非st段抬高急性冠脉综合征介入治疗-策略与选择(63p)课件

非ST段抬高急性冠脉综合征介入治疗 策略与选择阜外心血管病医院乔树宾 ACS住院患者 NSTE ACSvsSTEMI NationalCenterforHealthStatistics 2001 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 ACS的病理生理基础 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 1 g L或CK MB 正常上限的2倍 cTnT cTnI 0 1 g L或CK MB 正常上限的2倍 STEMI NSTEMI UA 非ST段抬高ACS的治疗 抗血小板治疗抗凝治疗抗缺血治疗调脂治疗介入治疗冠脉搭桥 诊断 常规血生化 特别包括TnT或I监测心电ST段的变化超声心动图检查如需排除主动脉夹层 做MRI 排除肺栓塞行CT或核素检查观察对抗缺血治疗的效果评定危险记分评价出血的危险性 NSTE ACS危险分层 NSTE ACS危险分层方法 早期CAG的价值 早期冠脉造影目的 病变范围和分布 狭窄程度和部位 适合何种血管重建术等 早期冠脉造影 提高预后分层的可靠性 确定治疗方案的有效方法 没有病变可迅速出院 罪犯病变适合PCI者可立即介入治疗加快出院 左主干病变 复杂病变伴左室功能不全者迅速CABG 发现高危病人 使患者从早期血管重建术中获益 ACC AHA 治疗的选择 一 有创治疗 1 尽管充分药物治疗仍发生静息或低水平活动心绞痛 2 TnT或TnI升高 3 新出现的ST压低 4 HF体征和症状或新出现或加重的二尖瓣返流 5 无创检查有高危的证据 6 持续性室速 7 六个月内曾PCI 8 先前CABG 9 危险积分属高危 TIMI GRACE 10 左心室功能降低 LVEF 40 ACC AHA 治疗的选择 二 保守治疗 计分属低危险 TIMI GRACE 无高危特征的患者或医生选择 2007 ESC介入治疗 紧急 Urgent 1 患者出现持续性或反复胸痛 伴有或不伴有ST改变 2mm 或深的倒置T波 抗缺血治疗效果不好2 出现心衰临床症状或血流动力学不稳定3 致命性心律失常 VF VT 早期 72小时 1 TnT或I 2 动态ST或T改变 有症状或无症状 3 糖尿病4 肾功能异常 GFR 60ml min 1 73m2 5 左心室功能降低 LVEF 40 6 梗塞后心绞痛7 有MI病史8 6个月内行PCI 有CABG史9 中高GRACE危险记分 不做或择期做 无再发胸痛无心衰的体征无新的ECG改变 就诊6 12小时 TnT或I正常 就诊6 12小时 0 2 0 5 1 2 5 FavorsInvasive FavorsConservative OddsRatioDeathorMI OR0 82 P 0 001 Trial TIMI3B VANQWISH MATE FRISCII TACTICS RITA3 TOTAL MehtaSRetal JAMA2005 293 2908 17 5 1 8 1 27 2 28 0 12 0 8 9 4 3 11 4 4 0 5 3 7 4 10 9 VINO 4 8 14 8 Inv Cons 7 4 11 0 InvasiveManagementofUA NSTEMIMeta analysis Death MIat17mo F U Overall 12 2 14 4 Trials 1999 19 3 19 6 Trials 1999 9 4 12 4 Troponin ve 10 0 14 0 Troponin ve 6 7 7 4 AnyMarker ve 14 7 17 4 AnyMarker ve 7 7 8 5 FavorsInvasive FavorsConservative 0 5 1 2 Trial Inv Cons OddsRatio Pvalue 0 001 0 82 0 40 0 90 0 012 0 82 0 42 0 89 0 001 0 69 0 0001 0 73 0 92 0 99 TIMI3B VANQWISHandMATE FRISCII TACTICS VINO RITA3DatabytroponinstatusavailableonlyinFRISCII TACTICS RITA3 InvasiveManagementofUA NSTEMIMeta analysis Subgroups MehtaSRetal JAMA2005 293 2908 17 DeathorMIatFollowup 360 180 90 30 0 ProbabilityofDeath 04 03 02 01 0 Non Invasive n 1235 Invasive n 1222 InvasiveNoninvasiveRR 95 CI 2 2 4 0 0 56 0 35 0 89 p 0 018 Wallentin Lancet2000 FRISC IIMortalityatOne YearInvasiveVs ConservativeManagementStrategies FRISCII 5YearOutcomes LagerqvistB WorldCongressofCardiology2006 September4 2006 Barcelona Spain FRISCII 5YearOutcomes DeathorMIat5yearsinhigh medium andlow riskpatients LagerqvistB WorldCongressofCardiology2006 September4 2006 Barcelona Spain 哪种治疗最好 InvasivevsConservative Conservative 保守 920Patients Invasive 介入 7 018Patients TIMIIIIB VANQWISH MATE FRISCII TACTICS TIMI18 VINO RITA 3 TRUCS ISAR COOL AdaptedfromCannonCP Cardiology 2002 8 specialedition 29 37 Conservative1 674Patients RoutinevsSelectiveInvasiveStrategiesinACS AdaptedfromMehtaS etal JAMA 2005 293 2908 2917 OddsRatio 95 CI 0 1 1 0 OR 0 8295 CI 0 72 0 93P 0 001 Total561 4608 12 2 663 4604 14 4 CompositeofDeathorMyocardialInfarction No Total FavorsRoutineInvasive FavorsSelectiveInvasive Source RoutineInvasive SelectiveInvasive TIMIIIIB86 740 11 6 101 733 13 8 VANQWISH152 462 32 9 139 458 30 3 MATE16 111 14 4 11 90 12 2 FRISCII127 1222 10 4 174 1235 14 1 TACTICS81 1114 7 3 105 1106 9 5 VINO4 64 6 3 15 67 22 4 RITA395 895 10 6 118 915 12 9 10 Study Mortalityduringhospitalization Mortalityafterdischarge Cons Inv OddsRatio 95 CI 0 1 0 2 0 5 1 2 5 10 FavorsRoutine FavorsSelective MehtaSRetal JAMA2005 293 2908 17 OR1 60 P 0 007 OR0 76 P 0 01 InvasiveRxinACS EarlyandLateMortality CRUSADE InvasiveCardiacProceduresintheUS ProceduresPerformed non transfer DiagnosticCath64 Within48hours41 Within24hours27 PercutaneousIntervention35 Within48hours25 CoronaryBypassGrafting11 AnInternationalRandomizedTrialofEarlyVersusDelayedInvasiveStrategiesinPatientswithNon STSegmentElevationAcuteCoronarySyndromesFUNDEDBYTHECANADIANINSTITUTESOFHEALTHRESEARCHGrant 150904 TIMACS Tim ingofIntervention inpatientswith A cute C oronary S yndromes StudyObjective Todeterminewhetherearlyinterventionissuperiortodelayedinterventioninpatientswithhighrisknon STsegmentelevationacutecoronarysyndrome Design EligibilityCriteriaandProtocol UAorNSTEMI2of3Criteria Age 60 ischemicEKG or biomarkerANDsuitableforrevascularization RANDOMIZE EarlyInvasiveCoronaryangiographyassoonaspossible nolaterthan24hours followedbyPCIorCABG DelayedInvasiveCoronaryangiographyanytime 36hrsfollowedbyPCIorCABG ASA clopidogrel GPIIb IIIaantagonistasperroutinepractice Centerchoserandomizationratio1 1 1 2or2 1Early Delayed ExcludedContraindicationforLMWHorhighriskofbleedingornotasuitablecandidateforrevascularization Follow upat30daysand6months Outcomes PrimaryCompositeofDeath newMIorStrokeat6mo SecondaryCompositeof Death newMIorrefractoryischemiaDeath newMI stroke refractoryischemiaorrepeatrevascularizationStroke StudyFlowChart TIMACSStandAloneN 1 398 TIMACSTotalN 3 031 TIMACSOASIS5N 1 633 30Dayand6monthFollow up3 029LosttoFollow up 4 RecommendedMedicalTreatment ASA clopidogrelGPIIb IIIainhibitoratdiscretionofattendingphysician especiallyifptisnotonathienopyridine Antithrombin OASIS5 EitherfondaparinuxorenoxaparinTIMACSstandalone UFHorLMWHorfondaparinuxorbivalirudin investigatordiscretion BetablockerStatin ParticipatingCountries NorthAmerica650 SouthAmerica442 Europe1065 Asia846 Australia28 TIMACSSteeringCommittee StudyOrganization CoordinatingCenter PHRI McMasterUniversityS Mehta S Yusuf S Jolly C Horsman S Chrolavicius B MeeksDSMB P Sleight chair J Anderson D DeMets D Johnstone D HolmesAdjudicationCommitteeChair C JoynerCoordinator M Lawrence CriteriaforCrossoverfromDelayedGrouptoEarlyGroup RefractoryischemiaNewMIHemodynamicinstabilityCrossoverfromEarlytoDelayed 11 9 CrossoverfromDelayedtoEarly 25 InterventionsandTiming Iqr interquartilerange BaselineCharacteristics In HospitalMedications PrimaryandSecondaryOutcomes At30days 5 9vs4 2 HR1 39 95 CI1 00 1 95 P 0 047 PrimaryOutcomeDeath MI orStroke Days CumulativeHazard 0 0 0 02 0 06 0 10 0 30 60 90 120 150 180 Death MI Strokeat180days Early No atRisk Delayed Early 1438 1328 1269 1254 1234 1229 1211 1593 1484 1413 1398 1391 1382 1363 Delayed HR0 8595 CI0 68 1 06P 0 15 SecondaryOutcomeDeath MI orrefractoryischemia HR0 7295 CI0 58 0 79P 0 002 SecondaryOutcomeDeath MI stroke RFIorRepIntervention Death MI RI Stroke RepIntat180days HR0 8495 CI0 71 0 99P 0 039 SafetyOutcomes Pre specifiedSubgroups Overall Age 65 65 Female Male NoSTdeviation STdeviation Noelevatedmarker ElevatedMarker GRACE0 140 GRACE 141 3031 1293 1736 1052 1976 1523 1508 668 2363 2070 961 9 7 6 5 12 3 9 7 9 8 7 6 11 7 10 5 9 5 7 7 14 1 0 463 0 540 0 722 0 423 0 0097 0 85 0 68 1 06 0 98 0 64 1 52 0 83 0 64 1 07 0 77 0 54 1 12 0 89 0 68 1 18 0 88 0 62 1 26 0 81 0 61 1 07 1 00 0 62 1 60 0 81 0 63 1 04 1 14 0 82 1 58 0 65 0 48 0 88 N Characteristic HR 95 CI Interactionp Value 0 33 0 5 0 7 1 00 1 5 2 0 3 0 EarlybetterDelayedbetter HazardRatio 95 CI Early 11 4 6 5 14 8 12 3 10 9 8 7 14 3 10 5 11 7 6 7 21 6 Delayed GRACERiskScore PrimaryOutcome HR1 1495 CI0 82 1 58P 0 43 HR0 6595 CI0 48 0 88P 0 005 InteractionP 0 0097 Low IntRiskGRACEScore 140N 2070 HighRiskGRACEScore 140N 961 Death MIorStrokeat6mo Conclusions Overall wefoundnosignificantdifferencebetweenanearlyandadelayedinvasivestrategyforpreventionofdeath MIorstroke primaryoutcome However inthesubgroupathighestrisk GRACEscore 140 anearlyinvasivestrategywassuperiortoadelayedinvasivestrategyforpreventionofdeath MIorstrokeTheearlyinvasivestrategyalsohadalargeimpactonreducingtherateofrefractoryischemiaby70 Therewerenosignificantdifferencesinmajorbleedingorothersafetyconcernsbetweenthetwostrategies Implications MostpatientswithACScanbemanagedsafelywitheitheranearlyoradelayedinvasivestrategyInasubsetofpatientsathighestrisk GRACEscore 140 earlyinterventionissuperiorandthesepatientsshouldbetakentothecathlabasearlyaspossibleInallotherpatients thedecisionregardingtimingofinterventioncandependonotherfactors suchascathlabavailabilityandeconomicconsiderations TIMACSAnInternationalRandomizedTrialofEarlyVersusDelayedInvasiveStrategiesinPatientswithNon STSegmentElevationAcuteCoronarySyndromes 对比非ST段抬高的急性冠状动脉综合征患者早期与延迟干预治疗的国际随机研究 中国亚组 TIMACSAnInternationalRandomizedTrialofEarlyVersusDelayedInvasiveStrategiesinPatientswithNon STSegmentElevationAcuteCoronarySyndromes 共有815名患者入选本研究早期介入组446名 随访率98 4 延迟介入组369名 随访率98 8 临床基线 合并用药及冠造结果两组无统计学差异冠造的平均时间早期介入组18 4小时延迟介入组72 6小时 TIMACSAnInternationalRandomizedTrialofEarlyVersusDelayedInvasiveStrategiesinPatientswithNon STSegmentElevationAcuteCoronarySyndromes 180天随访主要终点事件 死亡 心梗 卒中 早期介入组9 0 延迟介入组14 6 P 0 01 死亡早期介入组3 6 延迟介入组3 3 P 0 79 心梗早期介入组5 2 延迟介入组10 8 P 0 002 卒中早期介入组0 2 延迟介入组0 5 P 0 87 TIMACSAnInternationalRandomizedTrialofEarlyVersusDelayedInvasiveStrategiesinPatientswithNon STSegmentElevationAcuteCoronarySyndromes 180天随访次要终点事件死亡 心梗 难治性心肌缺血早期介入组14 6 延迟介入组22 0 P 0 01 死亡 心梗 卒中 难治性心肌缺血 再次血运重建早期介入组26 7 延迟介入组30 4 P 0 25 TIMACSAnInternationalRandomizedTrialofEarlyVersusDelayedInvasiveStrategiesinPatientswithNon STSegmentElevationAcuteCoronarySyndromes P 0 05 TIMACSAnInternationalRandomizedTrialofEarlyVersusDelayedInvasiveStrategiesinPatientswithNon STSegmentElevationAcuteCoronarySyndromes 30天随访主要终点事件 死亡 心梗 卒中 早期介入组8 1 延迟介入组12 5 P 0 04 死亡早期介入组2 9 延迟介入组2 2 P 0 503 心梗早期介入组5 2 延迟介入组10 0 P 0 01 卒中早期介入组0 延迟介入组0 3 P 0 45 TIMACSAnInternationalRandomizedTrialofEarlyVersusDelayedInvasiveStrategiesinPatientswithNon STSegmentElevationAcuteCoronarySyndromes 30天随访次要终点事件死亡 心梗 难治性心肌缺血早期介入组13 0 延迟介