ACS是否应该早期介入治疗课件

IsearlyinvasivetheanswerforACSDr.BenHeMD/PhD/FSCAI/FAPSICDirectorofCardiologyDepartmentRenjiHospitalAffiliatedtoShanghaiJiaotonguniversity编辑课件PathophysiologyofAcuteCoronarySyndrome编辑课件ACSisanImportantManifestationofAtherothrombosis11.CannonCP.JThrombThrombolysis1995;2:205–218.AntithrombotictherapyStableanginaUANon-

Q-waveMIThrombolysisprimaryPCIQ-waveMIMinutes–

hoursDays–weeksSTEMIUA/NSTEMIAtherothrombosisNewtermOldtermPlaque

rupture编辑课件编辑课件RelationofTIMIriskscoreandMACErate编辑课件HottopicinACSIsearlyinvasivesuperiortoconservativestrategyinACS?Shouldinvasivebedeferredforcoolingoff?

Whatistheoptimaltimeforinvasive?编辑课件编辑课件OptimalStrategyforUA/NSTEMITIMIIIIB2005ConservativeInvasiveVANQWISHFRISCIITACTICS-

TIMI18RITA-3编辑课件FRICS-II:highriskgetmore编辑课件TIMI-18:highriskgetmore编辑课件RITA-3:1&3yrsoutcome编辑课件RITA-3:5yrsoutcome编辑课件编辑课件编辑课件编辑课件In2005,ItseemswefoundanswerInACS,earlyinvasivesuperiortoearlyconservativeThisisparticulartrueinhighriskpatients编辑课件ESCGuideline2005编辑课件编辑课件Istheproblemsettled?编辑课件ICTUSDesigned编辑课件编辑课件编辑课件编辑课件编辑课件编辑课件编辑课件4yrsICTUSLancet2007;369:827-835However,mostofselectiveptswereperformedPCISo,thelong-termf/uresultsdonotinflectInv/Consstrategy编辑课件4yrsICTUSLancet2007;369:827-835编辑课件ICTUS’scriticism

LibertydefinitionofMI(only1*ULN)causingtheearlyMIincreaseinearlyinvasivegroup3yrsrevascularizationratewasequalin2group(81%PCI)1yearmortalityrateinACSinbotharmareverylow(2.5%),Isitarealhighrisk?编辑课件EvenputICTUSintopool,Inv>Cons编辑课件InvvsCons/AllcausedeathHighrisk?编辑课件编辑课件编辑课件2007ESCGuidelineUrgentCoronaryangiographyisrecommendedinPtswithrefractoryorrecurrentanginaassociatedwithdynamicSTdeviation,heartfailure,lifethreateningarrhythmias,orhaemodynamicinstability(I-C)Early(<72h)angiographyfollowedbyrevascularization(PCIorCABG)inpatientswithintermediatetohighriskfeaturesisrecommended(I-A)编辑课件MonocyteLDL-CAdhesion

moleculeMacrophageFoamcellOxidized

LDL-CPlaqueruptureSmoothmuscle

cellsCRP2编辑课件ISAR-COOLTrial编辑课件ISAR-COOLAntithromboticRegimen编辑课件编辑课件ISAR-COOL编辑课件编辑课件编辑课件编辑课件WhatistheoptimaltimeforPCI?编辑课件编辑课件MethodsforOptimaltrial编辑课件ResultsofOptimaltrial编辑课件ConclusionfromOptimaltrial编辑课件What’sthedifferencebetweenISAR-Cool&Optimal?2.5vs84+0.5vs25-编辑课件TimetoCoronaryAngiographyandOutcomesAmongPatientsWithHigh-RiskNon–ST-Segment–ElevationAcuteCoronarySyndromes:ResultsFromtheSYNERGYTrial

PierluigiTricoci,MD,MHS,PhD;YuliyaLokhnygina,PhD;LisaG.Berdan,PA-C,MHS;StevenR.Steinhubl,MD;DietrichC.Gulba,MD;HarveyD.White,MD;NealS.Kleiman,MD;PhilipE.Aylward,MD;AnatolyLanger,MD;RobertM.Califf,MD;JamesJ.Ferguson,MD;ElliottM.Antman,MD;L.KristinNewby,MD,MHS;RobertA.Harrington,MD;ShaunG.Goodman,MD;KennethW.Mahaffey,MDDivisionofCardiology,DukeClinicalResearchInstitute,Durham,NC编辑课件Background2007ACC/AHAGuidelinesforNSTEACSrecommendtheuseofanearlyinvasivestrategyforhigh-riskpatientsRandomizedclinicaltrialsonearlyvs.conservativestrategyuseddifferenttimingofcardiaccatheterizationOptimaltimingofcardiaccatheterizationinNSTEACSnotyetestablished(expeditedvs.deferred)ExpeditedcatheterizationincreasinglyadoptedintheUS编辑课件StudyObjectiveToevaluatetheassociationbetweentimefromhospitaladmissiontocardiaccatheterizationandadverseoutcomesamonghigh-riskpatientswithNSTEACStreatedwithanearlyinvasivestrategy(cardiaccatheterization<48hofhospitaladmission)编辑课件StudyPopulationPatientsrandomizedintheSYNERGYtrial

Ischemicsymptoms<24handatleast2of3high-riskfeatures

Age>60yearsST-segmentdepressionortransientelevationPositivetroponinand/orCK-MBUseofcoronaryangiographyinSYNERGY10,027ptsrandomizedintheSYNERGYtrial9,188ptsunderwentcardiaccatheterization6,352ptsunderwentcardiaccatheterization<48h编辑课件AdjustedEstimatesof30-dayDeath/MIRates(with95%CI).0.0编辑课件LandmarkAnalysis:AdjustedORof30-dayDeath/MI(with95%CI)编辑课件AdjustedEstimatesofIn-hospitalTransfusionRates

(with95%CI)编辑课件StudyLimitationsNon-randomizedobservationalanalysisPropensity-basedmodelsusedtodealwithlackofrandomizationTimetocathisapost-baselineand“dynamic”variableStatisticalmethodologiesattemptedtoaddresstheseissues

EventsfromhospitaladmissiontorandomizationnotavailableEventsunlikelypriortorandomizationMyocardialinfarctioninthefirsthoursfollowingthehospitalizationismoredifficulttoadjudicate编辑课件ConclusionsfromSynergy-1Observationalanalysisamonghigh-riskNSTEACSpatientsenrolledintheSYNERGYtrialtreatedwithanearlyinvasivestrategyReducedtimetocardiaccatheterizationwasassociatedwithdecreasedprobabilityof30-daydeath/MIandnochangesinbleedingNosignalssuggestingbenefitsofdelayingthecardiaccatheterizationwereobserved编辑课件ConclusionsfromSynergy-2RandomizedclinicaltrialstoestablishoptimaltimingofcatheterizationinNSTEACSareneededbutchallengingDelayingcathisproblematicforhospitaladoptingexpeditedcathstrategyLagfromhospitalizationtorandomizationmayconfoundactualtimetocatheterizationinter