ACS介入策略

非ST断抬高性急性冠脉综合的介入治疗,广东省心血管病研究所陈纪言,RITA-3-results,interventionconservativeRR(95%CI)pn=895n=9154-MonthD/MI/Angina86(9.6%)133(14.5%)0.66(0.51-0.85)0.0011-yearD/MI68(7.6%)76(8.3%)0.91(0.67-1.25)0.58,Symptoms of angina were improved and use of antianginal medications reduced with the interventional strategy(p0.0001),FRISC-II 2 years follow-up,JACC 2002.40:1902-14,invasive conservative RR(95%CI) PMortality(%)3.7 5.40.68(0.47-0.98) 0.038MI (%)9.2 12.70.72(0.57-0.91) 0.005D/MI (%)12.1 16.30.74(0.61-0.09) 0.003,After the first year, there was no difference in mortality between the two groups, fewer MIs in invasive group.,Number of D/MIs within 1 year,Combined risk ratio 0.88(95%CI 0.78-0.99),0.1,0.5,1.0,2.0,10.0,早期侵入治疗优于早期保守治疗,这些试验比较些什么?,早期介入治疗与早期保守治疗？早期介入策略与早期保守策略？,非ST断抬高性急性冠脉综合的介入治疗,是早期介入策略获益！,非ST断抬高性急性冠脉综合的介入策略,是早期介入策略获益！,早期介入策略如何获益？,UA & NSTEMI,Early invasive vs. early conservative strategiesEarly invasive: Early coronary arteriography followed by revascularization as indicated by arteriographic findingsEarly conservative: Catheterization, and if indicated, revascularization, only in the event of failure of medical therapy,6-month Mortality for Acute Coronary Syndromes,T-wave inversionACS,ST ACS,Granger CB et al. J Am Coll Cardiol. 1998; 31:79A.,% Cumulative mortality at 6 months,ST MI with fibrinolytics,2457 patients with ACS (follow-up 6 months),Early Invasive Strategies-FRISC ,Lancet 1999, Vol354,04/05:我们的策略是否有所改变？ICTUS研究对我们的启示,Class I:一、无严重合并症,合并以下高危因素,早期介入治疗:1 抗缺血治疗中,反复休息时或轻微活动时胸痛/缺血2 TnT 或TnI升高3 新出现ST段压低4 反复胸痛/缺血,伴CHF症状,S3奔马律,肺水肿,MR5 非创伤性负荷试验高危发现,非ST段抬高性ACS早期介入干预时机-AHA/ACC指南（2002）,Class I:6 LV收缩功能降低(EF.40,负荷试验,非低危,低危,药物治疗,反复缺血症状心衰严重心律失常,EF.40,早期介入策略,早期保守策略,ACS: 院内治疗,UA/NSTEMI:血运重建术策略,心导管术,药物治疗、PCI 或 CABG,1 支或 2支病变,PCI 或 CABG,否,CABG,心衰或糖尿病,CABG,是,查胸痛原因,无,3支或2支(伴LAD近端)病变,冠心病,有,左主干病变,是,无,小结,早期介入策略优于早期保守策略早期介入策略的意义在于通过冠脉造影深化危险分层早期介入策略使中危和高危病人获益,THANK YOU!,Early invasive vs. early conservative strategies,Early invasive: early coronary arteriography followed by revascularization as indicated by arteriographic findingsEarly conservative: catheterization, and if indicated, revascularization, only in the event of failure of medical therapy,UA & NSTEMI,Benefit of Intervention,7.6,8.3,9.6,14.5,0,5,10,15,Patients (%),Conservati