不稳定型心绞痛和非ST段抬高心梗的治疗.ppt

AcuteCoronarySyndromes:ManagementofUA/NSTEMI,Overviewof2019UpdatestotheACC/AHAGuidelineforUA/NSTEMI,AssesslikelihoodofCADRiskstratificationTargettherapy:moreaggressivetreatmentinhigher-riskpatientsAnti-ischemic,antithrombotictherapyInvasivevsconservativestrategyDischargeplanning(riskfactormodificationandlong-termmedicaltherapy),ACC/AHA,AmericanCollegeofCardiology/AmericanHeartAssociation;UA,unstableangina;NSTEMI,nonST-segmentelevationmyocardialinfarction.BraunwaldE,etal.JAmCol.Cardiol.2000;36:970-1062.,AcuteManagementofUA/NSTEMI,Anti-IschemicTherapyOxygen,bedrest,ECGmonitoringNitroglycerin-BlockersACEinhibitors,UA,unstableangina;NSTEMI,non-ST-segmentelevationmyocardialinfarction;ECG,electrocardiogram;ACE,angiotensin-convertingenzyme.BraunwaldE,etal.JAmCollCardiol.2000;36:970-1062.,AntithromboticTherapyAntiplatelettherapyAnticoagulanttherapy,PossibleACS,Aspirin,Aspirin+IVHeparin+IVPlateletGPIIb/IIIaAntagonist,DefiniteACSWithInvasiveStrategy(Catheterization/PCI)orHighRisk(IIa)*,Clopidogrel,Aspirin+SQLMWH*orIVHeparin,Likely/DefiniteACS,Clopidogrel,*ClassIIa:enoxaparinpreferredoverUFHunlessCABGplannedwithin24hours.ACC,AmericanCollegeofCardiology;AHA,AmericanHeartassociation;ACS,acutecoronarysyndrome;PCI,percutaneouscoronaryintervention;SQLMWH,subcutaneouslowmolecular-weightheparin;IV,intravenous.BraunwaldE,etal.JAmCollCardiol.2000;36:970-1062.,ACC/AHAClassIRecommendationsforAntithromboticTherapy*,17.1,6.5*,Placebo,ASA,0,5,10,15,20,Patients(%),UnstableAngina,25.0,11.0*,ASA,0,10,20,30,3.3,1.9*,ASA,0,1,2,3,4,11.8,9.4*,ASA,0,5,10,15,AcuteMI,AspirininAcuteCoronarySyndromes,*P.0001DeathorMI,*P=.003Reocclusion,*P=.012MI,*P.001Death,N=3973995134198587860085878600,MI,myocardialinfarction;ASA,acetylsalicylicacid;RISC,ResearchonInStabilityinCoronaryarterydisease.RISCGroup.Lancet.1990;336:827-830.RouxS,etal.JAmCollCardiol.1992;19:671-677.ISIS-2.Lancet.1988;2:349-360.,Placebo,Placebo,Placebo,AspirininAcuteCoronarySyndromes,12.9,3.9*,ASA,0,5,10,15,11.9,3.3*,ASA,0,5,10,15,12.9,6.2*,ASA,0,5,10,15,2.2,1.3*,ASA,0,0.5,1,1.5,2,2.5,UA/NSTEMI,PrimaryPrevention,StableAngina,*P.0001MI,*P=.0003MI,*P=.008DeathorMI,*P=.012DeathorMI,N=1103411037155178279276118121,MI,myocardialinfarction;ASA,acetylsalicylicacid;RISC,ResearchonInStabilityinCoronaryarterydisease;ISIS-2,SecondInternationalStudyofInfarctSurvival.PHS.NEnglJMed.1989;321:129-35.RidkerPM,etal.AJC.1991;114:835-839.CairnsJA,etal.NEnglJMed.1985;313:1369-1375.TherouxP,etal.NEnglJMed.1988;319:1105-1111.,Placebo,Placebo,Placebo,Placebo,Patients(%),IndirectComparisonsofASADosesonVascularEventsinHigh-RiskPatients,*Oddsreduction.TreatmenteffectP.0001.ASA,acetylsalicylicacid.AdaptedwithpermissionfromBMJPublishingGroup.AntithromboticTrialistsCollaboration.BMJ.2019;324:71-86.,0.5,1.0,1.5,2.0,500-1500mg3419,160-325mg1926,75-150mg1232,162mg/d(n=2179),Primaryendpoint16.418.6Death,MI,stroke6.26.1Death2.81.7MI2.02.1Stroke2.12.8Urgenthospitalcare9.510.6Urgentresuscitation7.310.0Internalbleeding2.43.3Anybleeding11.115.4Transfusion1.02.0,Clopidogrel+ASA(N=6259),Placebo+ASA*(N=6303),CURE:MajorBleedingat1yearbyASADose,200mg(N=4110)3.7%4.9%Pvaluefortrend.0001.0009,*P=.0001.P=.0009.AdaptedfromPetersRJG,etal.Circulation.2019;108:1682-1687.,ASADose,RR:Death/MI,ASAAlone68/655=10.4%,Heparin+ASA55/698=7.9%,B,B,B,B,B,B,B,0.1,1,10,SummaryRelativeRisk,0.67(0.44-0.1.02),Theroux,RISC,Cohen1990,ATACS,Holdright,Gurfinkel,ComparisonofHeparin+ASAvsASAAlone,ASA,acetylsalicylicacid;RISC,ResearchonInStabilityinCoronaryarterydisease;ATACS,AntithromboticTherapyinAcuteCompanySyndromes;RR,relativerisk;MI,myocardialinfarction.OlerA,etal.JAMA.2019;276:811-815.(withpermission),TIMI,ThrombosisinMyocardialInfarction;ESSENCE,EfficacyandSafetyofSubcutaneousEnozapaminNonQ-WaveCoronaryEvents;UHF,unfractionatedheparin;ENOX,enoxaparin;MI,myocardialinfarction;OR,oddsratio.AntmanEM,etal.Circulation.2019;100:1602-1608.(withpermission),TIMIIIB/ESSENCEMetanalysis:EnoxaparinvsUnfractionatedHeparin,UHF,unfractionatedheparin;ENOX,enoxaparin;RRR,relativeriskratio.AntmanEM.Circulation.2019;100:1593-1601.(withpermission),TIMIIIB:EarlyPhaseDeath/MI/UrgentRevasc,UFH,Enoxaparin,P=.03,MajorBleeds96Hours,INTERACT:EnoxaparinvsUnfractionatedHeparinWithGPIIb/IIIaInhibitors,GoodmanSG,etal.Circulation.2019;107:238-244.,Death/MI30Days,P=.031,UFH,Enoxaparin,Percent,A-PhaseStudyDesign,UA/NSTEMI,FinalAvisit30days,Randomize,-24hours,Chestpain,Min0hourMax120hour,Tirofiban+ASA,Hour0,Aggressiveorconservativecareperlocalpractice,2026,1961,ENOX1mg/kgq12hr,UFHWeight-adjusted,Z,Z,Treat42:1132-1139.(withpermission),Death/MI/UrgTVRBleeding,30,25,20,15,10,5,0,200,250,300,350,400,450,500,550,600,200,250,300,350,400,450,500,550,600,ProbabilityofMACE(%),ProbabilityofAnyBleeding(%),30,25,20,15,10,5,0,ENOXTime(sec),ENOXTime(sec),DirectThrombinInhibitorTrialistsCollaboration,DirectThrombinInhibitorTrialistsCollaborativeGroup.Lancet.2019;359:294-302.(withpermission),11RCTS36,000PtsACS,PCI,DeathorMyocardialInfarction,DirectThrombinInhibitorHeparin(N=18,736)(N=17,184),OR(95%Cl),Endoftreatment7days30days,Endoftreatment7days3days,Death,MyocardialInfarction,Endoftreatment7days30days,Endoftreatment7days30days,Stroke,MajorbleedingduringtreatmentIntracranialbleedingduringtreatment,815(4.3%)883(5.1%)947(5.0%)990(5.8%)1399(7.4%)1409(8.2%),355(1.9%)346(2.0%)422(2.2%)395(2.3%)685(3.6%)642(3.7%),522(2.8%)596(3.5%)601(3.2%)672(3.9%)876(4.7%)917(5.3%),62(0.33%)60(0.35%)72(0.38%)70(0.41%)120(0.64%)110(0.64%)360(1.90%)403(2.30%)21(0.11%)28(0.16%),0.85(0.77-0.94%)0.88(0.80-0.96%)0.91(0.84-0.99%),0.97(0.83-1.13%)1.00(0.87-1.16%)1.01(0.90-1.12%),0.80(0.71-0.90%)0.81(0.72-0.91%)0.87(0.79-0.95%),0.95(0.66-1.35%)0.94(0.68-1.31%)1.01(0.78-1.31%)0.75(0.65-0.87%)0.72(0.42-1.23%),Earlyinvasivestrategy,+/-GPIIb/IIIa,Catheterizationwithin8hoursoflastsubcutaneousdose,UA/NSTEMIIdentified,LMWH,-GPIIb/IIIa,+GPIIb/IIIa,Catheterizationbetween8-12hoursoflastsubcutaneousdose,NoadditionalUFHorLMWH,AdditionalEnoxaparin0.3mg/kgIVbolus,SupplementwithUFH50U/kg,aimforACT200-250,SupplementwithUFH0.1g/L,DeathorMIat30days(%),GPIIb/IIIaInhibitioninTnI+PatientsbyRevascularization:PRISMStudy,TnI,troponinI;PRISM,PlateletReceptorInhibitionforIschemicSyndromeManagementstudy;MI,myocardialinfarction.HeeschenC,etal.Lancet.2019;354:1757-1762.(withpermission),Death/MIat30Days,0.37(0.15-0.93)P=.02,0.30(0.10-0.84)P=.004,16,12,8,4,0,0,5,10,15,20,25,30,Eventrate(%),Follow-up(days),Norevascularization,Revascularization,HeparinHeparinTirofibanTirofiban,GPIIb/IIIaInhibitioninDiabetics,RoffiM,etal.Circulation.2019;104:2767-2771.(withpermission),30-DayMortalityinDiabeticPatients,2163687362167741211576458,PURSUITPRISMPRISM-PLUSGUSTOIVPARAGONAPARAGONBPooled,6.1%4.2%6.7%7.8%6.2%4.8%6.2%,5.1%1.8%3.6%5.0%4.6%4.9%4.6%,P=.33P=.07P=.17P=.022P=.51P=.93P=.007,TrialNOddsRatioMI,myocardialinfarction;PCI,percutaneouscoronaryintervention;CABG,coronaryarterybypassgraft;NS,notsignificant.BoersmaE,etal.Lancet.2019;359:189-198.,InteractionP5dpostcatheterizationanyway)Tradeoffper1000UA/NSTEMIpatientRx:EarlyRxpreventsadditional10majorcardiaceventsvscreating1.5TIMIminorbleedpost-CABG,ACS,acutecoronarysyndrome;PCI,percutaneouscoronaryintervention;CURE,ClopidogrelinUnstableAnginatoPreventRecurrentEvents;CREDO,ClopidogrelforReductionofEventsDuringObservation;CABG,coronaryarterybypassgraft;UA,unstableangina;NSTEMI,nonST-segmentmyocardialinfarction;TIMIThrombosisinMyocardialInfarction.BoersmaE,etal.Lancet.2019;359:189-198.,PRONTOStudy:EffectofCo-AdministrationofVariousStatinsWithClopidogrel,PRONTOStudy100PatientsUndergoingElectiveStenting,InducedPlateletAggregation%SD(5MADPinducedPlateletAggregation),PRONTO,PlavixReductionOfNewThrombusOccurrence.GurbelPA,etal.AmHeartJ.2019;145:239-247.,NoInteractionofClopidogrelandAtorvastatin,SawP,etal.Circulation.2019;108:921-924.(withpermission),18161412108420,1-YearDeath/MI/StrokeEventRate(%),Allpatients(n=2116),Nostatin(n=944),Anystatin(n=1172),CYP3A4-METstatin(n=1001),Atorvastatinstatin(n=564),Prevastatin(n=142),Non-CYP3A4-METstatin(n=158),RRR26.9%P=.02,RRR12.4%P=.51,RRR38.6%P=.01,RRR36.4%P=.03,RRR60.6%P=.11,RRR49.8%P=.02,RRR63.3%P=.13,2159low-riskpatientsundergoingelectivestenting,excludingpatientswith:,Endpoints:Primary:30daydeath/MI/urgenttargetvesselrevascularizationSecondary:30-daybleedingcomplications,ISAR-REACTTrial,ACC2019,LateBreakingTrials.,AcutecoronarysyndromeAcuteMIwith14daysST-segmentdepressionPositivebiomarkersInsulin-dependentdiabetes,ChronictotalocclusionsEF30%ThrombuspresenceLesionsinbypassgrafts,Clopidogrel(600-mgloadingdose,2x75mg/dthroughdischarge,75mg/dfor4weeks),ISAR-REACT:30DayEndpoints,4.0,4.2,0,2,4,6,Death/MI/UrgentTVR(%)P=.82,Abciximab,Placebo,ACC2019,LateBreakingTrials.,Death(%)P=NS,0.3,0.3,0,2,4,6,Abciximab,Placebo,UrgentTVR(%)P=NS,0.9,0.7,0,2,4,6,Abciximab,Placebo,CRP,C-reactiveprotein;MI,myocardialinfarction;PCI,percutaneouscoronaryintervention;RRR,relativeriskratio.ChewDP,etal.AmJCardiol.2019;88:672-674.,DeathorMIbyDay30inPatientsUndergoingPCIWithStenting,58%RRRP=.002,0,5,10,15,20,25,TotalPopulation011mg/L,13(n=295),10(n=565),24(n=74),10.2(n=136),Percent,Thienopyridinepretreatment,NoThienopyridinepretreatment,ClopidogrelTherapyMayReducetheRiskAssociatedWithElevatedBaselineCRPStatus,30-DayDeathorMIinPatientsUndergoingPCIwithStenting,AdaptedfromChewDP,etal.AmJCardiol.2019;88:672-674.,ClopidogrelTherapyAttenuatestheRiskAssociatedWithBaselineCRPStatus,7.9,7.7,24.0,12.3,5.7,11.8,12.5,10.2,0,5,10,15,20,25,1stQuartile,2ndQuartile,3rdQuartile,4thQuartile,n=216,n=218,n=227,58%RRRP=.002,n=216,Clopidogrelpretreatment,Nopretreatment,CRPQuartiles(mg/dl),Patients(%),InvasivevsConservativeStrategyforUA/NSTEMI,UA,unstableangina,NSTEMI,nonST-segmentmyocardialinfarction;ISAR,IntracoronaryStentingandAntithrombicRegimenTrial;RITA,RandomizedInterventionTreatmentofAngina;VANQWISH,VeteransAffairsNon-Q-WaveInfarctionStrategiesinHospitalstudy;MATE,MedicinevsAngioplastyforThrombolyticExclusionstrial;TACTICS-TIMI18,TreatAnginawithAggrestatandDetermineCostofTherpaywithInvasiveorConservativeStrategy;FRISC,FragminduringInStabilityinCoronaryarterydisease.,TIMIIIIB,2019,Conservative,Invasive,VANQWISH,MATE,FRISCII,TACTICS-TIMI18,VINO,RITA-3,No.ofPatients:92016747018,TRUCS,ISAR-COOL,TnT,troponinT;ST,STsegment.MorrowDA.JAMA.2019;286:2405-2412;CannonCP.NEnglJMed.2019;344:1879-1887.,BenefitofInvasiveStrategybyTroponinandSTChanges,Death,MI,RehospACSat6Months,12.4,25.0*,16.0,15.3*,0,5,10,15,20,25,30,TnT-,TnT+,CVEvents(%),P=NS,15.1,24.5*,16.6,16.4*,0,5,10,15,20,25,30,NoSTchange,STchange,P=NS,P.001,P.001,2000ACC/AHAUA/NSTEMIGuidelines:EarlyInvasiveStrategy,ClassIAnyofthehigh-riskindicators(LevelofEvidence:A)a)Recurrentanginaatrest/low-levelactivitydespiteRxb)ElevatedTnTorTnIc)NewST-segmentdepressiond)Rec.angina/ischemiawithCHFsymptoms,rales,MRe)Positivestresstestf)EF0.40g)BPh)SustainedVTi)PCI6mos,