急性冠脉综合征指南ppt课件

11 02 1 TheManagementofPatientswithUnstableAnginaandNon ST SegmentElevationMyocardialInfarction ACC AHAPocketGuidelinesNovember 2002 11 02 2 ACC AHAClassificationsExpertOpinionandRecommendations ClassIConditionsforwhichthereisevidenceand orgeneralagreementthatagivenprocedureortreatmentisbeneficial useful andeffectiveClassIIConditionsforwhichthereisconflictingevidenceand oradivergenceofopinionabouttheusefulness efficacyofaprocedureortreatmentClassIIaweightofevidence opinionisinfavorofusefulness efficacyClassIIbusefulness efficacyislesswellestablishedbyevidence opinionClassIIIConditionsforwhichthereisevidenceand orgeneralagreementthattheprocedure treatmentisnotuseful effectiveandinsomecasesmaybeharmful 11 02 3 II InitialEvaluationandManagement A ClinicalAssessmentB EarlyRiskStratificationC ImmediateManagement 11 02 4 A ClinicalAssessmentRecommendationforInitialTriage ClassI1 PatientwithpossibleACSshouldnotbeevaluatedsolelyoverthetelephonebutshouldbereferredtoafacilitythatallowsevaluationbyaphysicianandtherecordingofa12 leadelectrocardiogram ECG 2 PatientswithasuspectedACSwithchestdiscomfortatrestfor 20minutes hemodynamicinstability orrecentsyncopeorpresyncopeshouldbestronglyconsideredforimmediatereferraltoanemergencydepartmentoraspecializedchestpainunit 11 02 5 B EarlyRiskStratificationRecommendation ClassI1 Patientswhopresentwithchestdiscomfortshouldundergoearlyriskstratificationthatfocusesonanginalsymptoms physicalfindings ECGfindings andbiomarkersofcardiacinjury2 A12 leadECGshouldbeobtainedimmediatelyinpatientswithongoingchestdiscomfort 11 02 6 B EarlyRiskStratificationRecommendation ClassI3 BiomarkersofcardiacinjuryshouldbemeasuredinallpatientswhopresentwithchestdiscomfortconsistentwithACS Acardiac specifictroponinisthepreferredmarker andifavailable itshouldbemeasuredinallpatients Creatinephosphokinase MBisoenzyme CK MB bymassassayisalsoacceptable Inpatientswithnegativecardiacmarkerswithin6hoursoftheonsetofpain anothersampleshouldbedrawnbetween6and12hours 11 02 7 B EarlyRiskStratificationRecommendation ClassIIb1 C reactiveprotein CRP andothermarkersofinflammationshouldbemeasuredClassIII1 TotalCK withoutMB aspartateaminotransferase AST serumglutamicoxaloacetictransaminase SGOT hydroxybutyricdehydrogenaseand orlactatedehydrogenaseforthedetectionofmyocardialinjury 11 02 8 Short TermRiskofDeathorNonfatalMIinPatientswithUnstableAngina High Risk 1oftheFollowingFeaturesMustbePresent HistoryAcceleratingtempoofischemicsymptomsinpreceding48hCharacterofpainProlongedongoing 20min restpainClinicalfindingsPulmonaryedema mostlikelyrelatedtoischemiaNewofworseningMRmurmurS3ornew worseningralesHypotension bradycardia tachycardiaAge 75yrsECGfindingsAnginaatrest withtransientST segmentchanges 0 05mVBundle branchblock neworpresumednewSustainedventriculartachycardiaCardiacmarkersElevated eg TnTorTnI 0 1ng ml 11 02 9 Short TermRiskofDeathorNonfatalMIinPatientswithUnstableAngina Intermediate Risk Musthave1oftheFollowingFeatures HistoryPriorMI peripheralorcerebrovasculardisease orCABG prioraspirinuseCharacterofpainProlonged 20min restangina nowresolved withmoderateorhighlikelihoodofCADRestanigna 70yrsECGfindingsT waveinversion 0 2mVPathologicalQwavesCardiacmarkersSlightlyelevated eg TnT 0 01but 0 1ng ml 11 02 10 Short TermRiskofDeathorNonfatalMIinPatientswithUnstableAngina Low Risk MayhaveanyoftheFollowingFeatures HistoryCharacterofpainNew onsetorprogressiveCCSClassIIIorIVanginainthepast2weekswithmoderateorhighlikelihoodofCADClinicalfindingsECGfindingsNormalorunchangedECGduringanepisodeofchestdiscomfortCardiacmarkersNormal 11 02 11 RecommendationfortheDiagnosisofNoncardiacCauseofSymptoms ClassI1 theinitialevaluationofthepatientwithsuspectedACSshouldincludeasearchfornoncoronarycausesthatcouldexplainthedevelopmentofsymptomsThemajorobjectivesofthephysicalexaminationsaretoidentifypotentialprecipitatingcausesofmyocardialischemia e g uncontrolledhypertensionorthyrotoxicosis evidenceofotherchronicdisease e g aorticstenosisorhypertrophiccardiomyopathy andcomorbidconditions e g pulmonarydisease andtoassessthehemodynamicimpactoftheischemicevent 11 02 12 ToolsforRiskStratification The12 leadECGliesatthecenterofthedecisionpathwayfortheevaluationandmanagementofpatientswithischemicdiscomfort Arecordingmadeduringanepisodeofpresentingsymptomsisparticularlyvaluable Importantly transientST segmentchanges 0 05mV thatdevelopduringasymptomaticepisodeatrestandthatresolvewhenthepatientbecomesasymptomaticstronglysuggestacuteischemiaandaveryhighlikelihoodofunderlyingsevereCAD 11 02 13 ToolsforRiskStratification BiomarkersareofcriticalimportanceintheevaluationofpatientswithUA NSTEMI Thetroponinsoffergreatdiagnosticsensitivitybecauseofyourabilitytoidentifypatientswithlesseramountsofmyocardialdamage Nevertheless theselesseramountsofdamageareassociatedwithhigh riskpatientswithACSsbecausetheyarethoughttorepresentmicroinfarctionsthatresultfrommicroembolifromanunstableplaque 11 02 14 BiochemicalCardiacMarkersforEvaluationandManagementofPatientsSuspectedofHavinganACSbutWithoutST SegmentElevationon12 LeadECG Point of CareTests1 Cardiactroponins2 CK MB3 Myoglobin 11 02 15 PeakA earlyreleaseofmyoglobinorCK MBisoformsafterAMIPeakB cardiactroponinafterAMIPeakC CK MBafterAMIPeakD cardiactroponinafterunstableangina 11 02 16 CardiacTroponins AdvantagespowerfultoolforriskstratificationgreatersensitivityandspecificitythanCK MBdetectionofrecentMIupto2weeksafteronsetDisadvantageslowsensitivityinveryearlyphaseofMI 6haftersymptomonset limitedabilitytodetectlateminorreinfarctionClinicalrecommendationsusefulasasingletesttoefficientlydiagnoseNSTEMI includingminormyocardialdamage withserialmeasurements 11 02 17 CK MB Advantagesrapid cost efficient accurateassaysabilitytodetectearlyreinfarctionDisadvantageslossofspecificityinsettingofskeletalmusclediseaseorinjury includingsurgerylowsensitivityduringveryearlyMI 36h andforminormyocardialdamage detectablebytroponins Clinicalrecommendationspriorstandardandstillacceptablediagnostictestinmostclinicalcircumstances 11 02 18 Myoglobin AdvantageshighsensitivityusefulinearlydetectionofMIdetectionofreperfusionmostusefulinrulingoutMIDisadvantagesverylowspecificityinsettingofskeletalmuscleinjuryordiseaserapidreturntonormalrangelimitssensitivityforlaterpresentationsClinicalrecommendationsshouldnotbeusedasonlydiagnosticmarkerbecauseoflackofcardiacspecificity 11 02 19 C ImmediateManagementClassI Recommendations 1 Thehistory physicalexamination 12 leadECG andinitialcardiacmarkertestsshouldbeintegratedtoassignpatientswithchestpaintooneoffourcategories annoncardiacdiagnosis chronicstableangina possibleACS anddefiniteACS 2 PatientswithdefiniteorpossibleACSwhoseinitial12 leadECGandcardiacmarkerlevelsarenormalshouldbeobservedinfacilitywithcardiacmonitoring andrepeatECGandcardiacmarkermeasurementshouldbeobtained6to12hoursaftertheonsetofsymptoms 11 02 20 C ImmediateManagementClassIRecommendations 3 Inpatientsinwhomischemicheartdiseaseispresentorsuspected ifthefollow up12 leadECGandcardiacmarkermeasurementsarenormal astresstest exerciseorpharmacological toprovokeischemiamaybeperformed Low riskpatientswithanegativestresstestcanbemanagedasoutpatients4 PatientswithdefiniteACSandongoingpain positivecardiacmarkers newST segmentdeviations newdeepT waveinversions hemodynamicabnormalities orapositivestresstestshouldbeadmittedtothehospital5 PatientswithpossibleACSandnegativecardiacmarkerswhoareunabletoexerciseorwhohaveanabnormalrestingECGshouldhaveapharmacologicalstresstest 11 02 21 SymptomsSuggestiveofACS DefiniteACS NoSTelevation AlgorithmfortheEvaluationandManagementofPatientsSuspectedofHavinganACS STelevation PossibleACS ChronicStableAngina NoncardiacDiagnosis Treatmentasindicatedbyalternativediagnosis SeeACC AHA ACPGuidelinesforChronicStableAngina NondiagnosticECGNormalInitialserumcardiacmarkers STand orTwavechangesOngoingpainPositivecardiacmarkersHemodynamicabnormalities ObserveFollow upat4 8hours ECG cardiacmarkers Evaluationforreperfusiontherapy SeeACC AHAGuidelinesforAcuteMI Norecurrentpain Negativefollow upstudies Recurrentischemicpainorpositivefollow upstudiesDiagnosisofACSconfirmed AdmittohospitalManageviaacuteischemiapathway StressstudytoprovokeischemiaConsiderevaluationofLVfunctionifischemiapresent Testmaybeperformedpriortodischargeorasoutpatient Negative Potentialdiagnoses nonischemicdiscomfortlow riskACS Positive DiagnosisofACSconfirmed Arrangementforoutpatientfollow up 11 02 22 III HospitalCare A Anti ischemicTherapyB AntiplateletandAnticoagulationTherapyC RiskStratificationD EarlyConservativevs InvasiveStrategies 11 02 23 AcuteIschemicPathway RecurrentIschemiaand orSTsegmentshift orDeepT waveInversion orPositivecardiacmarkers EarlyInvasivestrategy AspirinBeta blockersNitratesAntithrombinregimenGPIIb IIIainhibitorMonitoring rhythmandischemia Immediateangiography 12 24hourangiography Patientstabilizes Recurrentsymptoms ischemiaHeartfailureSeriousarrhythmia FollowonMedicalRx EF 40 EarlyConservativestrategy EvaluateLVfunction EF 40 StressTest Notlowrisk Lowrisk 11 02 24 A Anti IschemicTherapyClassI Recommendations 1 BedrestwithcontinuousECGmonitoringforischemiaandarrhythmiadetectioninpatientswithongoingrestpain2 Sublingualfollowbyintravenousnitroglycerin NTG forimmediatereliefofischemiaandassociatedsymptoms3 MorphinesulfateintravenouslywhensymptomsarenotimmediatelyrelievedwithNTGorwhenacutepulmonarycongestionispresent4 Abeta blocker withthefirstdoseadministeredintravenouslyifthereisongoingchestpain followedbyoraladministration intheabsenceofcontraindications 11 02 25 A Anti IschemicTherapyClassI Recommendations 5 Anondihydropyridinecalciumantagonists e g verapamilordiltiazem intheabsenceofsevereleftventricular LV dysfunctionorothercontraindicationsinpatientswithcontinuingorfrequentrecurringischemiawhenbeta blockersarecontraindicated6 Andangiotensin convertingenzymeinhibitor ACEI whenhypertensionpersistsdespitetreatmentwithNTGandabeta blockersinpatientswithLVsystolicdysfunctionorcongestiveheartfailure CHF andinACSpatientswithdiabetes 11 02 26 A Anti IschemicTherapyRecommendations ClassIIa1 orallong actingcalciumantagonistsforrecurrentischemiaintheabsenceofcontraindicationsandwhenbeta blockersandnitratesarefullyused2 AnACEIforallpost ACSpatientsClassIIb1 extended releaseformofnondihydropyridinecalciumantagonistsinsteadofabeta blocker2 immediate releasedihydropyridinecalciumantagonistsinthepresenceofa blocker 11 02 27 A Anti IschemicTherapyRecommendations ClassIII1 NTGorothernitrateswithin24hoursofsildenafil Viagra use2 Immediate releaseddihydropyridinecalciumantagonistsintheabsenceofabeta blocker 11 02 28 B AntiplateletandAnticoagulationTherapy Antithrombotictherapyisessentialtomodifythediseaseprocessesanditsprogressiontodeath myocardialinfarction MI orrecurrentMI Acombinationofaspirin ASA clopidogrel andunfractionated UFH orlowmolecularweight LMWH heparin representsthemosteffectivetherapy AplateletglycoproteinGPIIb IIIareceptorantagonistsshouldbeusedinpatientswithcontinuingischemiaorwithotherhigh riskfeaturesinwhomanearlyinvasivestrategyisplanned 11 02 29 B AntiplateletandAnticoagulationTherapy ForpatientsinwhomtherearecontraindicationsforASAuse clopidogrelshouldbeadministered Intheabsenceofahighriskforbleeding aspirinandclopidogrelshouldbeadministeredpriortoPCIandclopidogrelshouldbecontinuedforatleastonemonthafterstenting Aspirinshouldbecontinuedforanindefiniteperiod 11 02 30 B AntiplateletandAnticoagulationTherapy Heparin eitherUFHorlowmolecularweightheparin LMWH isakeycomponentintheantithromboticmanagementofUA NSTEMI ThedoseofUFHshouldbetitratedtoanactivatedpartialthromboplastintimethatis1 5to2 5timescontrol AdvantageofLMWHpreparationsaretheeaseofsubcutaneousadministrationandtheabsenceofaneedformonitoring Furthermore theLMWHsstimulateplateletslessthanUFHdoesandarelessfrequentlyassociatedwithheparin inducedthrombocytopenia However theyappeartobeassociatedwithsignificantlymorefrequentminor butnotmajor bleeding 11 02 31 B AntiplateletandAnticoagulationTherapy Whenplateletsareactivated theGPIIb IIIareceptorundergoesachangeinconfigurationthatresultsinbindingoffibrinogentoplateletreceptors resultinginplateletaggregation TheefficacyofGPIIb IIIaantagonistsinpreventionofthecomplicationsassociatedwithpercutaneouscoronaryintervention PCI hasbeendocumentedinnumeroustrials manyofwhichwerecomposedentirelyorinlargepartofpatientswithUA 11 02 32 B AntiplateletandAnticoagulationTherapy TrialswithtirofIbanandonetrialwitheptifibatidehavealsoshownefficacyinUA NSEMIpatients onlysomeofwhomunderwentinterventions InPCItrials theadministrationofabciximabconsistentlyshowedasignificantreductionintherateofMIandtheneedforurgentrevascularization 11 02 33 B AntiplateletandAnticoagulationTherapy TreatmentwithtoGPIIb IIIablockersincreasetheriskofbleeding whichistypicallymucocutaneousorinvolvestheaccesssiteofvascularintervention Bloodhemoglobinandplateletcountsshouldbemonitored andpatientsurveillanceforbleedingshouldbeperformeddailyduringtheadministrationofGPIIb IIIablockers 11 02 34 B AntiplateletandAnticoagulationTherapyClassI Recommendations 1 Antiplatelettherapyshouldbeinitiatedpromptly ASAshouldbeadministeredassoonaspossibleafterpresentationandcontinuedindefinitely2 ClopidogrelshouldbeadministeredtohospitalizedpatientswhoareunabletotakeASAbecauseofhypersensitivityormajorgastrointestinalintolerance3 Inhospitalizedpatientsinwhomanearlynon interventionalapproachisplanned clopidogrelshouldbeaddedtoASAassoonaspossibleonadmissionandadministeredforatleast1monthandforupto9months 11 02 35 B AntiplateletandAnticoagulationTherapyClassIRecommendations 4 InpatientsforwhomaPCIisplanned clopidogrelshouldbestartedandcontinuedforatleast1monthandupto9monthsinpatientswhoarenotathighriskforbleeding5 InpatientstakingclopidogrelinwhomCABGisplanned ifpossiblethedrugshouldbewithheldforatleast5days andpreferablyfor7days 11 02 36 B AntiplateletandAnticoagulationTherapyClassIRecommendations 6 AnticoagulationwithsubcutaneousLMWHorintravenousunfractionated UFH shouldbeaddedtoantiplatelettherapywithASAand orclopidogrel7 AplateletGPIIb IIIaantagonistshouldbeadministered inadditiontoASAandheparin topatientsinwhomcatheterizationandPCIareplanned TheGPIIb IIIaantagonistmayalsobeadministeredjustpriortoPCI 11 02 37 B AntiplateletandAnticoagulationTherapyRecommendations ClassIIa1 EnoxaparinispreferabletoUFHasananticoagulantintheabsenceofrenalfailureandunlessCABGisplannedwithin24h ClassIII1 IntravenousfibrinolytictherapyinpatientswithoutacuteST segmentelevation atrueposteriorMI orapresumednewleft bundle branchclock LBBB 2 AbciximabadministrationinpatientsinwhomPCIisnotplanned 11 02 38 B AntiplateletandAnticoagulationTherapyClassIIIRecommendations IntravenousThrombolyticTherapyinNon STElevationMI 11 02 39 C RiskStratification ThemanagementofpatientswithanACSrequirescontinuousriskstratification ThegoalofnoninvasivetestingaretodeterminethepresenceorabsenceofischemiainpatientswithalowlikelihoodofCADandtoestimateprognosis 11 02 40 C RiskStratification Becauseofsimplicity lowercost andwidespreadfamiliaritywithperformanceandinterpretation thestandardlow levelexerciseECGstresstestremainsthemostreasonabletestinpatientsabletoexercisewhohavearestingECGthatisinterpretableforST segmentshifts PatientswithanECGpatternthatwouldinterferewithinterpretationoftheSTsegmentshouldhaveanexercisetestwithimaging Patientswhoareunabletoexerciseshouldhaveapharmacologicalstresstestwithimaging 11 02 41 C RiskStratificationClassI Recommendations 1 Noninvasivestresstestinginlow riskpatientswhohavebeenfreeofischemiaatrestorwithlow levelactivityandfreeofCHFforaminimumof12to24hours2 Non invasivestresstestinginpatientsatintermediateriskwhohavebeenfreeofischemiaatrestorwithlow levelactivityandofCHFforaminimumof2or3days3 ChoiceofstresstestisbasedontherestingECG abilitytoperformexercise localexpertise andtechnologiesavailable4 Promptangiographywithoutnoninvasiveriskstratificationforfailureofstabilizationwithintensivemedicaltreatment 11 02 42 C RiskStratificationRecommendations ClassIIa1 Anoninvasivetest echocardiogramorradionuclideangiogram toevaluateLVfunctioninpatientswithdefiniteACSwhoarenotscheduledforcoronaryarteriographyandleftventriculography 11 02 43 D EarlyConservativeVersusInvasiveStrategies Twodifferenttreatmentstrategies termed earlyconservative and earlyinvasive haveevolvedforpatientswithUA NSTEMI Intheearlyconservativestrategy coronaryangiogrpahyisreservedforpatientswithevidenceofrecurrentischemia anginaorST segmentchangesatrestorwithminimalactivity orastronglypositivestresstestdespitevigorousmedicaltherapy Intheearlyinvsivestrategy patientswithoutclinicallyobviouscontraindicationstocoroanryrevascularizationareroutinelyrecommendedforearlycoronaryangiographyandangiographicallydirectedrevascularizationifpossible 11 02 44 D EarlyConservativeVersusInvasiveStrategies InpatientswithUA NSTEMIwithoutrecurrentischemiainthefirst24hours theuseofearlyangiographyprovidesaconvenientapproachtoriskstratification Itcanidentifythepatientswithnosignificantcoronarystenosesandthosewith3 vesseldiseasewithLVdysfunctionorleftmaindisease Theformergrouphasanexcellentprognosis whereasthelatergourpmayderiveasurvivalbenefitfromcoronaryarterybypassgraftsurgery CABG 11 02 45 D EarlyConservativeVersusInvasiveStrategies Inaddition earlyPCIoftheculpritlesionhasthepotentialtoreducetheriskforsubsequenthospitalizationandtheneedformultipleantianginaldrugscomparedwiththeearlyconservativestrategy Inpatientswithouthigh riskfeatures coronaryarteriographyisoptionalandcanbesafelydeferred 11 02 46 D EarlyConservativeVersusInvasiveStrategiesClassI Recommendations 1 AnearlyinvasivestrategyisrecommendedinpatientswithUA NSTEMIandanyofthefollowinghigh riskindicators Recurrentangina ischemiaatrestorwithlow levelactivitiesdespiteintensiveanti ischemiatherapyElevatedTnTorTnINeworpresumednewST segmentdepressionatpresentationRecurrentangian ischemiawithCHFsymptoms anS3gallop pulmonaryedema worseningrales orneworworseningmitralregurgitation 11 02 47 D EarlyConservativeVersusInvasiveStrategiesClassI Recommendations High riskfindingsonnoninvasi