冠心病二级预防培训课件.ppt

,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。,Prevalence US including polyvascular patients(1.8M),时间发生 1 year,曾经有事件,(n=15 million),急性/新近有事件,(n=3 million),血 管 事 件,危险因素,终末期（死 亡）,一级预防,二级预防,动脉粥样硬化血栓疾病的长期预防的必要性,AMI,二级预防,A aspirin,抗心绞痛,B B-B 高血压治疗,C 戒烟 血脂异常治疗,D 控制饮食 治疗糖尿病,E 病人教育 适当锻炼,AMI,二级预防,非药物治疗,合理饮食,适当锻炼,戒烟,限酒,心理平衡,药物治疗,二级预防药物,控制冠心病危险因素,高血压,血脂异常,糖尿病,AMI,二级预防药物治疗,B-B(B,受体阻滞剂）,AMI,后用B-B明显降低MI后病残率和死亡率,早用，长期用,AMI,二级预防药物治疗,B,受体阻滞剂,AMI,后二级预防B-B长期治疗建议,除低危患者外，所有无禁忌症者应在AMI发病数天内开始治疗，并长期服用,非ST段抬高的MI存活者及中重度左心衰竭或其他B-B相对禁忌症者可在密切监测下使用,ACC/AHA,指南：,AMI,一般药物治疗的,类建议,（1999,年版）,阿司匹林（无禁忌证者）,静脉使用硝酸甘油：伴有心衰、高血压或持续心肌缺血患者以及广泛前壁心梗患者,受体阻滞剂：,12,小时内开始使用（无禁忌证者）,ACEI,：,伴有心衰或,LVEF40%,（,无禁忌证者）,急性心肌梗死,（AMI）,及早常规应用（无禁忌证）,减少心肌氧耗，缩小梗死面积，减轻胸痛，减少镇痛剂的使用,减少儿茶酚胺的细胞毒性和致心律失常作用；提高室颤阈,降低急性期的病死率、梗死后总死亡率、心血管病死亡率、猝死和再梗死的危险,最适合早期使用,BB,的是有高血流动力学状态的患者（如窦性心动过速、高血压）,用药方法与注意事项同高危,UAP,BB,治疗,AMI,的临床试验,试验名称,病例数,平均随访时间,结果或结论,歌德堡美托洛尔试验,（GMT，1984）,1395,3,个月,美托洛尔组死亡率,5.7%,，,安慰剂组,8.9%，RR,下降,36%，P0.03,美托洛尔在急性心肌梗死中的作用试验,（MIAMI，1985）,5778,15,天和,1,年,疑似或确诊,AMI,的病人早期用美托洛尔,，,15,天病死率与安慰剂比无差异，也不能改善长期预后,国际心肌梗死生存研究,（ISIS-1，1986）,16027,20,个月,第,1,周死亡率阿替洛尔组,3.89%，,常规处理组,4.57%,，,RR,下降,15%,，,P,0.02,心肌梗死溶栓试验-,2B（TIMI-2B，1991）,2948,1,年,AMI,溶栓后立即给,BB，6,天和,6,周再梗死率较延期给药组低,BB,治疗,AMI,的荟萃分析,MI,后早期应用,MI,后延迟应用,合并分析,试验数量,29,26,55,病例数量,28 970,24 298,53 268,治疗组（死亡数/每组例数）,530/14 535,934/12 438,1 464/26 295,对照组（死亡数/每组例数）,603/14 435,1 124/11 860,1 727/26 295,死亡的相对危险,0.87,0.77,0.81,95%,可信区间,0.770.98,0.700.84,0.750.87,P,值,0.02,0.0001,190mg/dl,和/或,LDL-C115mg/dl,则使用他汀类,A,BB,对心肌梗死的二级预防,BB,是心肌梗死后二级预防的有效药物,降低心肌梗死后再梗率、猝死率、心脏死亡率和总死亡率,所有心肌梗死后的病人只要没有禁忌证都应长期使用,心肌梗死后高危患者如心功能减低者使用,BB,得益更明显,合并糖尿病宜用心脏选择性,BB,溶栓治疗和血管成形术后的患者长期用,BB,获益,BB,用于,AMI,二级预防的临床试验,实验名称,药物,病例数,平均随访时间,死亡的相对危险,95%,可信限,P,值,挪威多中心研究,（NMS，1981）,噻吗洛尔,1884,33,个月,0.61,0.460.80,0.001,受体阻滞剂心脏病事件试验,（BHAT，1982）,普萘洛尔,3837,25,个月,0.72,0.740.80,0.005,卡维地洛对心肌梗死后生存率的对照研究,（CAPRICORN，2001）,卡维地洛,1959,15,个月,0.77,0.600.98,0.03,AMI,二级预防药物治疗,aspirin,大量研究证明,AMI后长期服用aspirin可以显著减少死亡率,长期服用aspirin者，发生MI时，梗死范围小，常为非Q波MI,AMI无禁忌症者，都应长期服用aspirin,剂量 75-150mg/d,对aspirin过敏者用噻氯匹定 250mg/d或氯吡格雷75mg/d,17.1,6.5*,Placebo,ASA,0,5,10,15,20,Patients(%),Unstable Angina,25.0,11.0*,ASA,0,10,20,30,3.3,1.9*,ASA,0,1,2,3,4,11.8,9.4*,ASA,0,5,10,15,Acute MI,阿司匹林对,ACS,的治疗,*,P,.0001,Death or MI,*,P,=.003,Reocclusion,*,P,=.012,MI,*,P,.001,Death,N=3973995134198587860085878600,MI,myocardial infarction;ASA,acetylsalicylic acid;RISC,Research on InStability in Coronary artery disease.,RISC Group.,Lancet.,1990;336:827-830.,Roux S,et al.,J Am Coll Cardiol.,1992;19:671-677.,ISIS-2.,Lancet.,1988;2:349-360.,Placebo,Placebo,Placebo,阿司匹林对冠心病,的一级和二级预防,12.9,3.9*,ASA,0,5,10,15,11.9,3.3*,ASA,0,5,10,15,12.9,6.2*,ASA,0,5,10,15,2.2,1.3*,ASA,0,0.5,1,1.5,2,2.5,UA/NSTEMI,Primary Prevention,Stable Angina,*,P,.0001MI,*,P,=.0003MI,*,P,=.008Death or MI,*,P,=.012Death or MI,N=1103411037155178279276118121,MI,myocardial infarction;ASA,acetylsalicylic acid;RISC,Research on InStability in Coronary artery disease;ISIS-2,Second International Study of Infarct Survival.,PHS.,N Engl J Med.,1989;321:129-35.,Ridker PM,et al.,AJC.,1991;114:835-839.,Cairns JA,et al.,N Engl J Med.,1985;313:1369-1375.,Theroux P,et al.,N Engl J Med.,1988;319:1105-1111.,Placebo,Placebo,Placebo,Placebo,Patients(%),阿司匹林的不同剂量,*Odds reduction.,Treatment effect,P,.0001.,ASA,acetylsalicylic acid.,Adapted with permission from,BMJ Publishing Group.Antithrombotic Trialists Collaboration,.BMJ.,2002;324:71-86.,0.5,1.0,1.5,2.0,500-1500 mg34 19,160-325 mg19 26,75-150 mg12 32,75 mg 3 13,Any aspirin65 23,Antiplatelet Better,Antiplatelet Worse,Aspirin DoseNo.of Trials (%),Odds Ratio,0,OR*,Clopidogrel,in the treatment of ACS,plavix+ASA:ASA,ACS患者持续服用氯吡格雷9-12个月,能使缺血性事件相对危险降低达20(,p=0.00009),plavix+ASA:ASA,波立维的长期治疗（1年）可以显著地减少PCI病人的死亡，心梗和中风,(RRR 27%,p=0.02),CAPRIE,CREDO,动脉粥样硬化疾病患者长期服用波立维1-3年比阿司林更能有效降低缺血性卒中、心肌梗死和血管性死亡的相对危险性达8.7%,plavix:ASA,CAPRIE,:,氯吡格雷,vs,阿司匹林,心梗，中风，血管性死亡,(N=19,185),*ITT analysis.,CAPRIE,Clopidogrel vs aspirin in Patients at Risk of Ischemic Events;MI,myocardial infarction;RRR,relative risk ratio.,CAPRIE Steering Committee.,Lancet,.1996;348:1329-1339.(with permission),Plavix,(clopidogrel bisulfate)prescribing information.,Follow-up(mo),Cumulative,Event Rate(%),0,4,8,12,16,Clopidogrel,Aspirin,Overall RRR,2,8.7%*,0,3,6,9,12,15,18,21,24,27,30,33,36,Aspirin,5.83%,1,5.32%,1,Clopidogrel,P,=.045,2,Median Follow-up=1.91 years,5/18/2025,CURE,Clopidogrel in Unstable Angina to Prevent Recurrent Ischemic Events;MI,myocardial infarction;CV,cardiovascular;RRR,relative risk reduction.,Plavix,package insert;2002.,Adapted with permission(2002)from the Massachusetts Medical Society.Yusuf S,et al.,N Engl J Med.,2001;345:494-502.,0.00,0.02,0.04,0.06,0.08,0.10,0.12,0.14,Cumulative Hazard Rate,Clopidogrel+Aspirin,3,6,9,Placebo+Aspirin,Follow-up(mo),P,=.00009,(N=12,562),0,12,20%,RRR,CURE:Primary End Point,心梗/中风/血管性死亡,CREDO:PCI,后一年结果,CV Death,MI or Stroke,*Plus ASA and other standard therapies,.,Steinhubl S,et al.,JAMA,.2002;288:2411-2420,.,(with permission),Combined Endpoint Occurrence(%),Months From Randomization,27%,RRR,P,=.02,Placebo*,Clopidogrel*,0,5,10,15,8.5%,11.5%,0,3,6,9,12,Initial Medical Treatment,（,初始治疗）,ASA,Betablockers,LMWH,Clopidogrel,Planned,CABG,Clopidogrel,Withheld for,5 days,Prefer 7 days,New ACC/AHA guidelines 2002:,Planned,catheterisation,and PCI,Early,non interventional,approach,ASA,Betablockers,LMWH,ASA,Betablockers,LMWH,Clopidogrel,Clopidogrel,GP b/a,Receptor Inhibitor,ASA,Clopidogrel,for 9 months,Beta-blockers,+,+,Lipid lowering therapy,+,ACE I,+,Class I Recommendations for Long Term Therapy,*,ACC/AHA 2002 Guidelines Update for UA and NSTEMI,（长期治疗）,1.,Braunwald E,et al.,American College of Cardiology(ACC)and the American Heart Association(AHA)Guidelines,USA:ACC/AHA;2002.,*,At hospital discharge and post-hospital discharge,In the absence of contraindications,Clopidogrel should be administered to hospitalized patients who are unable to take ASA because of hypersensitivity or major GI intolerance,AMI,二级预防药物治疗,调脂药,“中国血脂异常防治建议”推荐的治疗目标值,CHD,状况,LDL-C,目标,TC,目标,动脉粥样硬化病,(-)，,140,mg/dl,220 mg/dl,冠心病危险因子,(-),(3.64 mmol/L),(5.72 mmol/L),动脉粥样硬化病,(-)，,120,mg/dl,200 mg/dl,冠心病危险因子,(+),(3.12 mmol/L),(5.20 mmol/L),动脉粥样硬化病,(+),100 mg/dl,180 mg/d,(,2.60 mmol/L),(4.68 mmol/L),中华心血管杂志 1997年6月第 25 卷第期。,TG,目标值：,150 mg/dl(1.70 mmol/L),0,1,2,3,CHD RISK,100,160,220,LDL-cholesterol(mg/dL),*Men aged 50-70,85,65,45,25,HDL-C (mg/dL),FRAMINGHAM:CHD RISK OVER 4 YEARS,4S Study Group.Lancet.1995;345:1274-1275Sacks FM et al.N Engl J Med.1996;335:1001-1009,LIPID Study Group.N Engl J Med,1998;339:1349-1357,0,10,20,30,CARE-S,LIPID-S,4S-S,CARE-P,LIPID-P,4S-P,Statin Trials:LDL-C Levels vs Events Secondary Prevention,210,(5.4),90,(2.3),110,(2.8),130,(3.35),150,(3.9),170,(4.4),190,(4.9),LDL-C,S=statin treated,P=placebo treated,%with CHD event,(mmol/L),mg/dL,临床试验,5年心梗发生率（%）,危险性,115,150,142,192,94,139,112,150,122,188,35,31,23,24,34,事件%,终点 LDL,基础 LDL,无冠心病/一般胆固醇水平/低HDL胆固醇水平,冠心病,无冠心病高胆固醇水平,22.6,13.2/15.9,7.9,2.8,4S,CARE Lipid,WOSCOPS,AFCAPS/TexCAPS,4s(Lancet 94344:1383-89).CARE(1001-09),LIPID(NEJM 98:339:1349-57),AFCAPS(Tex Caps)(JAMA98:279:1615-22),WOSCOPS(NEJM95333:1301-07).,LDL,下降幅度（%）,35,25,32,26,23,冠心病高胆固醇水平,MIRACL Study Design,4 months,3073patients,Atorvastatin 80 mg,Non-Q-wave infarction or unstable angina,Randomised,2496 hours from admission,Exclusions:,Planned CABG/PTCA,Prior Q-wave 28 days,CABG 3 months,PTCA,7,.1,mmol,/L(270mg/dL),Patient population,Primary end point:,Time to,ischaemic,events(CHD death,non-fatal MI,cardiac arrest,documented angina requiring,hospitalisation,),Usual care+double-blindplacebo,MIRACL Results,Effects on LDL-C:,placebo group124 mg/dl,atorvastatin group 74 mg/dl,MIRACL Results,Effects on primary endpoint,(death,non-fatal MI,cardiac arrest,recurrent ischemia requiring hospitalisation),placebo group17.4%,atorvastatin group 14.8%,16%reduction(p 0.05),MIRACL Results,Effects on stroke,(secondary endpoint),placebo group24%,atorvastatin group 12%,(p925 events),Primary Endpoint:Death,MI,Documented UA requiring hospitalization,revascularization(30 days after randomization),or Stroke,PROVE-IT,Double-blind,Cannon CP,Braunwald E,McCabe CH,et al.,N Engl J Med,2004;350:15 www.nejm.org,Patient Population,Hospitalization for acute MI or high-risk unstable angina,Total cholesterol,240 mg/dL(200 mg/dL if on Lipid,Rx),Stabilized(i.e.,without ischemia,CHF,post PCI if performed),PROVE-IT,Cannon CP,Braunwald E,McCabe CH,et al.,N Engl J Med,2004;350:15 www.nejm.org,Baseline Characteristics,Atorvastatin 80mgPravastatin 40mg,(2099)(2063),Mean Age(years)5858,Male/Female(%)78/2278/22,History of HTN(%)5149,Current Smoker(%)3637,History of Diabetes(%)1918,History of CHD(%)3739,STEMI/NSTEMI/UA(%)36/36/2933/37/30,Prior Statin Use(%)2625,PROVE-IT,Cannon CP,Braunwald E,McCabe CH,et al.,N Engl J Med,2004;350:15 www.nejm.org,Changes in LDL-C from Baseline,LDL-C,(mg/dL),20,40,60,80,100,120,Rand,1,4,8,16,Final,Pravastatin 40mg,Atorvastatin 80mg,49%,21%,P0.001,Months,Screen,PROVE-IT,Cannon CP,Braunwald E,McCabe CH,et al.,N Engl J Med,2004;350:15 www.nejm.org,All-Cause Death or Major CV Events,0,3,18,21,24,27,30,6,9,12,15,%with Event,Months of Follow-up,Pravastatin 40mg,(26.3%),Atorvastatin 80mg,(22.4%),16%RR,(P=0.005),30,25,20,15,10,5,0,PROVE-IT,Cannon CP,Braunwald E,McCabe CH,et al.,N Engl J Med,2004;350:15 www.nejm.org,%with Event,0,3,18,21,24,27,30,6,9,12,15,20,15,10,5,0,Months of Follow-up,All-Cause Death,Non-Fatal MI,or Urgent Revascularization,Pravastatin 40mg16.7%,Atorvastatin 80mg12.9%,25%RRP=0.0004,PROVE-IT,Cannon CP,Braunwald E,McCabe CH,et al.,N Engl J Med,2004;350:15 www.nejm.org,PROVE-IT Conclusion,Our findings indicate that patients recently hospitalized for an acute coronary syndrome benefit from early and continued lowering of LDL-C to levels substantially below current target levels.,Cannon CP,Braunwald E,McCabe CH,et al.,N Engl J Med,2004;350:15 www.nejm.org,其他治疗,(,n=14,071),死亡率(%)*,*,Adjusted for 43 covariates,Adapted from Stenestrand U,Wallentin L.,JAMA,.2001;285:430-436.,注册后天数,400,300,200,100,0,5,4,3,2,1,5.0%,3.7%,瑞典注册研究:早期应用他汀类药治疗改善,AMI,后生存率,RR 0.75(95%CI,0.63-0.89),P,=.001,他汀治疗(,n=5,528,),AMI,二级预防血脂目标,TC 180mg/dl,LDL-C 40mg/dl,TG 150mg/dl,2004年7月12日Circulation发表的NCEP报告:新近的临床研究对NCEP ATPIII指南的影响,高危患者推荐的,LDL-C目标100mg/dl,危险度很高时,将LDL-C的目标定为70mg/dl,高危及中等高危患者建议将LDL-C水平降低30%-40%,用什么药物进行治疗更好,（Which drug is better）,分类,代表药物,HMG-CoA,还原酶,抑制剂（他汀类）,洛伐他汀；辛伐他汀,普伐他汀；氟伐他汀,阿托伐他汀；,贝特类,非诺贝特；苯扎贝特；吉非贝齐,胆酸鳌合剂(树脂类),考来烯胺；考来替哌,烟酸类,烟酸；阿西莫司,分类,TC LDLC TG HDLC,他汀类,20-40 20-60 10-50 5-10,贝特类,10-20 5-20 20-50 10-20,树脂类,15-30 15-30 5-8 3-5,烟酸类,15-25 15-30 5-8 3-5,用什么药物进行治疗更好,（Which drug is better）,ACE,抑制剂,AMI,二级预防治疗指南,年龄100mmHg者应长期服用ACEI,小剂量开始达到靶剂量或最大耐受剂量,（卡托普利150mg/d，依那普利40mg/d，雷米普利15mg/d，福辛普利10mg/d),对MI面积小或下壁MI，无明显LV功能障碍者不推荐长期应用ACEI,ACEI降低心肌梗死死亡率研究,早期治疗,CONSENSUS II,GISSI 3,ISIS 4,Chinese-Cap,高风险患者、长期治疗,SAVE (EF 40%),AIRE (临床心力衰竭),SMILE (前壁心肌梗死、未溶栓),TRACE (室壁运动评分,EF 35%),SAVE/AIRE/TRACE研究荟萃分析,年,0,0.05,0.1,0.15,0.2,0.25,0.3,0,1,2,3,0.35,0.4,4,ACEI,安慰剂,Flather MD,et al.,Lancet,.2000;355:15751581,OR:0.74(0.660.83),ACE-I:702/2995(23.4%),安慰剂,:866/2971(29.1%),ACEI可以使高危心梗的总死亡率降低26%,总死亡率,ARBs:,用于心梗后的证据,OPTIMAAL,OPtimal Trial In Myocardial infarction with,the Angiotensin II Antagonist Losartan,血管紧张素II拮抗剂氯沙坦心肌梗死最佳试验,VALIANT,VALsartan In Acute myocardial iNfarction Trial,缬沙坦急性心肌梗死试验,OPTIMAAL:,研究特征,目的,比较氯沙坦与卡托普利对高危心梗后患者的疗效,N=5,477,;,随机分为,:,卡托普利,50,mg tid,氯沙坦,50,mg qd,终点,主要终点:,所有原因死亡率,次级终点:,心源性猝死 或 复苏停搏,致死性及非致死性心梗,安全性与耐受性,25,20,15,10,5,0,终点率(%),氯沙坦,卡托普利,RR 1.13,(95%CI;0.99 1.28),p,=0.069,061218243036,月,OPTIMAAL:,所有原因死亡率,Dickstein K,et al.,Lancet,2002;360:752-60.,氯沙坦,卡托普利,20,15,0,5,10,25,终点率,0 6 12 18 24 30 36,月,RR 1.13,95%CI 0.99-1.28,P=0.069,OPTIMAAL:,结论,本研究显示氯沙坦并不比卡托普利占优势，而且也未显示出其与卡托普利等效,根据,OPTIMAAL,研究:-对这组人群不推荐使用氯沙坦,-,ACEI,仍是有并发症的急性心梗患者的一线治疗,主要终点:,总死亡率,次要终点:,心血管死亡、心肌梗死、心力衰竭,其他终点:,安全性和耐受性,卡托普利 50mg tid,(n=4909),缬沙坦 160mg bid,(n=4909),卡托普利 50mg tid+,缬沙坦 80mg bid,(n=4885),急性心肌梗死(0.510天)符合SAVE、AIRE或者TRACE研究的入选标准,(具备心力衰竭的临床/放射影象学证据和/或左室收缩功能障碍),随机、双盲、活性对照,平均随访时间:24.7月,事件驱动,VALIANT研究设计,Cap 6.25 mg,Val 20 mg,Cap 12.5 mg,Val 20 mg,Cap 25 mg,Val 40 mg,Cap 50 mg(tid),Val 80 mg(bid),联合用药,Cap 6.25 mg,Cap 12.5 mg,Cap 25 mg,Cap 50 mg(tid),卡托普利,(tid),(Cap),Val 20 mg,Val 40 mg,Val 80 mg,Val 160 mg(bid),缬沙坦,(bid),(Val),步骤,I,3个月达到目标剂量,步骤,IV,步骤,III,步骤,II,将得到证实的ACEI有效剂量作为对照,Am Heart J.,2000;140:727734,.,Pfeffer,McMurray,Velazquez,et al.N Engl J Med,2003;349,缬沙坦+卡托普利 VS.卡托普利:危险比=0.98；P=0.726,卡托普利,0,0.05,0.1,0.15,0.2,0.25,0.3,0,6,12,18,24,30,36,月,缬沙坦 VS.卡托普利:危险比=1.00；P=0.982,缬沙坦,卡托普利+缬沙坦,VALIANT研究主要终点：总死亡率,总死亡率,总死亡率非劣效性检验,0.8,1,1.2,危险比,(97.5%可信区间),1.13,P值,(非劣效性),0.002,方案治疗患者群体,(n=14,285),0.004,意向治疗患者群体,(n=14,703),非劣效性成立,缬沙坦优于卡托普利,卡托普利优于缬沙坦,非劣效性不成立,非劣效性,检验界值,非劣效性检验,首次证实ARB与ACEI作用相当,代文可降低心肌梗死高危患者死亡率达25%,死亡率危险比,利于有效药物,利于安慰剂,Pfeffer,McMurray,Velazquez,et al.N Engl J Med,2003;349,0.5,1,2,三项研究的联合死亡率,TRACE,SAVE,AIRE,VALIANT,(归因分析),缬沙坦可保 留卡托普利99.6%的生存利益,25%,卡托普利,心血管死亡、心梗或心衰的发生率,Pfeffer,McMurray,Velazquez,et al.N Engl J Med,2003;349,月,缬沙坦 VS.卡托普利:危险比=0.96；P=0.198,缬沙坦+卡托普利 VS.卡托普利:危险比=0.97；P=0.369,0,0.1,0.2,0.3,0.4,0,6,12,18,24,30,36,缬沙坦,卡托普利+缬沙坦,VALIANT研究次要终点,非劣效性成立,缬沙坦优于卡托普利,卡托普利优于缬沙坦,非劣效性不成立,缬沙坦降低心血管死亡和主要心血管事件危险与,ACEI,相当,0.8,1,1.2,危险比,(97.5%可信区间),1.13,P值,(非劣效性),非劣效性,检验界值,心血管死亡,(1657例事件),0.001,心血管死亡或心衰,(2661例事件),0.0001,心血管死亡或心梗复发,(2234例事件),0.00001,心血管死亡、,心梗复发或心衰,(3096例事件),0.000001,心血管死亡率和并发症率,研 究 结 论,针对合并心力衰竭和/或左室功能障碍的心肌梗死患者:,缬沙坦与证实剂量的卡托普利可同样有效地降低下列事件的发生危险,:,死亡,心血管死亡、非致死性心肌梗死、心衰住院,归因分析,缬沙坦,可降低心肌梗死高危患者死亡率达,25%,缬沙坦与证实剂量的卡托普利联合用药未能进一步降低死亡率,同时可能增加不良反应。,临床意义:,VALIANT研究首次证实，ARB(缬沙坦)对心肌梗死后高危患者的治疗作用与,ACEI,相当.,降低心肌梗死高危患者死亡率达25%,钙结抗剂,不主张将,CCB作为AMI的常规治疗和二级预防,对合并高血压，心绞痛，周围血管疾病的患者，如其他药物不能有效控制，可应用长效二氢吡定类或非二氢吡定类制剂,如,受体阻滞剂禁忌可用维拉帕米或地尔硫卓替代，用于心功能正常患者,抗心律失常药物,MI,后室性心律失常的大型临床试验表明I类抗心律失常药虽然抑制心律失常，但死亡率较安慰剂明显增加,负性肌力及致心律失常超过了抑制心律失常的作用,不能把抑制,AMI后的,心律失常作为治疗的最终目标,CAST-I,Echt DS.,N.Engl J Med.,1991;324:781-788.,Prognosis of Post-MI Patients Treated with,Placebo vs.Encainide/Flecainide,80,85,90,95,100,0,91,182,273,364,455,Days After Randomization,Patients Without Event(%),Placebo(n=743),Encainide or Flecainide(n=755),P=0.001,CAST-II,CAST-II Investigators.N Engl J Med.1992;327:227-233.,Moricizine,100,80,60,40,20,0,0,1,2,3,Year,Adjusted P=0.40,Survival(%),Placebo,No.at risk(%surviving),Placebo,Moricizine,574(100),581(100),351(95.2),350(94.9),175(89.6),181(88.8),56(88.0),56(85.0),Absence of Benefit of Moricizine Over Placebo,抗心律失常药物,EMIAT,(The European myocardial infarction amiodarone trial),CAMIAT,(Canadian amiodarone myocardial infarction arrhythmia trial),胺碘酮可减少MI后室性心律失常,降低伴/不伴LV功能障碍患者的心律失常死亡和,心脏骤停,总死亡率无影响,FACTOR,EMIAT,1,CAMIAT,2,Protocol,Amiodarone vs.placebo,Amiodarone vs.placebo,Patient characteristics,Poor LV function,(LVEF,10 VPDs/hr),Recruitment,5-21 days post-MI,6-45 days post-MI,Risk reduction of arrhythmic death at 24 months,35%,48.5%,All-cause mortality at 24 months,No difference,No difference,1,Julian DG.,Lancet.,1997;349:667-674.,2,Cairns JA.,Lancet.,1997;349:675-682.,While amiodarone was effective in reducing arrhythmic death,it did not reduce total morta