高 ACS的临床分型 ACS ST 段持续抬高的 ACS无 ST 段抬高的 ACS cTnT ( cTnI ) 0.1g/L 或CK-MB正常上限的2倍 cTnT ( cTnI ) 0.1g/L 或CK-MB 19999.412.4 Troponin +ve10.014.0 Troponin ve6.77.4 Any Marker +ve14.717.4 Any Marker -ve7.78.5 Favors Invasive Favors Conservative 0.512 TrialInv (%) Cons (%) Odds Ratio P value 0.0010.82 0.400.90 0.0120.82 0.420.89 0.0010.69 0.00010.73 0.920.99 *TIMI 3B, VANQWISH and MATE FRISC II, TACTICS, VINO, RITA 3 Data by troponin status available only in FRISC II, TACTICS, RITA 3 Invasive Management of UA/NSTEMI Meta-analysis: Subgroups Mehta SR et al. JAMA 2005;293:2908-17 Death or MI at Followup UA / NSTEMI：早期介入策略的益处 （ FRISC II试验） Lancet 1999, Vol 354 Invasive (n=1222) Non-invasive (n=1226) Risk radio P Death/MI or both 113(9.4%) 148(12.1%) 0.78 0.031 MI 94(7.8%) 124(10.1%) 0.77 0.045 Death 23(1.9%) 36(2.9%) 0.65 0.10 注：2457例 ACS患者 (随访6个月) UA / NSTEMI：早期介入策略的益处 （ FRISC II试验） Probability of Death / MI Conservative (保守治疗) Invasive (介入治疗) 0.14 0.12 0.10 0.08 0.06 0.04 0.02 0 0 30 60 90 120 150 180 Time since start of open phase (days) FRISC II Investigators. Lancet. 1999;354:708-715. Dalteparin (达肝素) 12.1% 9.4% 36018090300 Probability of DeathProbability of Death .04 .03 .02 .01 0 Non-Invasive (n = 1235)Non-Invasive (n = 1235) Invasive (n = 1222)Invasive (n = 1222) InvasiveInvasiveNoninvasive Noninvasive RR (95 % CI) RR (95 % CI) 2.2 %2.2 %4.0 %4.0 % 0.56 (0.35 - 0.89) p = 0.018 0.56 (0.35 - 0.89) p = 0.018 Wallentin, Lancet 2000Wallentin, Lancet 2000 FRISC-II Mortality at One-Year Invasive Vs. Conservative Management Strategies FRISC II: 5 Year Outcomes End point Invasive strategy (%) Noninvasive strategy (%) Relative risk (95% CI) Death or MI19.924.5 0.81 (0.690.95) All-cause mortality 9.710.1 0.95 (0.751.21) MI12.917.7 0.73 (0.600.89) Lagerqvist B. World Congress of Cardiology 2006; September 4, 2006, Barcelona, Spain.Lagerqvist B. World Congress of Cardiology 2006; September 4, 2006, Barcelona, Spain. FRISC II: 5 Year Outcomes Death or MI at 5 years in high-, medium-, and low-risk patientsDeath or MI at 5 years in high-, medium-, and low-risk patients End point Invasive strategy (%) Noninvasive strategy (%) Relative risk (95% CI) Death or MI in high-risk patients (FRISC 47) 32.741.6 0.79 (0.640.97) Death or MI in medium-risk patients (FRISC 23) 14.620.40.72 (0.551.13) Death or MI in low-risk patients (FRISC 01) 10.38.21.26 (0.662.40) Lagerqvist B. World Congress of Cardiology 2006; September 4, 2006, Barcelona, Spain.Lagerqvist B. World Congress of Cardiology 2006; September 4, 2006, Barcelona, Spain. UA / NSTEMI：早期介入策略的益处 （TACTICS-TIMI 18） Cannon C, et al. N Engl J Med. 2001;344:1879-1887. Day 7: OR=0.59 P=0.033 Day 30: OR=0.51 P=0.002 0306090 Time (days) 120150180 0.00 0.02 0.04 0.06 0.08 0.10 0.12 0.14 Invasive (介入治疗) Conservative (保守治疗) 替罗非班（Tirofiban） 19.4% 15.9% Probability of Death / MI O.R 0.78 P=0.025 ECG and Outcome in TACTICS/TIMI 18 Death / MI / Rehospitalization at 6 MonthsDeath / MI / Rehospitalization at 6 Months ST Segment s (n=852) Non-ST Segment s (n=1368) Cannon et al. Cannon et al. N Engl J Med N Engl J Med 2001;344:1879-87.2001;344:1879-87. Troponin and Outcome in TACTICS/TIMI 18 6 Months6 Months Cannon et al. Cannon et al. N Engl J Med N Engl J Med 2001;344:1879-87.2001;344:1879-87. 30 Days30 Days TnT 0.01 ng/mlTnT 0.01 ng/ml TnT TnT 0.01 ng/mlTnT 0.01 ng/ml TnT TnT 0.01 ng/ml0.01 ng/ml RITA-3 (Randomized Intervention Trial of unstable Angina3) 针对NSTE-ACS中度危险患者；显著减少难治性心绞痛的发生率 。 Lancet. 2002;360(743-51) 随访时间 (月) Patients (%) 0412 0 2 4 6 8 10 12 14 16 18 20 4个月时 P=0.001 保守治疗(n=915) 介入治疗(n=895) P=0.003 Enoxaparin (依诺肝素) 死亡、心梗死亡、心梗、难治性心绞痛心绞痛 早期介入治疗优于保守治疗 Number of Deah/MIs within 1 year InvasiveConservative RITA 368/895(7.6%)76/915(8.3%) VINO4/64(6.3%)15/67(22.4%) TACTICS- TIMI18 81/1114(7.3%)105/1106(9.5%) TRUCS6/76(7.6%)12/72(16.7%) FRISC II127/1219(10.4%)174/1234(14.1%) MATE11/111(9.9%)6/90(6.7%) VANQWISH111/462(24.0%)85/458(18.6%) TIMI IIIB52/484(10.8%)62/509(12.2%) Combined risk ratio 0.88(95%CI 0.78-0.99) 0.10.51.02.0 哪种治疗最好？ （Invasive vs Conservative） Conservative（保守） 920 Patients Invasive（介入） 7,018 Patients TIMI IIIB VANQWISH MATE FRISC II TACTICS- TIMI 18 VINO RITA-3 TRUCS ISAR-COOL Adapted from Cannon CP. Cardiology. 2002;8(special edition):29-37. Conservative 1,674 Patients Death, MI, Rehospitalization for ACS Results 10% 20% 30% 100200300 Early invasive Selective invasive 21.7% 20.4% Relative Risk: 1.06 95% CI: 0.85 1.32 P = 0.59 Time (days) De Winter R., et al. N Engl J Med 2005;353: 1095-104 Routine vs Selective Invasive Strategies in ACS Adapted from Mehta S, et al. Adapted from Mehta S, et al. JAMA. JAMA. 2005;293;2908-2917.2005;293;2908-2917. Odds Ratio (95% CI) 0.11.0 OR - 0.82OR - 0.82 95% CI, 0.72-0.9395% CI, 0.72-0.93 P 0.001P 0.001 Total Total 561/4608 (12.2) 561/4608 (12.2) 663/4604 (14.4)663/4604 (14.4) Composite of Death or Myocardial Infarction No./Total (%) Favors Routine Invasive Favors Selective Invasive SourceSource RoutineRoutine InvasiveInvasive SelectiveSelective InvasiveInvasive TIMI IIIB TIMI IIIB 86/740 (11.6) 101/733 (13.8) 86/740 (11.6) 101/733 (13.8) VANQWISH 152/462 (32.9) 139/458 (30.3)VANQWISH 152/462 (32.9) 139/458 (30.3) MATE 16/111 (14.4) 11/90 (12.2)MATE 16/111 (14.4) 11/90 (12.2) FRISC II 127/1222 (10.4) 174/1235 (14.1)FRISC II 127/1222 (10.4) 174/1235 (14.1) TACTICS 81/1114 (7.3) 105/1106 (9.5)TACTICS 81/1114 (7.3) 105/1106 (9.5) VINO 4/64 (6.3) 15/67 (22.4)VINO 4/64 (6.3) 15/67 (22.4) RITA 3 95/895 (10.6) 118/915 (12.9)RITA 3 95/895 (10.6) 118/915 (12.9) 10 早期介入治疗 VS 择期介入策略 （随机试验 荟萃分析结果） 7 个试验共入选 9212 例患者。 联合终点事件（死亡或心梗) : ( P = 0.001 ) 择期介入组发生率 14.4% （663/ 4604） 早期介入组发生率 11.2% （561/4608） 伴有心脏生化标记物水平升高的高危患者获益最 大。 对于心脏生化标记物不升高的低危患者无显著差 异。 JAMA. 2005 Jun 15;293(23):2908-17. ISAR-COOL 结果 Neumann F-J, et al. JAMA. 2003;290:1593-1599. Cumulative Incidence of Death and Myocardial Infarction at 30 Days （30天死亡和心梗发生率） No. at Risk Prolonged Antithrombotic Pretreatment 207191185184183183183 Early Intervention203192191191191191191 15 10 5 0 051015202530 Days After Randomization Cumulative Incidence, % Prolonged Antithrombotic Pretreatment （抗栓预治疗） Early Intervention（早期介入） P=0.04 ISAR-COOL 结论 死亡和MI 的发生率早期介入治疗组(平均2.5 h) 比延迟 介入治疗组下降了50% ( 5.9 % VS 11.6 % , P 0.05) . PCI后，心脏事件的发生与抗血栓治疗的持续时间无关。 抗血栓预治疗后，延迟PCI 是没有必要的，不但不能改善 NSTE-ACS患者预后，且可增加风险。 Neumann F-J, et al. JAMA. 2003; 290:1593-1599. An International Randomized Trial of Early Versus Delayed Invasive Strategies in Patients with Non-ST Segment Elevation Acute Coronary Syndromes FUNDED BY THE CANADIAN INSTITUTES OF HEALTH RESEARCH Grant # 150904 TIMACS Timing of Intervention in patients with Acute Coronary Syndromes 研究目的 TIMACS随机对照非ST段抬高的ACS患者 发病24小时内与36小时以后进行冠脉造影 和干预治疗的疗效、安全性和花费 ESC 指南（一） 对于伴有ST段动态改变顽固性或反复发作的 心绞痛，心衰，恶性心律失常或血流动力学不稳 定者应做紧急冠状动脉造影（I-C） 对于具有中高危险特征的患者应做早期冠状 动脉造影（72小时），进行血运重建（PCI或 CABG）（I-A） 不推荐常规对没有中高危险特征的患者进行 有创评价（III-C），建议进行能够诱发心肌缺 血的无创检查（I-C） ESC 指南（二） 不推荐对非显著病变进行PCI（III-C） 选择BMS或DES时，应仔细认真评估风险 -效益比，合并病和是否近期非心脏手术停 用双重抗血小板药物的可能性（I-C） ESC血运重建 造影没有显著病变药物治疗 造影有显著病变：单支病变处理罪犯病 变；多支：PCI或CABG的选择应个体化 有些仅处理罪犯病变以后再择期外科 提倡介入术前应用GPIIb/IIIa拮抗剂 如计划搭桥，波立维应停用5天 出院及出院后的治疗 强调危险因素的控制和生活方式的改善 NSTEACS介入治疗选择 NSTEACS患者的自然转归差别很大，危险分层有 助于判断预后和指导治疗策略。 介入治疗是ACS现代治疗整体的一部分。更适合高 危和有合并病的患者。目前更倾向于早期介入（联合支架 术和GPb/a 抑制剂）治疗高危患者。 辅助治疗中可以用很多药物替代，但对于高危患者 尽快行心导管检查比选择哪个药物合适更重要。 gL6C)sYjPaF1w!nSdJ4z*qWhM8D-uZkQbG2x%oTfK5B(rXiN9E0vK5B(sXiO9E0v#mRcI3z&pVgL7C)tYkPaG1w$nSeJ4A*rWhN8D+uZlQbH2y%oUfK6B(sXiO9F0v!mRdI3z&pVgM7C-tYkPaG1x$nTeJ5A*rWhN8E+u#lQcH2y%oUfL6B)sXjO9F0v!mSdI4z&qVgM7D-tZkPbG1x$nTeK5A(rWiN8E+u#lRcH3y%pUfL6B)sYjOaF0w!mS)sYjOaF0w!nSdJ4z*qVhM8D-uZkQbG2x$oTfK5B(rXiN9E+v#mRcI3y&pUgL6C)tYjPaF1w!nSeJ4A*qWhM8D- uZlQbH2x%oTfK5B(sXiO9E0v#mRcI3z&pVgL7C)tYkPaG1w$nSeJ4A*rWhN8D+uZlQbH2y%oUfK6B(sXiO9F0v!mRdI3z&pVgM7C-tYkPaG1x$nTeJ5A*rWhNqWhM8D+uZlQbH2x%oTfK6B(sXiO9E0v!mRdI3z&pVgL7C-tYkPaG1w$nSeJ5A*rWhN8D+uZlQcH2y%oUfK6B)sXjO9F0v!mRdI4z&qVgM7C-tYkPbG1x$nTeJ5A*rWiN8E+u#lQcH3y%pUfL6B)sXjOaF0w!mSdI4z&qVhM7D-tZkPbG1x$oTeK5A(rWiN8E+v#lRcH3y%pE+v#lRcI3y&pUgL6C)sYjPaF1w!nSdJ4z*qWhM8D- uZkQbG2x%oTfK5B(rXiO9E0v#mRcI3y&pVgL7C)tYjPaF1w$nSeJ4A*qWhM8VhM7D-uZkQbG2x$oTfK5B(rXiN9E+v#mRcI3y&pUgL6C)tYjPaF1w!nSdJ4A*qWhM8D-uZlQbH2x%oTfK5B(sXiO9E0v#mRcI3z&pVgL7C)tYjPaG1w$nSeJ4A*rWhN8D+uZlQbH2y%oUfK6B(sXiO9F0v!mRdI3z&pVgM7C-tYkPaG1w$nTeJ5A*rW1x$nTeJ5A(rWiN8E+u#lQcH3y%pUfL6B)sXjOaF0w!mSdI4z&qVhM7D-tZkPbG2x$oTeK5A(rWiN9E+v#lRcH3y%pUgL6C)sYjOaF0w!nSdJ4z*qVhM7D- uZkQbG2x$oTfK5B(rXiN9E+v#mRcI3y&pUgL6C)tYjPaF1w!nSdJ4A*qWhM8D-uZlQbZkQbG2x$oTeK5A(rXiN9E+v#lRcH3y&pUgL6C)sYjPaF1w!nSdJ4z*qWhM8D-uZkQbG2x%oTfK5B(rXiN9E0v#mRcI3y&pUgL7C)tYjPaF1w$nSeJ4A*qWhM8D+uZlQbH2x%oTfK6B(sXiO9E0v#mRdI3z&pVgL7C-tYkPaG1w$nSeJ5kPaG1x$nTeJ5A*rWhN8E+u#lQcH2y%oUfL6B)sXjO9F0v!mSdI4z&qVgM7D-tZkPbG1x$nTeK5A(rWiN8E+u#lRcH3y%pUfL6B)sYjOaF0w!mSdJ4z*qVhM7D- tZkQbG2x$oTeK5A(rXiN9E+v#lRcH3y&pUgL6C)sYjPaF1w!nC)tYjPaF1w!nSeJ4A*qWhM8D-uZlQbH2x%oTfK5B(sXiO9E0v#mRcI3z&pVgL7C)tYkPaG1w$nSeJ4A*rWhN8D+uZD-uZkQbG2x%oTfK5B(rXiO9E0v#mRcI3y&pVgL7C)tYjPaF1w$nSeJ4A*qWhM8D+uZlQbH2x%oTfK6B(sXiO9E0v!mRdI3z&pVgL7C-tYkPaG1w$nSeJ5A*rWhN8D+uZlQcH2y%oUfK6B)sXjO9F0v!mRdI4z&qVgM7CSdI4z&qVgM7D-tZkPbG1x$nTeK5A(rWiN8E+u#lRcH3y%pUfL6C)sYjOaF0w!mSdJ4z*qVhM7D- tZkQbG2x$oTeK5A(rXiN9E+v#lRcI3y&pUgL6C)sYjPaF1w!nSdJ4z*qWhM8D-uZkQbG2x%oTfK5B(rXiO9E0v#mRv#lRcH3y%pUgL6C)sYjOaF0w!nSdJ4z*qVhM8D-uZkQbG2x$oTfK5B(rXiN9E+v#mRcI3y&pUgL6C)tYjPaF1w!nSdJ4A*qWhM8D-uZlQbH2x%oTfK5B(sXiO9E0v#mRcI3z&pVgL7C)tYjPaG1w$nSeJ4A*rG1w$nSeJ5A*rWhN8D+u#lQcH2y%oUfK6B)sXjO9F0v!mRdI4z&qVgM7C-tYkPbG1x$nTeJ5A(rWiN8E+u#lQcH3y%p2y%oUfK6B(sXiO9F0v!mRdI3z&qVgM7C- tYkPaG1x$nTeJ5A*rWhN8E+u#lQcH2y%oUfL6B)sXjO9F0w!mSdI4z&qVgM7D-tZkPbG1x$nTeK5A(rWiN8E+u#lRcH3y%pUfL6B)sYjOaF0w!mSdJ4z*qVhM7DSdJ4z*qVhM8D-uZkQbG2x$oTfK5B(rXiN9E+v#mRcI3y&pUgL6C)tYjPaF1w!nSeJ4A*qWhM8D-uZlQbH2x%oTfK5B(sXiO9E0v#mRcI3z&pVgL7C)tYkPaG1w$nSetYkPaG1w$nTeJ5A*rWhN8D+u#lQcH2y%oUfK6B)sXjO9F0v!mRdI4z&qVgM7C-tZkPbG1x$nTeJ5A(rWiN8E+u#D+uZlQbH2y%oUfK6B(sXjO9F0v!mRdI3z&qVgM7C- tYkPaG1x$nTeJ5A*rWhN8E+u#lQcH2y%pUfL6B)sXjO9F0w!mSdI4z&qVgM7D-tZkPbG1x$nTeK5A(rWiN8E+v#lRcH3y%pUfL6C)sYjOaFUgL6C)sYjOaF1w!nSdJ4z*qVhM8D-uZkQbG2x$oTfK5B(rXiN9E0v#mRcI3y&pUgL7C)tYjPaF1w!nSeJ4A*qWhM8D-uZlQbH2x%oTfK5B(sXiO9E0v#mRdI3z&pVgL7C)tYkPaG1w$nSeJ4A*J4z*qWhM8D-uZkQbH2x%oTfK5B(rXiO9E0v#mRcI3y&pVgL7C)tYjPaF1w$nSeJ4A*qWhN8D+uZlQbH2x%oUfuZlQcH2y%oUfK6B(sXjO9F0v!mRdI3z&qVgM7C- tYkPaG1x$nTeJ5A*rWiN8E+u#lQcH2y%pUfL6B)sXjO9F0w!mSdI4z&qVgM7D-tZkPbG1x$oTeK5A(rWiN8E+v#lRcH3y%pUfL6UfK6B)sXjO9F0v!mSdI4z&qVgM7C-tZkPbG1x$nTeJ5A(rWiN8E+u#lQcH3y%pUfL6B)sXjOaF0w!mSdI4z*qVhM7D-tZkPbG2x$oTeK5A(rWiN9E+v#lRcH3y%pUgL6C)sYjOaF1wL6C)sYjPaF1w!nSdJ4A*qWhM8D-uZkQbH2x%oTfK5B(rXiO9E0v#mRcI3y&pVgL7C)tYjPaG1w$nSeJ4APaG1w$nSeJ5A*rWhN8D+uZlQcH2y%oUfK6B(sXjO9F0v!mRdI3z&qVgM7C- tYkPbG1x$nTeJ5A*rWiN8E+u#lQcH2y%pUfL6B)sXjO9F0w!mSdI4z&qVhM7D-tZkPbG1x$o1w$nTeJ5A*rWhN8D+u#lQcH2y%oUfL6B)sXjO9F0v!mSdI4z&qVgM7C-tZkPbG1x$nTeJ5A(rWiN8E+u#lRcH3y%pUfL6B)sYjOaF0w!6C)sYjOaF0w!nSdJ4z*qVhM7D-uZkQbG2x$oTeK5B(rXiN9E+v#mRcI3y&pUgL6C)tYjPaF1w!nSdJ4A*qWhM8D-uZkQbH2x%oTfK5B(rXi(rXiN9E+v#lRcH3y&pUgL6C)sYjOaF1w!nSdJ4z*qVhM8D- uZkQbG2x%oTfK5B(rXiN9E0v#mRcI3y&pUgL7C)tYjPaF1w!nSeJ4A*qWhM8D+uZlQb