冠心病介入治疗再认识朱国英.ppt

武汉亚洲心脏病医院朱国英,多支血管病变血运重建,？,单纯球囊扩张（PTCA）时代多个临床试验结果有利于CABG,CABG完全血运重建率高,PCI再次血运重建率高,EventfreesurvivalMyrosyprophecy,AndreasGruentzigsLecture,ESC2000Amsterdam,EventfreesurvivalMyrosyprophecy,AndreasGruentzigsLecture,ESC2000Amsterdam,CurrentTrialsofCABGvs.DES,SYNTAXFREEDOMCOMBAT,SYNTAXTrialDesign,SYNTAX是多支血管血运重建的里程碑研究,第一个随机、对照临床研究设计基础：回顾分析了20192019年104家医疗中心的血运重建（CABG或PCI）12,072例患者:1/3为左主干，2/3为三支病变治疗策略：2/3选择CABG，1/3选择PCI,SYNTAX是多支血管病变治疗策略真实世界的研究,SYNTAXEligiblePatients,PatientCharacteristics(1)RandomizedCohort,PatientCharacteristics(2)RandomizedCohort,AllCauseDeathto12Months,Myocardialinfarctionto12Months,AllCauseDeath/CVA/MIto12Months,SymptomaticGraftOcclusionStentThrombosisto12Months,MACCEto12Months,RepeatRevascularizationto12Months,CVAto12Months,12MonthLMSubgroupMACCERates,12MonthLMSubgroupMACCERates,OutcomeaccordingtoDiabeticStatus,Conclusions,PatientProfiling,Thereis3-vesseldiseaseand3-vesseldisease,研究结果：12月MACE-SYNTAXSCORE,PatrickW.Serruys：,对于合并左主干冠心病患者：DES和CABG的有效性和安全性相近似对于采用SYNTAX计分系统评估的低计分组和中等计分组的左主干合并单支、双支或三支病变患者：DES是更为合理的治疗选择对于高计分（33分）组左主干合并多支病变患者：CABG是较为合理的治疗选择,SYNTAX的意义,SYNTAX的意义,SYNTAX,SYNTAX,STEMI的血运重建方式,ST段抬高心肌梗死,溶栓,直接PCI,溶栓后PCI,CABG,直接PCI和溶栓疗法的比较23个随机研究的汇萃分析（n=7739）,PTCA,KeeleyE.etal.,Lancet2019;361:13-20.,P=0.0002,P=0.0003,P0.0001,P0.0001,P0.0001,P=0.0004,P=0.032,P0.0001,Death,Death,noSHOCKdata,ReMI,Rec.Isch,TotalStroke,Hem.Stroke,MajorBleed,DeathMICVA,Fibrinolysis,(%)Events,DES能否常规用于直接PCI？,HarmonizingOutcomeswithRevascularizationandStentsinAMI,3602ptswithSTEMIwithsymptomonset12hours,ClinicalFUat30days,6months,1year,andthenyearlythrough5years;angioFUat13months,StentRandomizationHypotheses,InpatientswithSTEMIundergoingprimaryPCI,theuseofpaclitaxel-elutingTAXUSstentsratherthanbaremetalEXPRESSstentswillbe:Efficacious,asevidencedbyreducedratesofischemia-driventargetlesionrevascularizationat1-yearandangiographicbinaryrestenosisat13months;andSafe,withnon-inferiorratesofthecompositemeasureofdeath,reinfarction,stentthrombosisorstrokeat1-year,HorizonsEnrollment-Centers,USA(57),(1)Spain,(6)UK,(2)Norway,Poland(9),Germany(16),Austria(5),(3)Netherlands,Italy(2),Argentina(12),Israel(10),3,602ptsrandomizedat123centersin11countriesbetweenMarch25th,2019andMay7th,2019,HarmonizingOutcomeswithRevascularizationandStentsinAMI,UFH+GPI(n=1802)Bivalirudin(n=1800),3602ptswithSTEMI,93.1%ofallstentedptswererandomized,2257,2132,2098,2069,1868,749,697,675,658,603,Numberatrisk,TAXUSDES,EXPRESSBMS,PrimaryEfficacyEndpoint:IschemicTLR,IschemicTLR(%),0,1,2,3,4,5,6,7,8,9,10,TimeinMonths,0,1,2,3,4,5,6,7,8,9,10,11,12,7.5%,4.5%,Diff95%CI=-3.0%-5.1,-0.9HR95%CI=0.590.43,0.83P=0.002,TAXUSDES(n=2257),EXPRESSBMS(n=749),IschemicTVR(%),0,1,2,3,4,5,6,7,8,9,10,TimeinMonths,0,1,2,3,4,5,6,7,8,9,10,11,12,2257,2119,2078,2045,1848,749,695,669,650,598,Numberatrisk,TAXUSDES,EXPRESSBMS,8.7%,5.8%,Diff95%CI=-3.0%-5.2,-0.7HR95%CI=0.650.48,0.89P=0.006,TAXUSDES(n=2257),EXPRESSBMS(n=749),SecondaryEfficacyEndpoint:IschemicTVR,PrimarySafetyEndpoint:SafetyMACE*,SafetyMACE(%),0,1,2,3,4,5,6,7,8,9,10,TimeinMonths,0,1,2,3,4,5,6,7,8,9,10,11,12,2257,2115,2086,2057,1856,749,697,683,672,619,Numberatrisk,TAXUSDES,EXPRESSBMS,TAXUSDES(n=2257),EXPRESSBMS(n=749),8.1%,8.0%,Diff95%CI=0.1%-2.1,2.4HR95%CI=1.020.76,1.36PNI=0.01PSup=0.92,*SafetyMACE=death,reinfarction,stroke,orstentthrombosis,One-YearAll-CauseMortality,Mortality(%),0,1,2,3,4,5,TimeinMonths,0,1,2,3,4,5,6,7,8,9,10,11,12,2257,2180,2161,2147,1949,749,716,712,702,648,Numberatrisk,TAXUSDES,EXPRESSBMS,TAXUSDES(n=2257),EXPRESSBMS(n=749),3.5%,3.5%,HR95%CI=0.990.64,1.55P=0.98,One-YearDeathorReinfarction,StentThrombosis(ARCDefiniteorProbable),AngiographicFollow-up,TAXUSDESN=1348,EXPRESSBMSN=452,Randomized,Eligible,N=1308,N=441,1800consecutiveeligibleptsassignedto13monthangiographicFU*,*Randomizedinstentarm;stentproceduresuccessful(DS10%,TIMI-3flow,NHLBItypeAperi-stentdissection);nostentthrombosisorCABGw/i30days,40,11,DiedbeforeangioFU,N=942(72.0%),N=307(69.6%),CompletedAngioFU,366,134,AngioFUnotperformed,Notreceived/analyzableOutofwindow,N=911,N=293,Analyzed,Lesions,1081,332,BinaryAnalysisSegmentRestenosisat13MonthsPatientandLesionLevelAnalysis*,RR95%CI=0.440.33,0.57P0.0001,*ITT:Includesallstentrandomizedlesions,whetherornotastentwasimplanted,andwhetherornotnonstudystentswereplaced*Anylesionwithrestenosisperptrestenosis,RR95%CI=0.440.33,0.57P0.0001,Major2endpoint,AngiographicLateLossat13MonthLesionswithStentsImplanted,P0.0001,P0.0001,0.42,0.54,0.64,0.70,P=0.18,P=0.07,0.56,0.64,0.47,0.50,BinaryAngiographicRestenosisat13MonthsLesionswithStentsImplanted,RR95%CI=0.420.32,0.54P0.0001,RR95%CI=0.390.29,0.52P0.0001,P=0.13,P=0.42,Conclusions,Inthislarge-scale,prospective,randomizedtrialofptswithSTEMIundergoingprimarystenting,theimplantationofpaclitaxel-elutingTAXUSstentscomparedtobaremetalEXPRESSstentsresultedin:Asignificant41%reductioninthe1-yearprimaryefficacyendpointofischemia-drivenTLR,andasignificant56%reductioninthe13monthmajorsecondaryefficacyendpointofbinaryrestenosisNoninferiorratesoftheprimarycompositesafetyendpointofallcausedeath,reinfarction,stentthrombosisorstrokeat1-year,Conclusions,Thelong-termsafetyandefficacyprofileofpaclitaxel-elutingTAXUSstentscomparedtobaremetalEXPRESSstentsinSTEMIwillbedeterminedbytheongoing5yearfollow-upofpatientsrandomizedintheHORIZONS-AMItrial,慢性稳定型心绞痛PCI？,什么时候需要血运重建?,哪些病人需要血运重建?,ACC/AHA/SCAI2019年PCI指南推荐：病变血管供应大面积心肌（B）供应中等面积心肌（a