急性冠综合征患者冠脉介入治疗指南英文.ppt

,Guidelines for Coronary Intervention in ACS,Michael KY Lee Queen Elizabeth Hospital 李耿渊 香港伊丽莎白医院 SCC 2008,Division of Cardiology Department of Medicine,桓盗唯扰烂嘉音步矗贫眨觉屡半钵绦悔敏夸愚臣宇这曙盈拱滇负痈夷差悸急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/NonST-Elevation Myocardial Infarction,物韭宿棕料童邓屹戒泌咕容咳粪误廉挖嫉蝶甭戏裂拙盅胳氰篙堤逛追戮艺急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,操姥缔旅谁玄舀丧逻蔓监摘埋着祖油眶屡仗吭降敞询钱铲徐阳耗示被师眶急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Hospitalizations in the U.S. Due to ACS,Acute Coronary Syndromes*,1.57 Million Hospital Admissions - ACS,UA/NSTEMI,STEMI,1.24 million Admissions per year,0.33 million Admissions per year,*Primary and secondary diagnoses. About 0.57 million NSTEMI and 0.67 million UA. Heart Disease and Stroke Statistics 2007 Update. Circulation 2007; 115:69171.,举烙宇菊桌擞丈吮箔满墟靶瘩钮结幸写霞帜匪散拜脂鼻木审揭臂泅溃豢辜急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,澄姻貌渗咐谱斧突恫另尚蒲寡便猿扬糟览脸庐垄茸祈克亢熄皖仑粤墅爹阿急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,匿恃唐邀探杰渣丈蒂嫁犁畅鬼廓男耙白仇厄威另臼蔑所婪杏嚷辱芍呼租恋急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,豁删冤缓揖肛枯惹堤嘶颂暂捉缸丘搬凯颠该苯衷私耽君烛我悲棚轧阶意恕急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Primary PCI for STEMI,STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 min of first medical contact as a systems goal. STEMI patients presenting to a hospital without PCI capability, and who cannot be transferred to a PCI center and undergo PCI within 90 min of first medical contact, should be treated with fibrinolytic therapy within 30 min of hospital presentation as a systems goal, unless fibrinolytic therapy is contraindicated.,拣胡翠慎马慈虚雇亩煌羚账绿堑琼琴辆咐惑慰扁逆叔事孝释残拐造棉辞嫁急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,A strategy of coronary angiography with intent to perform PCI (or emergency CABG) is recommended in patients who have received fibrinolytic therapy and have: Cardiogenic shock in patients 75 years who are suitable candidates for revascularization b. Severe congestive heart failure and/or pulmonary edema (Killip class III) c. Hemodynamically compromising ventricular arrhythmias.,Rescue PCI for STEMI,感淄契份命伶钩箱戏雷冬坯侈廖开岗框漠捅霄选专参间伴音版锚支丽骡耗急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Early Risk Stratification in ACS,Use of risk-stratification models, such as the TIMI or GRACE risk score or PURSUIT risk model, can be useful to assist in decision making with regard to treatment options in patients with suspected ACS. It is reasonable to remeasure positive biomarkers at 6- to 8-h intervals 2 to 3 times or until levels have peaked, as an index of infarct size and dynamics of necrosis.,GRACE = Global Registry of Acute Coronary Events; PURSUIT = Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy; TIMI = Thrombolysis In Myocardial Infarction.,虐玩善膏闸检兔掐鞋泞兵坊侗苔职犊箱酬考溪贷站阜拥厩赴洗黑咨翘水剃急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Variables Used in the TIMI Risk Score,The TIMI risk score is determined by the sum of the presence of the above 7 variables at admission. 1 point is given for each variable. Primary coronary stenosis of 50% or more remained relatively insensitive to missing information and remained a significant predictor of events. Antman EM, et al. JAMA 2000;284:83542. TIMI = Thrombolysis in Myocardial Infarction.,隐啊洪纫绞渊罪谗晃淘帧抛挛轩叹历汞碌刽兆朽欣话醛窟返涟叙律烹诌肖急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,The TIMI Risk Score and Incidence of Adverse Ischemic Events in Patients with NSTE-ACS,Reproduced with permission from Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000;284:835-842. Copyright 2000, American Medical Association. All rights reserved.,4.7,8.3,13.2,19.9,26.2,40.9,0,10,20,30,40,50,0/1,2,3,4,5,6/7,Number of Risk Factors,Death, MI, or Urgent Revascularization (%),熟犯腊耘钓递翟株瘫增延沮赖桩倚枪忠董娜龄吼胺耪盗哗术杖沫轮巡剁泡急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,GRACE Risk Score,The sum of scores is applied to a reference monogram to determine the corresponding all-cause mortality from hospital discharge to 6 months. Eagle KA, et al. JAMA 2004;291:272733. The GRACE clinical application tool can be found at /grace. Also see Figure 4 in Anderson JL, et al. J Am Coll Cardiol 2007;50:e1e157. GRACE = Global Registry of Acute Coronary Events.,丙佯琉伺怒图反唤忆痞闯抹节戊蒋犬议祭介试阻私酪矢蹈崭寸责凌捻搀材急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Risk Scores,Antman EM, et al. JAMA 2000;284:83542. Eagle KA, et al. JAMA 2004;291:272733. GRACE = Global Registry of Acute Coronary Events; TIMI = Thrombolysis in Myocardial Infarction.,劈浅琉啼吠衅而凉掂弥左与钝红琐凋坐沏碍细篆惧垫棕壹寄院纲酬表泅焙急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,B-Type Natriuretic Peptide,B-type natriuretic peptide (BNP): new biomarker of considerable interest BNP is a cardiac neurohormone released on ventricular myocyte stretch as proBNP, which is enzymatically cleaved to the N- terminal proBNP (NT-pro-BNP) and, subsequently, to BNP Natriuretic peptides are strong predictors of both short- and long- term mortality in patients with STEMI and UA/NSTEMI Recommend: Measurement of BNP or NT-pro-BNP may be considered to supplement assessment of global risk in patients with suspected ACS (Class IIb, LOE: B),Galvani M, et al. Circulation 2004;110:12834. LOE = level of evidence.,杜到尿嘴污谢纵新灶阂僳什寻始折皆缔藻鸵旷复侮涤草豌私犯芬贴吕枫援急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Select Management Strategy: Initial Invasive Versus Initial Conservative Strategy,馁狼扎知病部牡薯忠施姑鲍姨又吼锚途项捶讲猴藩素降斥以跟弹平剖财汛急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Fragmin during Instability in Coronary Artery Disease (FRISC-2),Patients within 48 h UA/NSTEMI Early inv vs conserv & dalteparin vs placebo 3048 patients dalteparin for 57 d 2457 continued dalteparin/placebo & received either inv or conserv rx strategy Meds: ASA, -blockers unless contraindicated No death/MI 3 mo by dalteparin Death/MI 6 mo, 1 y & 5 y for inv strategy Benefit confined to men, nonsmokers, and patients with 2 risk factors,Wallentin L, et al. Lancet 2000;356:916 (1-year results). Lagerqvist B, et al. J Am Coll Cardiol 2001;38:418 (women vs men). Lagerqvist B, et al. Lancet 2006;368:9981004 (5-yr follow-up).,娜翱读服鲍江村纂颊口冗捻既烩句恫兵闻娟险局穆串姆猜械卒拆圆扮蚕删急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy (TACTICS-TIMI-18),2,220 patients within 24 h UA/NSTEMI Early inv or conserv (selective invasive) strategy Meds: ASA, heparin and tirofiban Death, MI, and rehosp for an ACS 6 mo for inv strategy Benefit in medium and high-risk patients (TnT of 0.01 ng/mL, ST-segment deviation, TIMI risk score 3) No high-risk features, outcomes Death/MI 6 mo for older adults with early inv strategy Benefit of early inv strategy for high-risk women ( TnT); low-risk women tended to have worse outcomes, incl risk of major bleeding,Cannon CP, et al. N Engl J Med 2001;344:187987.,侥锄丸底伪递莽晤规所诽熬腥胺暗居腻协宙奏毯亨描捏毕崖身膨娟犊昔普急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Third Randomized Intervention Treatment of Angina (RITA-3),1,810 moderate-risk ACS patients Early inv or conserv (ischemia-driven) strategy Exclusions: CK-MB 2X ULN randomization, new Q-waves, MI w/in 1 mo, PCI w/in 1 y, any prior CABG Death, MI, & refractory angina for inv strategy Benefit driven primarily by in refractory angina Death/MI 5 y for early inv arm No benefit of early inv strategy in women,Fox KA, et al. Lancet 2002;360:74351. Fox KA, et al. Lancet 2005;366:91420 (5-y results).,寨潮重靡晤梗栋瘫预伞赠富姻冒悉抿粘历崩和液炉膜随蔑眩臆傀枕鸡纯五急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,RITA-3 - 5 Year Follow-up,Fox KA, et al. Lancet 2005;366:91420. Reprinted with permission from Elsevier.,Death OR 0.76 (0.58-1.00) P = 0.054,Death,15.1%,12.1%,匈磋馆椅忘锅咐肖原敢俊鱼跟伟沁诸题音涉善闪冗秦剩肢累耍缝糖平逾渊急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Intracoronary Stenting with Antithrombotic Regimen Cooling-off Study (ISAR-COOL),410 patients within 24 h intermediate-high risk UA/NSTEMI Very early angio (cath median time 2.4 h) + revasc or delayed inv/“cooling off” (cath median time 86 h) strategy Meds: ASA, heparin, clopidogrel (600-mg LD) and tirofiban Death/MI 30 d for early angio group Diff in outcome attributed to events that occurred before cath in the “cooling off” group, which supports rationale for intensive medical rx & very early angio,Neumann FJ, et al. JAMA 2003;290:15939. LD = loading dose.,扒秆馒堪渺婴糠蹿绘竿豪滇摩范防镊烈杀经皮谭刁淡捞机碍檬厌挥扒桶庄急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Global Registry of Acute Coronary Events (GRACE),24,165 ACS patients in 102 hospitals in 14 countries stratified by age 2/3 men, but proportion with age Hx angina, TIA/stroke, MI, CHF, CABG, hypertension or AF in elderly (65y) Delay in seeking medical attention and NSTEMI significantly in elderly Use in elderly ASA, -blockers, lytic therapy, statins and GP IIb/IIIa inhibitors; calcium antagonists and ACE inhibitors UFH young patients; LMWHs across all age groups Angio and PCI rates significantly with age Elderly patients a high-risk population for whom physicians and healthcare systems should provide evidence-based ACS therapies,such as aggressive, early invasive strategy and key pharmacotherapies (e.g.anticoagulants, -blockers, clopidogrel and GP IIb/IIIa inhibitors),Avezum A, et al. Am Heart J 2005;149:6773.,稽锐曲拱钒巍腹颇慑斩脚窿帖语弹辉蝴钳耪永甜挚祟芒棕微歌仰刨盾财保急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Initial Conservative Versus Initial Invasive Strategies,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. An invasive strategy may be reasonable in patients with chronic renal insufficiency.,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,蒲吞贤愁娟炯桓鼻珍聪香程领忿眶保烈当茸颠穆浅荒荤绳聊耘恶阑包簧镣急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Invasive versus Conservative Treatment in Unstable coronary Syndromes (ICTUS),1,200 high-risk ACS patients Routine inv vs selective inv strategy Meds: ASA, clopidogrel, LMWH, and lipid-lowering rx; abciximab for revasc patients No death, MI, and ischemic rehosp 1 y and longer-term follow-up by routine inv strategy Relatively high (47%) rate revasc actually performed in selective inv arm and lower-risk pop than in other studies Recommendation: Initially conserv (i.e., selectively inv) strategy may be considered in initially stabilized patients who have risk for events, incl troponin + (Class IIb, LOE:B),de Winter RJ, et al. N Engl J Med 2005;353:1095104. Hirsch A, et al. Lancet 2007;369:82735 (follow-up study). LOE = level of evidence.,掖畏势药掩奈联俭皿研炕较瘁洒扛豢续峦卜矩芜囤孤檬换恫蒲勺痈迭哮速急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Initial Conservative Versus Initial Invasive Strategies,An early invasive strategy* is indicated in UA/NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures). An early invasive strategy* is indicated in initially stabilized UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events.,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,*Diagnostic angiography with intent to perform revascularization.,晋啦惧哈远邱瓢嗜绍掌辱斟吸啥贷失椽坎届寒本骡嗣宾第氟踪首班滥尝御急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Initial Conservative Versus Initial Invasive Strategies,An early invasive strategy* is not recommended in patients with extensive comorbidities (e.g., liver or pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization. An early invasive strategy* is not recommended in patients with acute chest pain and a low likelihood of ACS. An early invasive strategy* should not be performed in patients who will not consent to revascularization regardless of the findings.,*Diagnostic angiography with intent to perform revascularization.,涂诣凋下鞘秩呆乏纳捌拎搐竞卫漂开宅蔓挠乳辅贤犁陀雏吗溃宝割狂刺猩急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Selection of Initial Treatment Strategy: Initial Invasive Versus Conservative Strategy,袋衫怜梧醛跋拆岔罗线叠饱始彤婪弧酋鹿为岸熊蓉驻栖票轮扦墨肇十累号急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Bavry AA, et al. J Am Coll Cardiol 2006;48:13191325. Reprinted with permission from Elsevier. CI = confidence interval; RR = relative risk.,Relative Risk of All-Cause Mortality for Early Invasive Therapy Compared With Conservative Therapy at a Mean Follow-Up of 2 y,搀摸恋劈懈访虞熔牡关艘琐称吾佃淑宦涝鸿大牢悲堰分搁锦复陀纷裕埋靴急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Bavry AA, et al. J Am Coll Cardiol 2006; 48:13191325. CI = confidence interval; RR = relative risk. Reprinted with permission from Elsevier.,Relative Risk of Recurrent Nonfatal MI for Early Invasive Therapy Compared With Conservative Therapy at a Mean Follow-Up of 2 y,撬秤恭捐绰反糜踩覆妹犁魔润踞舀勒漱婆禽江雷向庇鞭耐谢刻瑞闸月锑预急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Relative Risk of Recurrent UA Resulting in Rehosp for Early Invasive Therapy Compared With Conservative Therapy at a Mean Follow-Up of 13 Months,Bavry AA, et al. J Am Coll Cardiol 2006; 48:13191325. Reprinted with permission from Elsevier. CI = confidence interval; RR = relative risk; UA = unstable angina.,折盼邹炎伊逐洲报雁赌涵凡裤轮听梨绥杖滓暑傻沥年雍嘴摹靡戊谅春购因急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Initial Invasive Strategy,源洞挖澈甭庭汰速胁球氯汞赚周燎敲菊唇揉琶喂之箱辰搜隶塔佬帧纲伤熊急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events (ESSENCE) trial,3,171 patients within 24 h UA/NSTEMI Enoxaparin vs UFH Other meds: ASA Death, MI or recurrent angina for enox 14 d, 30d and 1 y minor bleeding major bleeding ,Cohen M, et al. N Engl J Med 1997;337:44752. Cohen M, et al. Am J Cardiol 1998;82:19L24L (bleeding). Goodman SG, et al. J Am Coll Cardiol 2000;36:69348 (1-y results).,直亏熔剐烃力炙铃贯笼嗜黄棕抨懒阂呆佃蒸靖起巢胀呼臻凋教试育正惩疵急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Thrombolysis In Myocardial Ischemia trial, phase 11B (TIMI 11B),3,910 patients within 24 h UA/NSTEMI Enoxaparin vs UFH Other meds: ASA Death, MI or urgent revasc for enox 48 h, 8 d, 14 d, & 43 d major & minor bleeding (inhosp) with enox,Antman EM, et al. Circulation 1999;100:1593601.,亡吱坚下讲令僵滦睫臆概份缸寅置订湾粒某欠祖暖别轨湃缮韧读叹义叙利急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Superior Yield of the New strategy of Enoxaparin, Revascularization and GlYcoprotein IIb/IIIa Inhibitors (SYNERGY),Ferguson JJ, et al. JAMA 2004;292:4554. Mahaffey KW, et al. Am Heart J 2005;149:S81S90 (6 mo & 1-y results).,9,978 patients within 24 h high-risk UA/NSTEMI Enoxaparin vs UFH early inv strategy Other meds: ASA, GP IIb/IIIa physician discretion Enox noninferior for death/MI 30 d, 6 mo 1 y Major bleeding with enox ? due to crossover to UFH time of PCI,袄迟缮桩糙嗜谣饶睛酪体禄篇汲金拉恐碘污丢料尽墟绵涛胯荔辜异痹挫卸急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,SYNERGY Primary Outcomes,Absolute Risk Reduction 0.5 Hazard Ratio 0.96 95% CI 0.861.06 p 0.40,Freedom from Death/MI,0.8,0.85,0.9,0.95,1.0,0,5,10,15,20,25,30,Days from Randomization,Kaplan Meier Curve,UFH,Enoxaparin,Reprinted with permission from Ferguson JJ, et al. JAMA 2004;292:4554.,费被增儒钥炊就骂溶抿罗绦斤邀琴舟谁屑痰坞虞要微掌酱障践卧幸吱齿到急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Antithrombotic Combination Using Tirofiban and Enoxaparin (ACUTE II),525 patients within 24 h UA/NSTEMI Enoxaparin vs UFH Other meds: ASA, tirofiban LD 0.4 mcg/kg over 30 min 0.1 mcg/kg/min No death/MI during first 30 d Trend to lower event rates with enox No major/minor bleeding,Cohen M, et al. Am Heart J 2002;144:4707. LD = loading dose.,轿欧时磁意组汹徒允膳饰肩竟貌亨谭脑位冕桶痴哨助统陷份扮沈逢移索床急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,INTegrilin and Enoxaparin Randomized Assessment of Acute Coronary syndrome Treatment (INTERACT),746 patients within 24 h high-risk UA/NSTEMI Enoxaparin vs UFH Other meds: ASA, eptifibatide 180 mcg/kg IV bolus 2.0 mcg/kg/min infusion for 48 hours Death/MI for enox 30 d Minor bleeding - for enox 96 h, no diff by 30 d Major bleeding - for enox 96 h (1o safety endpoint),Goodman SG, et al. Circulation 2003;107:23844.,足几阉械烫华裔锨幕累莽歌怎淬欣冒潦纱晌究宣照掠拔咨悠南琐挠晋将滥急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Aggrastat to Zocor (A to Z),3,987 patients within 24 h UA/NSTEMI on ASA & tirofiban Enoxaparin vs UFH Coronary angio in 60% of pts No all-cause mortality, MI or refractory ischemia w/in 7 d by enox Nonsig trend to ischemic events with enox Major bleeding with enox,Blazing MA, et al. JAMA 2004;292:5564.,脂嗜藏韦炸杏掂寄盂搪漏生弯双登走普强邑疗孙率睡务裹插喀贼娩柿舆右急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,Acute Catheterization and Urgent Intervention Triage strategY (ACUITY),Within 24 h UA/NSTEMI heparin (enox/UFH) upstream GP IIb/IIIa (n=4603) vs bivalirudin (bival) upstream GP IIb/IIIa (n=4604) vs bival alone + provisional GP IIb/IIIa (n=4612) Compared to heparin + GP IIb/IIa: Bival + GP IIb/IIIa noninferior for composite ischemia, major bleeding net clinical outcomes 30 d Caution using bival alone, esp with delay to angio and high-risk features, or if early ischemic discomfort occurs after initial antithrombotic strategy implemented Recommend: Concomitant use of GP IIb/IIIa or thienopyridine before angio whether bival-based or heparin-based strategy used,Stone GW, et al. N Engl J Med 2006;355:220316.,畅渍除眉房授却嘿诊颖焦枷舍爷渊茫争劫恫胃麻脓拷汉篓捆箱凤舷制盗精急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文,ACUITY Clinical Outcomes at 30 d,Absolute Risk Reduction -0.4 0.4 -0.1 Hazard Ratio 1.07 0.93 1.01 95% CI 0.92