稳定性冠心病的治疗策略

稳定性冠心病的治疗策略2012-3当前1页，总共59页。2当前2页，总共59页。内容在稳定性冠心病治疗中标准药物治疗的价值血管重建在那些患者可能获益？如何选择CABG或是PCI

单支、双支病变

三支、左主干病变多支病变功能性完全血管重建选择药物洗脱支架还是裸金属支架？3当前3页，总共59页。COURAGE:StudydesignBodenWEetal.AmHeartJ.2006;151:1173-9.BodenWEetal.NEnglJMed.2007;356:1503-16.Optimalmedicaltherapy*+PCI(n=1149)Optimalmedicaltherapy

(n=1138)AHA/ACCClassI/IIindicationsforPCI,suitablecoronaryarteryanatomy+

≥70%stenosisin≥1proximalepicardialvessel+objectiveevidenceofischemia

(or≥80%stenosis+CCSclassIIIanginawithoutprovocationtesting)Primaryoutcomes:All-causemortality,nonfatalMIFollow-up:Median4.6yearsRandomized*Intensivepharmacologictherapy+lifestyleintervention

CCS=CanadianCardiovascularSocietySecondaryoutcomes:Death,MI,stroke;ACShospitalization当前4页，总共59页。COURAGE:TreatmenteffectonprimaryoutcomeHR1.05(0.87-1.27)P=0.62*BodenWEetal.NEnglJMed.2007;356:1503-16.All-causedeath,MI(timetofirstevent)*UnadjustedNo.atriskMedicaltherapy 1138 1017 959 834 638 408 192 30PCI 1149 1013 952 833 637 417 200 35MedicaltherapyPCI+medicaltherapySurvivalfreeofprimaryoutcome024700.50.60.70.81.00.9Years6531当前5页，总共59页。6当前6页，总共59页。当前7页，总共59页。当前8页，总共59页。PharmacologictherapyAntiplateletAspirinClopidogrelinaccordancewithestablishedpracticestandardsDyslipidemiaSimvastatin±ezetimibe

orERniacinACEIorARBLisinoprilorlosartan-blockerERmetoprololsuccinateCalciumchannelblockerAmlodipineNitrateIsosorbide5-mononitrateBodenWEetal.AmHeartJ.2006;151:1173-9.BodenWEetal.NEnglJMed.2007;356:1503-16.当前9页，总共59页。内容在稳定性冠心病治疗中标准药物治疗的价值血管重建在那些患者可能获益？如何选择CABG或是PCI

单支、双支病变

三支、左主干病变多支病变功能性完全血管重建选择药物洗脱支架还是裸金属支架？10当前10页，总共59页。11当前11页，总共59页。当前12页，总共59页。当前13页，总共59页。14当前14页，总共59页。内容在稳定性冠心病治疗中标准药物治疗的价值血管重建在那些患者可能获益？如何选择CABG或是PCI

单支、双支病变

三支、左主干病变多支病变功能性完全血管重建选择药物洗脱支架还是裸金属支架？15当前15页，总共59页。ProximalLADdisease,medicine,PTCAorCABG

（MASStrial）1724301.41.42.82.81.49.7420328298P=0.0002P=0.006NSNSP=0.019P<0.01P<0.01Eventrateatf-up(%)Huebetal.JAmCollCardiol1995;26:1600-1605SingleCenter,randomizedtrialStableangina,proximalLADsignificantlesion<12mminlength,nopriorMI,nototalocclusion,nopriorCABGorangioplasty.n=214:Medicaln=72;BAn=72;LIMAn=70当前16页，总共59页。稳定性冠心病血运重建策略SilberS,TCT2010当前17页，总共59页。内容在稳定性冠心病治疗中标准药物治疗的价值血管重建在那些患者可能获益？如何选择CABG或是PCI

单支、双支病变

三支、左主干病变

多支病变功能性完全血管重建选择药物洗脱支架还是裸金属支架？18当前18页，总共59页。71%enrolled

(N=3,075)AllPtswithdenovo3VDand/orLMdisease(N=4,337)Treatmentpreference(9.4%)ReferringMDorpts.refused

informedconsent(7.0%)Inclusion/exclusion(4.7%)Withdrewbeforeconsent(4.3%)Other(1.8%)Medicaltreatment(1.2%)TAXUSn=903PCIn=198CABGn=1077CABGn=897nof/un=4285yrf/un=649PCIallcapturedw/followupCABG2500750w/f/uvsTotalenrollmentN=3075Stratification:

LMandDiabetesTwoRegistryArmsRandomizedArmsn=1800TwoRegistryArmsN=1275RandomizedArmsN=1800HeartTeam(surgeon&interventionalist)PCIN=198CABGN=1077AmenableforonlyonetreatmentapproachTAXUS*N=903

CABGN=897vsAmenableforbothtreatmentoptionsStratification:

LMandDiabetesLM33.7%3VD66.3%LM34.6%3VD65.4%DM28.5%NonDM71.5%NonDM71.8%DM28.2%23USSites62EUSites+SYNTAXTrialDesign当前19页，总共59页。PatientProfiling

LocalHeartteam(surgeon&interventionalcardiologist)assessedeachpatientinregardsto:Patient’soperativerisk(EuroSCORE&Parsonnetscore)Coronarylesioncomplexity(newlydevelopedSYNTAXscore)ThegoaloftheSYNTAXscoreistoprovideatooltoassistphysiciansintheirrevascularizationstrategiesforpatientswithhighrisklesionsSianosetal,EuroIntervention2005;1:219-227Valgimiglietal,AmJCardiol2007;99:1072-1081Serruysetal,EuroIntervention2007;3:450-459CoronarytreesegmentsbasedontheclassificationproposedbytheAHAandmodifiedfortheARTSstudyCirculation1975;51:31-3&SeminIntervCardiol1999;4:209-19Leamanscore,Circ1981;63:285-299LesionsclassificationACC/AHA,Circ2001;103:3019-3041Bifurcationclassification,CCI2000;49:274-283CTOclassification,JAmCollCardiol1997;30:649-656TortuosityThrombusBifurcationTotalOcclusion3VesselLeftMainDominanceCalcificationNumber&locationoflesionsSYNTAXscore当前20页，总共59页。MACCEto12MonthsP=0.0015*061210200MonthsSinceAllocationCumulativeEventRate(%)ITTpopulation12.1%

17.8%EventRate±1.5SE.*Fisher’sExactTestTAXUS*

(N=903)CABG

(N=897).SerruysPW,atTCT2008当前21页，总共59页。SYNTAXTrial

AdverseEventsto12Months

ITTpopulationEventRate±1.5SE,*FisherexacttestAllDeathRevascularizationCVA(Stroke)MyocardialInfarctionTAXUS*(N=903)CABG(N=897).SerruysPW,atTCT2008当前22页，总共59页。当前23页，总共59页。SabikJF,TCT2010当前24页，总共59页。Patient1Patient1Patient2Patient2SYNTAXSCORE21SYNTAXSCORE52LCx70-90%LAD70-90%RCA270-90%RCA370-90%LM99%LCx100%LAD99%RCA100%Thereis‘3-vesseldisease’and‘3-vesseldisease’当前25页，总共59页。SYNTAXTrial,MACCEto12Months

LeftMainSubsetP=0.44*061220400MonthsSinceAllocationCumulativeEventRate(%)13.6%

15.8%TAXUS

(N=357)CABG

(N=348)Eventrate±1.5SE,*FisherexacttestITTpopulation当前26页，总共59页。P=0.2026.8%22.3%0CumulativeEventRate(%)2040Before1year*13.7%vs15.8%P=0.441-2years*7.5%vs10.3%P=0.222-3years*5.2%vs5.7%P=0.780123624MonthsSinceAllocationTAXUS

(N=357)CABG

(N=348)MACCEto3Years

LMSubsetCumulativeKMEventRate±1.5SE;log-rankPvalue;*BinaryratesSerruysP,TCT2010当前27页，总共59页。CABGPCIPvalueDeath6.0%2.6%0.21CVA4.1%0.9%0.12MI2.0%4.3%0.36Death,CVAorMI11.0%6.9%0.26Revasc.13.4%15.4%0.69MonthsSinceAllocationCumulativeEventRate(%)P=0.33LeftMainTAXUS

(N=118)CABG

(N=104)MACCEto3YearsbySYNTAXScoreTercileLowScores(0-22)18.0%23.0%MonthsSinceAllocationCumulativeEventRate(%)0122440020301036Site-reportedData;ITTpopulationCumulativeKMEventRate±1.5SE;log-rankPvalue>>><<当前28页，总共59页。CABGPCIPvalueDeath12.4%4.9%0.06CVA2.3%1.0%0.46MI3.3%5.0%0.63Death,CVAorMI15.6%10.8%0.29Revasc.14.0%15.9%0.75P=0.90LeftMainTAXUS

(N=103)CABG

(N=92)MACCEto3YearsbySYNTAXScoreTercile

IntermediateScores(23-32)23.4%23.4%MonthsSinceAllocationCumulativeEventRate(%)0122440020301036Site-reportedData;ITTpopulationCumulativeKMEventRate±1.5SE;log-rankPvalue>>><<当前29页，总共59页。P=0.003LeftMainTAXUS

(N=135)CABG

(N=149)MACCEto3YearsbySYNTAXScoreTercile

LeftMainSYNTAXScore3337.3%21.2%LeftMainMonthsSinceAllocationCumulativeEventRate(%)0122440020301036CABGPCIPvalueDeath7.6%13.4%0.10CVA4.9%1.6%0.13MI6.1%10.9%0.18Death,CVAorMI15.7%20.1%0.34Revasc.9.2%27.7%<0.001Site-reportedData;ITTpopulationCumulativeKMEventRate±1.5SE;log-rankPvalue><<<<当前30页，总共59页。ESC稳定性冠心病血运重建策略(2010)SilberS,TCT2010当前31页，总共59页。

血运重建策略的制定应由多学科完成32当前32页，总共59页。一站式杂交手术（MIDCAB+PCI）对部分三支或左主干病变可能是一选择ThefirstHybridOperatingRoominAsiawasbuiltatFuwaiHospitalin2007.33新技术、新理念呼唤新的治疗策略当前33页，总共59页。内容在稳定性冠心病治疗中标准药物治疗的价值血管重建在那些患者可能获益？如何选择CABG或是PCI

单支、双支病变

三支、左主干病变

多支病变功能性完全血管重建选择药物洗脱支架还是裸金属支架？当前34页，总共59页。Angiography-guidedPCIFFR-guidedPCIMeasureFFRinallindicatedstenosesStentallindicatedstenosesStentonlythosestenoseswithFFR≤0.80RandomizationIndicateallstenoses≥50%consideredforstentingPatientwithstenoses≥50%inatleast2ofthe3majorepicardialvessels1-yearfollow-upFLOWCHART当前35页，总共59页。

FAMEstudy:ProceduralResultsANGIO-groupN=496FFR-groupN=509P-valueProceduretime(min)70±4471±430.51Contrastagentused(ml)302±127272±133<0.001Materialsusedatprocedure(US$)60075332<0.001Lengthofhospitalstay(days)3.7±3.5

3.4±3.30.05stentsperpatient2.7±1.21.9±1.3<0.001当前36页，总共59页。FFR-guided30days2.9%90days3.8%180days4.9%360days5.3%Angio-guidedabsolutedifferenceinMACE-freesurvivalFAMEstudy:Event-freeSurvival当前37页，总共59页。

ANGIO-groupN=496FFR-groupN=509P-valueEventsat1year,No(%)Death,MI,CABG,orrepeat-PCI91(18.4)67(13.2)0.02Death15(3.0)9(1.8)0.19Deathormyocardialinfarction55(11.1)37(7.3)0.04CABGorrepeatPCI47(9.5)33(6.5)0.08Totalno.ofMACE113760.02AdverseEventsat1year当前38页，总共59页。

PCI应用的适当性（美国注册资料），全美1091所医院PCI500154例急症PCI占71.1%STEMI20.6%，NSTEMI21.1%，高危UA29.3%非急症PCI占28.9%适当性急症PCI：适当98.6%非急症PCI：适当50.4%，不肯定38.0%

不适当11.6%

无心绞痛53.8%

无创检查属低危71.6%

药物治疗不适当（≤1种药物）95.8%