急性冠脉综合症ppt课件

5/98,MedS,1,急性冠脉综合征（ACS）及其 治疗进展,5/98,MedS,2,急性冠状动脉综合征的定义和分类,定义：急性冠状动脉综合征(acute coronary syndomes , ACS) 是从不稳定性心绞痛到Q波心肌梗死的一组临床综合征 ，通常(但并非总是)由于CAD所致，在病理生理上有很多相似之处。 急性冠状动脉综合征的分类 ： ST段不抬高的急性冠状动脉综合征 非Q波心肌梗死NSTEMI（CK-MB大于正常上限的2倍） 不稳定性心绞痛UAP（CK-MB小于正常上限的2倍） ST段抬高的急性冠状动脉综合征 急性Q波心肌梗死STEMI,5/98,MedS,3,国际现状,每年: 4 million patients are admitted with unstable angina and acute MI 900,000 patients undergo PTCA with or without stent,5/98,MedS,4,Ischemic Heart Disease evaluation,Based on the patients history / physical exam electrocardiogram Patients are categorized into 3 groups non-cardiac chest pain unstable angina myocardial infarction,5/98,MedS,5,急性冠脉综合征 （ACS）,ACS,非 ST-segment 抬高,ST-segment 抬高,不稳定 非-Q波 Q-Wave 心绞痛 AMI AMI,ECG,Acute Reperfusion,History Physical Exam,5/98,MedS,6,Acute Coronary Syndrome,The spectrum of clinical conditions ranging from: unstable angina non-Q wave MI Q-wave MI characterized by the common pathophysiology of a disrupted atheroslerotic plaque,5/98,MedS,7,5/98,MedS,8,STEMI和UA/NSTEMI病理,MedS,9,不稳定心绞痛 定义,angina at rest ( 20 minutes) new-onset ( 2 months) exertional angina (at least CCSC III in severity) recent ( 2 months) acceleration of angina (increase in severity of at least one CCSC class to at least CCSC class III),Agency for Health Care Policy Research - 1994,Canadian Cardiovascular Society Classification,5/98,MedS,10,Non-Q-Wave MI clues to diagnosis,Prolonged chest pain Associated symptoms from the autonomic nervous system nausea, vomiting, diaphoresis Persistent ST-segment depression after resolution of chest pain,5/98,MedS,11,5/98,MedS,12,NSTEACS 诱发因素,Inappropriate tachycardia anemia, fever, hypoxia, tachyarrhythmias, thyrotoxicosis High afterload aortic valve stenosis, LVH High preload high cardiac output, chamber dilatation Inotropic state sympathomimetic drugs, cocaine intoxication,5/98,MedS,13,NSTEACS 预后预测因素,Presence of ST-T-wave changes with pain Hemodynamic deterioration pulmonary edema, new mitral regurgitation, 3rd heart sound, hypotension Other predictors left ventricular dysfunction, extensive CAD, age, comorbid conditions (diabetes mellitus, obstructive pulmonary disease, renal failure, malignancy),5/98,MedS,14,非ST段抬高ACS（NSTEACS）,Plaque disruption斑块破裂 Acute thrombosis急性血栓 Vasoconstriction血管收缩,5/98,MedS,15,NSTEACS pathogenesis,斑块破裂 Passive plaque disruption soft plaque with high concentration of cholesteryl esters and a thin fibrous cap Active plaque disruption macrophage-rich area with enzymes that may degrade and weaken the fibrous cap; predisposing it to rupture,5/98,MedS,16,NSTEACS pathogenesis,急性血栓 Vulnerable plaque disrupted plaque with ulceration occurring in 2/3 of unstable patients the exposed lipid-rich core abundant in cholesteryl ester is highly thrombogenic Systemic Hypercoagulable State disrupted plaque with erosion occurring in 1/3 of unstable patients,5/98,MedS,17,NSTEACS pathogenesis,血管收缩 the culprit lesion in response to deep arterial damage or plaque disruption area of dysfunctional endothelium near the culprit lesion platelet-dependent and thrombin-dependent vasoconstriction, mediated by serotonin and thromboxane A2,5/98,MedS,18,Risk Stratification by ECG,The risk of death or MI at 30 days is strongly related to the ECG at the time of chest pain. ST depression 10% T-wave inversion 5% No ECG changes 1-2%,5/98,MedS,19,有以下表现者为高危险性： (1) 危险性随病变血管支数、病变弥漫程度、小血管病变、闭 塞血管病变数而增高。 (2) 左主干病变 (3) 含血栓性病变(见图1) (4) 病变形态复杂,行介入治疗难以或无法植入支架。(见图2) 图1 图2,冠脉造影,5/98,MedS,20,NSTEACS 治疗目标,Therapeutic Goals 减少心肌缺血 控制症状 预防心肌梗死和猝死 Medical Management 抗缺血 therapy 抗血栓 therapy,5/98,MedS,21,药物治疗,抗缺血 therapy nitrates, beta blockers, calcium antagonists 抗血栓 therapy 抗血小板 therapy aspirin, ticlopidine, clopidogrel, GP IIb/IIIa inhibitors 抗凝 therapy heparin, low molecular weight heparin (LMWH), warfarin, hirudin, hirulog,5/98,MedS,22,5/98,MedS,23,NSTEACS Anti-thrombotic Therapy,不适宜溶栓 “lytic agents may stimulate the thrombogenic process and result in paradoxical aggravation of ischemia and myocardial infarction”,TIMI IIIB Investigators Circulation 1994; 89:1545-1556,5/98,MedS,24,5/98,MedS,25,Unstable Angina Anti-platelet Therapy,阿司匹林是“金标准” irreversible inhibition of the cyclooxygenase pathway in platelets, blocking formation of thromboxane A2, and platelet aggregation in AMI, ASA reduced the risk of death by 20-25% in UA, ASA reduced the risk of fatal or nonfatal MI by 71% during the acute phase, 60% at 3 months, and 52% at 2 years bolus dose of 160-325 mg, followed by maintenance dose of 80-160 mg/d,5/98,MedS,26,缺血事件发生率,无阿司匹林 (early 1980s),阿司匹林,Aspirin + Heparin,16%,12%,9%,Incidence of death and MI,5/98,MedS,27,Unstable Angina Anti-platelet Therapy,Clopidogrel氯比格雷 CAPRIE (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events) 19,000 patients randomly assigned to clopidogrel (75 mg/d) or to aspirin (325 mg/d) there was an 8.7% reduction in the combined incidence of stroke, MI, or death (P=.043) patients with MI did better with aspirin patients with PVD or stroke did better with clopidogrel,Lancet 1996;348:1329-1339 Circulation 1998;97:1107,5/98,MedS,28,GP IIb/IIIa Receptor 血小板聚集的最终通路,Platelet activation and aggregation are early events in the development of coronary thrombosis GP IIb/IIIa receptors on activated platelets undergo a conformational change allowing recognition and binding of fibrinogen Fibrinogen “acts like glue”, bridging GP IIb/IIIa receptors on adjacent platelets, leading to platelet aggregation,5/98,MedS,29,Unstable Angina Anti-platelet Therapy,Tirofiban (Aggrastat; Merk & Co.) PRISM (Platelet Receptor Inhibition for Ischemic Syndrome Management) 3,200 patients with unstable angina were treated with either heparin or tirofiban At 48 hours, there was significant risk reduction (5.9% to 3.6%) in the rate of death, MI, or refractory ischemia. The benefit was lost at 30 days.,N Engl J Med 1998;338:1498-505,5/98,MedS,30,5/98,MedS,31,调脂治疗 他汀类药物,5/98,MedS,32,回顾分析显示： 急性冠脉综合症后使用他汀治疗可降低死亡率,5/98,MedS,33,ACS 的治疗策略进展,冠脉综合征治疗策略进展主要表现在以下三个方面： (1) 抗血小板制剂：包括阿斯匹林,ADP受体拮抗剂(抵克力得Ticlopidine、氯吡格雷Clopidogrel )和GPb / a 受体拮抗剂(Rrepro) (2) 抗凝制剂：包括肝素、低分子肝素(LMWH)、凝血酶抑制剂(水蛭素 Hirudin )和戊聚糖钠 (3) 介入治疗,5/98,MedS,34,Unstable Angina 介入治疗,TIMI 3B early intervention vs conservative strategy (coronary angiography within 24-48 hrs, followed by angioplasty or bypass surgery) 1473 patients with UA or non-Q-wave MI were randomized, there were no difference between the groups in the rates of death or MI at 1 year,Circulation 1994;89:1545-1556,5/98,MedS,35,非ST段抬高ACS的PCI,复发静息心绞痛 动态ST段改变：ST压低0.1mv或一过性抬 高 0.1mv TnT、TnIC或CK-MB升高 血流动力学不稳定 室速、室颤 AMI后不稳定心绞痛 糖尿病 高危患者可能迅速发生血栓事件，进展为严重AMI或死亡，专家建议常规置入支架,5/98,MedS,36,AMI的再灌注治疗, 溶栓治疗 介入治疗,5/98,MedS,37,再灌注策略危险和获益,时间,静脉溶栓,5/98,MedS,38,再灌注开始的时间与获益,5/98,MedS,39,ST段抬高ACS的再灌注 -溶栓,优先溶栓治疗： AMI患者来院3小时 不能行PCI PCI慢（D-TO-B90分钟）,5/98,MedS,40,介入治疗的优点,梗塞相关血管（IRA）开通率 开通率 95% TIMI-3级率 90% 死亡率低 30天3% 脑卒中率低 再闭塞率低 适应症范围广,5/98,MedS,41,ST段抬高ACS的再灌注 -PCI,优先PCI治疗： AMI患者来院3小时 PC