稳定型冠心病的诊断和治疗：从循证医学到临床指南

1、稳定型冠心病的诊断和治疗：从循证医学到临床指南陈纪言广东省人民医院SIHD：常见诊疗误区诊断推侧性诊断过度使用CTA过度使用冠脉造影无创性缺血检查使用不足治疗介入治疗降低病人风险？死亡、心梗强化药物治疗已经足够？冠心病的诊断检查前冠心病可能性评估病人是否有冠心病？ -缺血的客观依据 -可视性冠状动脉狭窄 严重症状诊断流程疑冠心病，PTP15-85%思考：病人适应证设备条件/医生经验PTP15-50%病人冠脉CTA检查-如病人合适-如有设备和足够的经验病人是否有冠心病？ -缺血的客观依据 -可视性冠状动脉狭窄 严重症状强化药物治疗评估危险性（死亡率？) -缺血范围 -冠脉解剖有创性冠脉造影血运重

2、建冠心病的治疗SIHD药物治疗:从经验到循证-改善症状硝酸甘油B-阻断剂钙离子拮抗剂-改善预后阿斯匹林他丁类药物ACEICABG对死亡率的影响020406080100CABGYear 5Year 7Year10Medical TherapyActual CABG Rate(%)Total 2649 stable CAD patients (not severe enough to necessitate surgery) between 1972-1884.051015202530355 yrs7 yrs10 yrsMortalityMedical TherpayCABG(%)P=0.0001

3、P0.001P=0.03Yusuf, et al. Lancet 1994Odds Ratios of Morality at 5 years (CABG over MT)00.20.40.60.8LM3VD1/2VDTotal 2649 stable CAD patients (not severe enough to necessitate surgery) between 1972-1884.Yusuf, et al. Lancet 1994不同亚组CABG 10年后对寿命延长的影响Yusuf, et al. Lancet 1994COURAGE研究: PCI与药物治疗没有差异Total

4、ly 2287 patients with stable CAD and those in whom initial CCS IV angina subsequently stabilized medically.药物的使用强化药物治疗对稳定性冠心病已经足够！结论对吗?COURAGE研究:OMT组1/3强的病人接受血运重建OMT GroupPCI Group25.5% PCI7.1% CABG4% No PCINagajoth, et al. NEJM 2007,357:416.The data were analyzed in a intend-to-treat style.COURAGE:

5、 把很多重冠心病排除在外！Meta 分析: 死亡率7513 patients with stable IHDSchmig,et al. JACC2008Shaw, et al. Circulation 2008SPECT检查：负荷诱发心肌缺血PCI+OMT (N=159)OMT (N=155)P=0.0004P0.0001Shaw, et al. Circulation 2008心肌缺血面积减少对预后的影响86.6%75.3%Shaw, et al. Circulation 2008残存缺血对预后影响100%84.4%77.7%60.7%Hachamovitch, et al. Circula

6、tion 2003心肌缺血范围与疗效关系10 627 patients who underwent stress Myocardial Perfusion Stress SPECT and had no prior MI or revascularization 心肌缺血对死亡危险性的影响不是非常明确，也许与下述因素有关.缺血的不良作用 Adverse effect of ischemia严重狭窄病变闭塞 Occlusion of severe stenosis恶性心律失常 Arrhythmia严重缺血往往提示动脉硬化负荷较大、更可能有更多不稳定斑块 More severe ischemia

7、as a marker of atherosclerotic burden with more vulnerable plaques单纯药物治疗对不同冠心病严重程度预后影响Non-Invasive Stratification (1)Non-Invasive Stratification (2)Indications for Revascularization in Stable Angina or Silent Ischemia男性，48岁，下壁心梗3周，LCX 介入失败DEFERFAMEFAMEOutcomeAngiography GuidedFFR GuidedDifference (9

8、5% CI)MACEs, %18.313.25.2 (0.79.7)MI, %8.75.73.0 (0.26.2)Death, %3.01.81.3 (0.63.2)MI or death, %11.17.33.8 (0.37.4)QALY0.8380.8530.015 (0.0080.037)$ of initial procedure60075332$ of initial hospitalization14 87813 1821697 (2893510)$ of events during 12-mo f/(138325)Overall $16 70014 31

9、52384 (38261011)3-VD 14%1-VD 34%2-VD 43%0-VD9%Proportions of functionally diseased coronary arteries in patients with angiographic 3-vessel disease (n=115) FAME: Angiography versus FFRTonino, et al. JACC 2010FFR-guided SYNTAX Score (FSS) versus Conventional SYNTAX Score (SS)LOW risk 33%MEDIUM risk 3

10、3%HIGH risk 33%LOW risk 59 %MEDIUM risk 21%HIGH risk 21%FSSSS32% of patients moved to a lower-risk group 497 patients of the FFR-arm of FAMENam, et al. JACC 2011SYNTAX scoreFunctional SYNTAX scoreLowMediumHighp ValueLowMediumHighp ValueDeath1 (0.6)3 (1.8)5 (3.1)0.241 (0.3)5 (4.7)3 (3.0)0.01MI8 (4.8)

11、7 (4.2)15 (9.2)0.1113 (4.5)4 (3.8)13 (12.9)0.005Repeat PCI / CABG 6 (3.6)7 (4.2)17 (10.4)0.0213 (4.5)4 (3.8)13 (12.9)0.005Death / MI 9 (5.4)10 (6.0)19 (11.7)0.0614 (4.8)8 (7.5)16 (15.8)0.005MACE14 (8.4)17 (10.2)34 (20.9)0.00126 (9.0)12 (11.3)27 (26.7)0.001FSS vs. SS and Clinical Outcome 497 patients

12、 of the FFR-arm of FAMENam, et al. JACC 2011FAME II: Inclusion CriteriaPatients withstable angina or, stabilized angina pectoris or, atypical chest pain or no chest pain but with documented silent ischemiaat least one stenosis is present of at least 50% in one major native epicardial coronary artery

13、 and supplying viable myocardium Eligible for PCI Signed written informed consent NCT01132495FAME II: Study FlowPts w/ stable agina or silent ischemia scheduled for 1, 2 or 3 vessel DES stentingOMTPCI + OMTEnrollment stopped due to more MACEs in OMT alone groupinterim analysis FFR in indicated steno

14、sesOMT NCT01132495RN=1600N=200Rate of Any Revascularisation International Study of Comparative Health Effectiveness With Medical & Invasive Approaches (ISCHEMIA)Population: 8000 patients with moderate/ high ischemia on stress imaging nuclear myocardial perfusion (10% myocardium)echo or cardiac magne

15、tic resonance wall motion (3/16 segments with stress-induced severe hypo-/a-kinesiscardiac MR perfusion (12% myocardium). Verified February 2012 by NHLBI, not yet open for participant recruitment. Cath Revasc + OMTOMT男性，48岁，下壁心梗3周，LCX 介入失败小结-诊断应按照规范流程-SIHD包含着差异很大的各种病人-不能用一种 方式治疗所有的病人 -药物治疗和二级预防是SIHD的基础-了解病人的具体情况，评估死亡风险症状缺血的依据心功能SYNTAX评分STS评分并存疾病 其他-高危病人应选择血运重建治疗（PCI/CABG）-了解循证依据/指南-新的评价方式（FFR)谢谢！Summary 2CABG saved more patients compared with MTPCI not definitely superior to OMT in CRTs, due toUnder-representativeHigh crossover rateVaria