ACS治疗原则双语版

The

Management

of

AcuteMyocardial

InfarctionEarly

RepolarizationBrugada

SyndromePrinzmetal

AnginaPericarditisST

Segment

Elevation

(Transmural

ischemia)Anterior

AMI

Acute

Inf.

AMINon-infarct

ST

ElevationST

Segment

Depression

(Non-transmural

ischemia)ST

DepressionNSTEMIT

wave

inversionNSTEMINSTE

ACS

:

Key

ThemesNSTE

ACS:

a

high

risk

population

patient

risk benefit

from

treatmentwith

medications,

an

invasive

strategy

Interaction

between

invasive

strategy

andpharmacologic

txAntithrombotics

cornerstone

of

treatment

Anticoagulants:

heparin,

LMWH,

directthrombin

inhibitors

Antiplatelet

agents:

aspirin,

IIb/IIIa,

ADPinhibitorsAntman

EM

et

al

N

Engl

J

Med

1996;335:1342-9Invasive

vs.

Conservative

Strategy

for

ACSDeath

or

(re)-MITrialN

PCIConsRITA

31810

7.68.3VINO131

6.322.4TACTICS2220

7.39.5TRUCS148

7.616.7FRISC

II2451

10.414.1MATE201

9.96.7VANQUISH920

24.012.2Overall7876RR=

0.88,

p=0.05Intervention

better0.1

0.2

0.3

0.5

0.7

1.0

1.5

2.0Fox,

Lancet

360:743

‘03Death/(re)-MIDeath/(re)InfarctionCP971744-45%ConsInvTnT

cut

point

=

0.01

ng/mL(54%

of

pt

TnT

+)TACTICS–TIMI

18Troponin

T:

Death,

MI,

Rehosp

ACS,

6

MonthsOR=0.52*P<0.001InteractionP<0.001P=NS*n=414n=396n=463n=495Benefits

of

an

Invasive

Strategy

inNon-ST

Elevation

ACSOnly

shown

to

reduce

death

and

MI

in highrisk

ptsReduces

re-hospitalization,

angina

in many

othersShortens

hospitalization,

may

be

cost effectiveWhat

about

the

optimal

timing

of

an invasive

strategy?Medical

Tx

for

72-170

hrThen,

cath

labn=207Cath

lab

6

hrn=203ISAR-COOLCP1107655-467%

had troponin,65%

had

ST

depressionNeumann

FJ

et

al

JAMA

2004500

mg,

100

mg

bid600

mg,

75

mg

bid10

mg/kg

bolus,

0.10AspirinClopidogrelTirofibanmg/kg/min

infusionHeparin(PTT

60-85

seconds)Non-ST

Acute

Coronary

Syndrometroponin

or

ST

depressionn=410ISAR-COOLPrimary

EndpointCP1107655-230-dayevent

rate(%)Death

&

MIDeathNeumann

FJ

et

al

JAMA

2004Any

nonfatalMINonfatal

Q-wave

MIRR

1.96

(1.01-3.82)P=0.04

P=0.23Cooling

off

(n=207)Early

intervention(n=203)P=0.12

P=0.56Timing

of

an

Invasive

Strategy

inNon-ST

Elevation

ACSISAR-REACT

was

a

small,

singlecenter

study.Clinical

trials

are

still

gon.Other

analyses

also

indicate

that

cath within

24

hours

is

better

than

later

cathOught

to

use

intensive

antiplatelet therapy

with

a

veryearly

invasive

stratWhat

medical

therapy

ought

to

beused

in

ACS?Antithrombotic

Trialists’

Collaboration.

BMJ.

2002;324:71–86.Aspirin

DoseOR*No.

of

Trials

(%)Odds

RatioAspirin

Dose

and

Events

in

High-Risk

PtsFrequency

of

CV

Death,

MI,

Stroke500–1500mg3419160–325mg192675–150mg1232P=0.0001<750

0.5

1.01.5

2.0mg3Antiplatelet

B13

erettAntiplateletAnyWorseaspirin6523CURECP999547-2Non-ST

elevation

ACS12,562

patientsASA

75

to

325

mg

po

qdplacebon=6,3033-12

month

follow-up(average

9

mo)Yusuf

S

et

al

NEJM

2001;16:494-502ASA

+

clopidogrel(300

mg

load,

75

mg

qd)n=6,259CURECV

Death/MI/Stroke,

1

YearCP999731-3Placebo

(n=6,259)Clopidogrel

(n=6,303)ath,

MI,

stroke

(%)P=0.00003Days

after

enrollmentCUREEventrate(%)RR

0.80P=0.00005CP995058-6Aspirin

andPlacebo

(n=6,303)Clopidogrel

(n=6,259)CV

death,

CVMI,

stroke

deathMIStrokeNon-CVdeathRR

0.92P=NSRR

0.77P<0.001RR

0.85P=NSRR

0.96P=NSCUREMajor/Life-Threatening

Bleeds

in

the

7

Days

After

CABGPlaceboClopRRpN

=

476N

=

436Stopped

<

5

daysprior

to

CABG:Pts

with

Major

orLife

ThreateningBleeding6.3%

9.6%

1.53

0.06Major

Bleeds:

Significantly

disabling,

intraocular,or

transfusion 2

unitsLife

Threatening:

Hgb

>5g/dl,

hypotension(inotropes),

surgery

to

stop

bleeding,symptomatic

ICH

or

transfusion 4

unitsACC/AHA

ACS

Guideline

UpdateClass

I

Aspirin

75

to

325

mg/day

(level

ofevidence:

A)

ASA

and

clopidogrel

for

9

months

afterNSTE

ACS

(level

of

evidence:

B)Class

3

Do

not

administer

clopidogrel

in

the

5days

before

CABGBraunwald

E,

et

al.

Heparin

(UF

or

LMW)

in

ACS

Without

STDeath

or

MIUFH

or

LMWHControlOR95%

CITheroux

2/122

(1.6%)4/121

(3.3%)0.500.10-2.53Cohen

0/371/32

(3.1%)0.120.01-5.89RISC

3/210

(1.4%)7/189

(3.7%)0.400.11-1.39Cohen

4/105

(3.8%)9/109

(8.2%)0.460.15-1.41Holdright*

42/154

(27.3%)40/131

(30.5%)0.850.51-1.43Gurfinkel(UFH)4/70

(5.7%)

7/73

(9.6%)0.580.17-1.98Gurfinkel(LMWH)0/68

7/73

(9.6%)0.130.03-0.60FRISC

4/70

(5.7%)36/757

(4.8%)0.390.22-0.68UFH

vs55/698

(7.9%)

68/655

(10.4%)0.670.45-0.99placebo/coLMWH

vsplacebontrol13/809

(1.6%)

43/830

(5.2%)

0.340.20-0.58Total68/1507

(4.5%)

104/1412

(7.4%)0.530.38-0.73Only

RCTs,

placebo

or

untreated

controlsEikelboom

JW

et

al:

Lancet

55:1936-42,

2000CP951342-10.1Heparin

better1.010.0Control

betterFRAXIS(nadroparin;

n=2357)ESSENCE(enoxaparin;

n=3171)TIMI

IIB(enoxaparin;

n=3910).751.5(P=0.032)(P=0.029)Braunwald

E

et

al.Circulation

2000;102:1193-1209LMWHBetter1.0UFHBetterLMWH

versus

UFH

in

UA/NSTEMI

ManagedNon-invasively:Effect

on

Death,

MI,

Recurrent

IschemiaTrial:FRIC(dalteparin;

n=1482)CLASS

Ia

（Ia级推荐）一旦出现UA/NSTEMI，需尽快在抗血小板治疗的基础上给予患者抗凝药物。介入方案：证据级别A-包括依诺肝素和普通肝素；证据级别B-包括比伐 卢定和戊聚糖钠保守方案：药物选择可以是依诺肝素、普通肝素（证据级别A）或者戊聚 糖钠（证据级别B），有效性已经确立。对于选择保守治疗的病人，如果有较高的出血风险，倾向于选择戊聚糖钠（证据级别B）CLASS

IIa

（IIa级推荐）对于最初选择保守治疗策略的UA/NSTEMI病人，作为抗凝治疗，依诺肝素或者戊聚糖钠要优于普通肝素，除非计划在24小时内进行冠脉搭桥手术。（证据级别B）2007年ACC/AHA

UA/NSTEMI的指南抗凝治疗推荐ACC/AHA

2007更新的抗凝治疗指南高危或确诊ACS实行导管或PCI疑似/确诊ACS可能ACS阿司匹林+IV

UFH/LMWH*GP

IIb/IIIa拮抗剂阿司匹林+皮下LMWH

*或IV

UFH阿司匹林氯吡格雷氯吡格雷*证据等级Ia：依诺肝素优于IV

UFHACC/AHA治疗建议2007“不稳定型心绞痛/非ST段抬高心梗患者，除非计划在24小时内行冠脉搭桥手术，相对于普通肝素，依诺肝素（Enoxaparin）作为抗凝剂应优先选用。(证据级别A)”2002

update

ACC/AHA

guidelineACCP7指南对LMWH的治疗建议n

急性期LMWH优于UFH（1B级）；n

LMWH治疗时不需常规监测（1C级）；n

已使用LMWH的患者如需进行PCI，应继续使用LMWH（2C级）；n

应用GPIIb/IIIa受体拮抗剂者，

LMWH安全性优于UFH（2B级）。n

NSTE

ACS患者中LMWH的疗程评价是：NSTE

ACS患者应早期介入治疗，如果冠脉干预延迟，可考虑延长LMWH治疗作为血运重建的“桥梁”。Rest

pain

>

5

min

andST

Δ

>

0.1

mVorDocumented

CADorCK-MBN=132Heparin70

U/kg

bolus+15

U/kg/hr

infusionBivalirudin0.1

mg/kg

bolus+0.25

mg/kg

infusionTIMI

-

8:

Bivalirudin

vs.

Placebo

in

ACSTIMI

-

8:

Bivalirudin

vs.

Placebo

in

ACS4-6wks7days4-6wks7daysp=0.008p=0.024p=NSp=NSBeta

Blockers

Reduce

CV

death,

MI,

stroke

by

25-30%

in

high

risk

ptsNot

well

studied

in

non-STE

ACS

Reduce

heart

rate,

blood

pressure,ischemia,

chest

discomfortClass

1

indication;

quality

indicator

Use

in

everyone

withoutcontraindications5.617.915.714.23.812.911.710.312.811.805101520ry

Endpoint

%PlaceboGP

IIb/IIIaPURSUIT30

daysPRISM48

hrsPRISMPLUS7

daysP

=

0.04P

=

0.01P

=

0.004PARAGON

A30

daysP

=

0.48PARAGON

B30

daysP

=

0.33Platelet

GP

IIb/IIIa

Inhibition

for

Non-ST

ACSPrimary

Endpoint

Results

from

the

5

Major

RCTsIIb/IIIa

Inhibitors

in

ACS

PatientsGreatest

benefit

is

during

PCI

If

pursuing

a

non-invasive

strategy,recommend

treating

pts

with

elevatedtroponins,

high

TIMIscores,

etc;probably

those

with

diabetes,

markedST

segment

shifts

Do

not

recommend

their

routineadministration

to

all

ACS

pts

in

whoma

non-invasive

strategy

is

plannedConclusions

Much

remains

to

be

learned

about

theoptimal

medical

therapy

for

ACS

pts

The

data

favor

an

invasive

strategy,and

suggest

different

medications

anddoses

ought

be

administered

ifpursuing

an

invasive

vs.

non-invasivestrategy,

and

in

high

vs.

low

risk

ptsUA

/

NSTEMI:Pharmacological

and

Mechanical

InterventionBraunwald

E

et

al.

J

AmColl

Cardiol

2000;36:970-1062Braunwald

E

et

al.Circulation2002;106:1893-1900危险分层(TIMI危险评分)高危TIMI评分5-7低危TIMI评分0-2中危TIMI评分3-4ASA+LMWH(普通肝素)+氯吡格雷依替巴肽/替罗非班ASA+LMWH

or普通肝素+氯吡格雷ASA+LMWH(普通肝素)+氯吡格雷依替巴肽/替罗非班Cath/PCI/CABG进行监测/危险评估缺血二级预防无缺血Algorithm

for

Patients

withUA/NSTEMI

Managed

byan

Initial

Invasive

StrategyProceed

to

Diagnostic

AngiographyASA

(Class

I,

LOE:

A)Clopidogrel

if

ASA

intolerant

(Class

I,

LOE:A)Diagnosis

of

UA/NSTEMI

is

Likely

orDefiniteInvasive

StrategyInitiate

A/C

Rx

(Class

I,

LOE:

A)Acceptable

options:

enoxaparin

or

UFH

(Class

I,

LOE:

A)bivalirudin

or

fondaparinux

(Class

I,

LOE:

B)Select

Management

StrategyProceed

with

anInitialConservativeStrategyAnderson

JL.

J

Am

Coll

Cardiol.

2007,

In

press.

Figure

7ABB1B2Prior

to

AngiographyInitiate

at

least

one

(Class

I,

LOE:

A)

orboth

(Class

IIa,

LOE:

B)

of

the

following:ClopidogrelIV

GP

IIb/IIIa

inhibitorFactors

favoring

admin

of

both

clopidogreland

GP

IIb/IIIa

inhibitor

include:Delay

to

AngiographyHigh

Risk

FeaturesEarly

recurrent

ischemic

discomfortInitiate

clopidogrel

(Class

I,

LOE:

A)Consider

adding

IV

eptifibatide

or

tirofiban

(ClassIIb,

LOE:

B)Conservative

StrategyInitiate

A/C

Rx

(Class

I,

LOE:

A):Acceptable

options:

enoxaparin

or

UFH

(Class

I,LOE:

A)

or

fondaparinux

(Class

I,

LOE:

B),

butenoxaparin

or

fondaparinux

are

preferable

(Class

IIA,LOE:

B)Select

Management

StrategyASA

(Class

I,

LOE:

A)Clopidogrel

if

ASA

intolerant

(Class

I,

LOE:

A)Diagnosis

of

UA/NSTEMI

is

Likelyor

DefiniteAlgorithm

for

Patients

with

UA/NSTEMIManaged

by

an

Initial

Conservative

StrategyProceed

withInvasiveStrategy(Continued)Anderson

JL.

J

Am

Coll

Cardiol.

2007.

In

press.

Figure

8C2C1AEvidence

for

Primary

PCI

asTreatment

of

Choice

for

STEMI

ACSp=0.0003p<0.0001p=0.0004p<0.0001OR=0.57Keeley

&

Grines

Lancet

2003PCILyticRisk

ReductionDeath28%Death/MI/CVA43%Primary

PCI:The

Preferred

Reperfusion

StrategySummary

of

23

Randomized

Trials

(n=7739)Primary,

Transfer,

Facilitated

&

Rescue

PCIfor

STEMIn

Primary

PCI

(PPCI)Direct

to

CVL

for

PCI

reperfusion

therapyn

Transfer

PCIPts

transferred

from

hospitals

without

PCI

facilities(no

lysis)

to

a

PCI

centren

Facilitated

PCIPatients

receiving

thrombolysis*

followed

byintentional

PCIn

Rescue

PCIPCI

after

failed

thrombolysis

(at

90

mins)*Thrombolysis

may

be

Pre-hospitalDoor-To-Balloon

(DTB)

Time&

Choice

of

Reperfusion

Therapy

in

STEMIn

Sx

onset

<3

hr:Fibrinolysis

only

if

estimated

DTB

>

60

minn

Sx

onset

>3

hrs

<12hr:Primary

PCI

withDTB

of

90min;

otherwiseFibrinolysis

is

acceptable

alternativen

Sx

onset

>12hr:No

lysis

but

PCI

may

still

be

beneficialEvidence

for

Pre-Hospital

Thrombolysisfor

Early

(

<2

Hour)

STEMIEvidence

to

support

Transfe