急性冠脉综合征评估及危险分层

1、Acute Coronary SyndromesEvaluation and Risk StratificationNew Terminology in ACSACS, acute coronary syndrome; MI, myocardial infarction; UA, unstable angina; NSTEMI, nonST-segment elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction; PCI, percutaneous coronary intervent

2、ion.Cannon CP. J Thromb Thrombolysis. 1995;2:205-218.AntithromboticTherapyStable AnginaUnstableAnginaNonQ-wave MIThrombolysisPrimary PCIQ-wave MIMinutes-hoursDays-weeksSTEMIUA/NSTEMIAtherothrombosisNew termOld termPlaqueRuptureTroponin I (TnI), C-Reactive Protein (CRP), and B-type Natriuretic Peptid

3、e (BNP) as Determinants of 30-Day Mortality Risks in Acute Coronary Ischemia: A Multimarker ApproachOPUS-TIMI 1611.83.5601234560123No. of Elevated Biomarkers30-Day Mortality Relative Risk TACTICS-TIMI 1812.15.713024681012140123No. of Elevated BiomarkersP=.014P50%) Aspirin in last 7 days2 anginal eve

4、nts in 24 hoursST deviation Elevated cardiac markers (CK-MB or troponin)TIMI Risk Score For UA/NSTEMIAntman EM, et al. JAMA. 2000;284:835-442. (with permission) Age 65 years 3CAD Risk Factors Prior Stenosis 50 % ST deviation 2 Anginal events 24 hours ASA in last 7 days Elev Cardiac Markers (CK-MB or

5、 troponin)4.78.313.219.926.240.9010203040500/123456/7D/MI/Urg Revasc (%)Number of Risk FactorsPopulation (%):4.317.332.029.313.03.4C Statistic=0.65c c2 trend P.0014.13.97.119.56.54.910.835.121.010.749.624.4P.001P=.004P.001P.001Scirica BM, et al. Am J Cardiol. 2002;90:303-305. (with permission)TIMI R

6、isk Score vs Prognosis in Unselected Patients (TIMI 3 Registry)TRS 0-2TRS 3-4TRS 5-70%10%20%30%40%50%DeathMIDeath/MIDeath/MI/RIEvent Rate at 1 year (%)Prognostic Value of Troponin T or I in ACS: A Meta-analysis1.96.76.420.80510152025DeathDeath/MI%RR 3.9(2.9-5.3)RR 3.8(2.6-5.5)No. Studies:136 NegPos

7、(Trop I + T)36341849737322Heidenreich PA, J Am Coll Cardiol. 2001;38:478-485.TIMI IIIB: Troponin I Levels Predict Mortality In UA/NSTEMI1.01.73.43.76.07.5024680 to 0.40.4 to 1.01.0 to 2.0 2.0 to 5.05.0 to 9.08311741481346750Risk Cardiac Troponin I (ng/ml)Ratio1.0 1.83.5 3.96.27.8Mortality at 42 Days

8、 (% of Patients)Antman EA, et al. N Engl J Med. 1996;335:1342-1349. (with permission)Lindahl B, et al. N Engl J Med. 2000;343:1139-1147. (with permission)Predictive Value of Troponin T and hs-CRP for Mortality from ACS in FRISC Substudy201000612182430364248Cumulative Probability of Death (%)MonthsTr

9、oponin T 0.60 g/l (n=377)Troponin T 0.60-0.59 g/l (n=367)Troponin T 10mg/l (n=309)CRP 2mg/l (n=314)P=.001P=.29CRPTroponinMonthsRisk Stratification With CRP and Troponin TChi Square: P=.00079.1%4.7%0.4%012345678910RcTnT Neg AND CRP 1.55RcTnT(early +) ANDCRP 1.5514-Day Mortality (%)N=277N=129N=22Morro

10、w DA, et al. J Am Coll Cardiol. 1998;31:1460-1465.WBC Count (x103)30-Day Mortality0510152005%10%15%20%White Blood Cell Count vs MortalityCannon CP, et al. Am J Cardiol. 2001;87:636-639. (with permission)B-type Natriuretic Peptide (BNP) and Mortality in ACS Patientsde Lemos JA, et al. N Engl J Med. 2

11、001;345:1014-1021. (with permission)0246810Mortality (%)050100150200250300Days After RandomizationP.001Quartile 4(n=630)Quartile 3(n=632)Quartile 2(n=632)Quartile 1(n=631)05101520Mortality at 10 mo (%)Q1Q2Q3Q4ST MINon-ST MIUnstable Angina8255651133 P=.02P.0001P=.001de Lemos JA, et al. N Engl J Med.

12、2001;345:1014-1021. (with permission) BNP and Risk of Death in ACSMultimarker Approach: Troponin I, CRP, and BNP to Predict 30-Day Mortality in ACSSabatine M, et al. Circulation. 2002;105:1760-1763. (with permission)OPUS-TIMI 1611.83.5601234560123No. of Elevated BiomarkersTACTICS-TIMI 1812.15.713024

13、681012140123No. of Elevated BiomarkersP=.014P=.001671501557850471732490 30 Day Mortality (%)30-Day Mortality Rel RiskInflammation, ACS, and CD-40L* SCD40L = soluble CD40LAndre P, et al. Circulation. 2002;106:896-899. (with permission)Varo N, et al. Circulation. 2003;108:1049-1052. (with permission)C

14、linical Investigation ReportsSoluble CD40LRisk Prediction After Acute Coronary Syndromes3.532.521.510.50DeathMIDIMICHFDIMI CHFQ1Q2Q3Q4Hazard Ratios (HR)*P.01 compared to first quartile P.03 compared to first quartileSoluble CD-40L in ACSHeeschen C, et al. N Engl J Med. 2003;348:1104-1111. (with perm

15、ission)Association between soluble CD40 ligand levels and the rate of cardiac events (death or nonfatal myocardial infarction) at 24 hours, 72 hours, 30 days, and 6 months among 544 patients receiving placebo.TimeDeath or Nonfatal Myocardial Infarction (%)24 hours72 hours30 hours6 monthsP=.13P=.003P

16、=.004P=.0011st quartile2nd quartile3rd quartile4th quartile5th quartileHermann A, et al. Platelets. 2001;12:74-82. (with permission)ADP, 30 MControl00.10.20.30.40.5CD40L Expression (Mn X)ControlASAClopidogrelASA + ClopidogrelP.05 vs ADP- stimulated controlsEffect of Treatment with Abciximab According to the Levels of Troponin T and Soluble CD40 LigandHeeschen C, et al. N Eng J Med. 2003;348:1104-1111. (with permission)0.00.51.01.52.02.5Quintile of Soluble CD40 Ligand12345All patientsHazard Ratio for Death or Nonfatal Myocardial InfarctionP=.10