ACS治疗原则专题知识.pptx

Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,The Management of Acute Myocardial Infarction,北京协和医院急诊科,朱华栋,ACS治疗原则专题知识,第1页,Early Repolarization,Brugada Syndrome,Anterior AMI,Prinzmetal Angina,Pericarditis,Acute Inf.AMI,ST Segment Elevation(Transmural ischemia),Non-infarct ST Elevation,ACS治疗原则专题知识,第2页,ST Segment Depression(Non-transmural ischemia),ST Depression,NSTEMI,T wave inversion,NSTEMI,ACS治疗原则专题知识,第3页,ACS治疗原则专题知识,第4页,NSTE ACS:Key Themes,NSTE ACS:a high risk population,patient risk,benefit from treatment with medications,an invasive strategy,Interaction between invasive strategy and pharmacologic tx,Antithrombotics cornerstone of treatment,Anticoagulants:heparin,LMWH,direct thrombin inhibitors,Antiplatelet agents:aspirin,IIb/IIIa,ADP inhibitors,ACS治疗原则专题知识,第5页,Antman EM et al N Engl J Med 1996;335:1342-9,ACS治疗原则专题知识,第6页,Invasive vs.Conservative Strategy for ACS,Death or(re)-MI,Trial N PCI Cons,RITA 3 1810 7.6 8.3,VINO 131 6.3 22.4,TACTICS 2220 7.3 9.5,TRUCS 148 7.6 16.7,FRISC II 2451 10.4 14.1,MATE 201 9.9 6.7,VANQUISH 920 24.0 12.2,Overall 7876,Fox,Lancet 360:743 03,Death/(re)Infarction,RR=0.88,p=0.05,Intervention better,0.1 0.2 0.3 0.5 0.7 1.0 1.5 2.0,Death/(re)-MI,ACS治疗原则专题知识,第7页,CP971744-45,%,Cons,Inv,TACTICSTIMI 18,TnT cut point=0.01 ng/mL (54%of pt TnT+),Troponin T:Death,MI,Rehosp ACS,6 Months,OR=0.52,*P0.001,Interaction,P0.001,P=NS,*,n=414,n=396,n=463,n=495,ACS治疗原则专题知识,第8页,Benefits of an Invasive Strategy in Non-ST Elevation ACS,Only shown to reduce death and MI in high risk pts,Reduces re-hospitalization,angina in many others,Shortens hospitalization,may be cost effective,What about the optimal timing of an invasive strategy?,ACS治疗原则专题知识,第9页,Medical Tx for 72-170 hr,Then,cath lab,n=207,Cath lab,6 hr,n=203,ISAR-COOL,CP1107655-4,Neumann FJ et al JAMA,67%had,troponin,65%had ST depression,Aspirin,500 mg,100 mg bid,Clopidogrel,600 mg,75 mg bid,Tirofiban,10 mg/kg bolus,0.10 mg/kg/min infusion,Heparin,(PTT 60-85 seconds),Non-ST,Acute Coronary Syndrome,troponin or ST depression,n=410,ACS治疗原则专题知识,第10页,ISAR-COOL,Primary Endpoint,CP1107655-2,30-day,event rate,(%),Death&MI,Death,Neumann FJ et al JAMA,P=0.04,P=0.23,P=0.12,P=0.56,Any nonfatal MI,Nonfatal Q-wave MI,RR 1.96(1.01-3.82),Cooling off(n=207),Early intervention(n=203),ACS治疗原则专题知识,第11页,Timing of an Invasive Strategy in Non-ST Elevation ACS,ISAR-REACT was a small,single center study.Clinical trials are still going on.,Other analyses also indicate that cath within 24 hours is better than later cath,Ought to use intensive antiplatelet therapy with a very early invasive strategy,What medical therapy ought to be used in ACS?,ACS治疗原则专题知识,第12页,Antithrombotic Trialists Collaboration,.BMJ.,;324:7186,.,OR*,0.5,1.0,1.5,2.0,500,1500 mg,34 19,160,325 mg,19 26,75,150 mg,12 32,75 mg,3 13,Any aspirin,65 23,Antiplatelet Better,Antiplatelet Worse,Aspirin DoseNo.of Trials(%),Odds Ratio,0,Aspirin Dose and Events in High-Risk Pts,Frequency of CV Death,MI,Stroke,P=0.0001,ACS治疗原则专题知识,第13页,CURE,CP999547-2,Yusuf S et al NEJM;16:494-502,Non-ST elevation ACS,12,562 patients,ASA 75 to 325 mg po qd,placebo,n=6,303,3-12 month follow-up,(average 9 mo),ASA+clopidogrel,(300 mg load,75 mg qd),n=6,259,ACS治疗原则专题知识,第14页,CURE,CV Death/MI/Stroke,1 Year,CP999731-3,CV death,MI,stroke(%),Clopidogrel(n=6,303),Placebo(n=6,259),P=0.00003,Days after enrollment,ACS治疗原则专题知识,第15页,CURE,Eventrate(%),RR 0.80,P=0.00005,CP995058-6,CV death,MI,stroke,Clopidogrel(n=6,259),Placebo(n=6,303),Aspirin and,CVdeath,MI,Stroke,Non-CVdeath,RR 0.92,P=NS,RR 0.77,P0.001,RR 0.85,P=NS,RR 0.96,P=NS,ACS治疗原则专题知识,第16页,CURE,Major/Life-Threatening Bleeds in the 7 Days After CABG,Placebo,Clop,RR,p,Stopped,5g/dl,hypotension(inotropes),surgery to stop bleeding,symptomatic ICH or transfusion 4 units,ACS治疗原则专题知识,第17页,ACC/AHA ACS Guideline Update,Class I,Aspirin 75 to 325 mg/day(level of evidence:A),ASA and clopidogrel for 9 months after NSTE ACS(level of evidence:B),Class 3,Do not administer clopidogrel in the 5 days before CABG,Braunwald E,et al.,www.acc.org,ACS治疗原则专题知识,第18页,Heparin(UF or LMW)in ACS Without ST,Death or MI,UFH or LMWH,Control,OR95%CI,Theroux2/122(1.6%)4/121(3.3%)0.500.10-2.53,Cohen0/371/32(3.1%)0.120.01-5.89,RISC3/210(1.4%)7/189(3.7%)0.400.11-1.39,Cohen4/105(3.8%)9/109(8.2%)0.460.15-1.41,Holdright*42/154(27.3%)40/131(30.5%)0.850.51-1.43,Gurfinkel4/70(5.7%)7/73(9.6%)0.580.17-1.98(UFH),Gurfinkel0/687/73(9.6%)0.130.03-0.60(LMWH),FRISC4/70(5.7%)36/757(4.8%)0.390.22-0.68,UFH vs55/698(7.9%)68/655(10.4%)0.670.45-0.99placebo/control,LMWH vs13/809(1.6%)43/830(5.2%)0.340.20-0.58placebo,Total,68/1507(4.5%)104/1412(7.4%)0.530.38-0.73,Only RCTs,placebo or untreated controlsEikelboom JW et al:Lancet 55:1936-42,CP951342-1,0.1,Heparin better,1.0,10.0,Control better,ACS治疗原则专题知识,第19页,Trial:,FRIC,(dalteparin;n=1482),FRAXIS,(nadroparin;n=2357),ESSENCE,(enoxaparin;n=3171),TIMI IIB,(enoxaparin;n=3910),.751.01.5,(,P,=0.032),(,P,=0.029),Braunwald E et al.,Circulation,;102:1193-1209,LMWH,Better,UFH,Better,LMWH versus UFH in UA/NSTEMI Managed Non-invasively:,Effect on Death,MI,Recurrent Ischemia,ACS治疗原则专题知识,第20页,CLASS Ia,（,Ia,级推荐）,一旦出现,UA/NSTEMI,，需尽快在抗血小板治疗基础上给予患者抗凝药品。,a.,介入方案：证据级别,A-,包含,依诺肝素,和普通肝素；证据级别,B-,包含比伐卢定和戊聚糖钠,b.,保守方案：药品选择能够是,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。,c.,对于选择保守治疗病人，假如有较高出血风险，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,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,）,年,ACC/AHA UA/NSTEMI,指南,抗凝治疗推荐,ACS治疗原则专题知识,第21页,ACC/AHA,更新抗凝治疗指南,高危或确诊,ACS,实施导管或,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,氯吡格雷,氯吡格雷,阿司匹林,*,证据等级,Ia,：依诺肝素优于,IV UFH,ACS治疗原则专题知识,第22页,ACC/AHA,治疗提议,“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取。,(,证据级别,A)”,update ACC/AHA guideline,ACS治疗原则专题知识,第23页,ACCP7,指南对,LMWH,治疗提议,急性期,LMWH,优于,UFH,（,1B,级）；,LMWH,治疗时不需常规监测（,1C,级）；,已使用,LMWH,患者如需进行,PCI,，应继续使用,LMWH,（,2C,级）；,应用,GPIIb/IIIa,受体拮抗剂者，,LMWH,安全性优于,UFH,（,2B,级）。,NSTE ACS,患者中,LMWH,疗程评价是：,NSTE ACS,患者应早期介入治疗，假如冠脉干预延迟，可考虑延长,LMWH,治疗作为血运重建“桥梁”。,ACS治疗原则专题知识,第24页,Rest pain,5 min and,ST,0.1 mV,or,Documented CAD,or,CK-MB,N=132,Heparin,70 U/kg bolus,+,15 U/kg/hr infusion,Bivalirudin,0.1 mg/kg bolus,+,0.25 mg/kg infusion,TIMI-8:Bivalirudin vs.Placebo in ACS,ACS治疗原则专题知识,第25页,TIMI-8:Bivalirudin vs.Placebo in ACS,4-6 wks,7 days,4-6 wks,7 days,p=0.008,p=0.024,p=NS,p=NS,ACS治疗原则专题知识,第26页,ACS治疗原则专题知识,第27页,Beta Blockers,Reduce CV death,MI,stroke by 25-30%in high risk pts,Not well studied in non-STE ACS,Reduce heart rate,blood pressure,ischemia,chest discomfort,Class 1 indication;quality indicator,Use in everyone without contraindications,ACS治疗原则专题知识,第28页,15.7,5.6,17.9,11.7,12.8,14.2,3.8,12.9,10.3,11.8,0,5,10,15,20,Primary Endpoint%,Placebo,GP IIb/IIIa,PURSUIT30 days,PRISM48 hrs,PRISM PLUS7 days,P=0.04,P=0.01,P=0.004,PARAGON A30 days,P=0.48,PARAGON B30 days,P=0.33,Platelet GP IIb/IIIa Inhibition for Non-ST ACS,Primary Endpoint Results from the 5 Major RCTs,ACS治疗原则专题知识,第29页,1.0,2.0,0.25,All PCI trials17,3930.668.55.6,All ACS trials24,3110.8912.811.4,ACS troponin(+)1,3680.4216.36.9,ACS PCI2,3110.6614.49.6,ACS no PCI12,6850.9314.313.3,ACS troponin()2,9011.056.26.5,IIb/IIIa Meta-Analysis,30-Day Death,MI at 30 Days,CP944328-1,RelativeriskPlaceboIIb/IIIaNo.ratio(%)(%),Chew DP et al:JACC;36:2028 35,IIb/IIIa better,Placebo better,ACS治疗原则专题知识,第30页,IIb/IIIa Inhibitors in ACS Patients,Greatest benefit is during PCI,If pursuing a non-invasive strategy,recommend treating pts with elevated troponins,high TIMIscores,etc;probably those with diabetes,marked ST segment shifts,Do not recommend their routine administration to all ACS pts in whom a non-invasive strategy is planned,ACS治疗原则专题知识,第31页,Conclusions,Much remains to be learned about the optimal medical therapy for ACS pts,The data favor an invasive strategy,and suggest different medications and doses ought be administered if pursuing an invasive vs.non-invasive strategy,and in high vs.low risk pts,ACS治疗原则专题知识,第32页,UA/NSTEMI:Pharmacological and Mechanical Intervention,Braunwald E et al.,J Am Coll Cardiol,;36:970-1062,Braunwald E et al.,Circulation,;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,3-4,ASA+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,/,危险评定,缺血,二级预防,无缺血,ACS治疗原则专题知识,第33页,Algorithm for Patients with UA/NSTEMI Managed by an Initial Invasive Strategy,Proceed to Diagnostic Angiography,ASA(Class I,LOE:A),Clopidogrel if ASA intolerant(Class I,LOE:A),Diagnosis of UA/NSTEMI is Likely or Definite,Invasive Strategy,Initiate 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 Strategy,Proceed with an Initial Conservative Strategy,Anderson JL.J Am Coll Cardiol.,In press.Figure 7,A,B,B1,B2,Prior to Angiography,Initiate at least one(Class I,LOE:A)or,both(Class IIa,LOE:B)of the following:,Clopidogrel,IV GP IIb/IIIa inhibitor,Factors favoring admin of both clopidogrel and GP IIb/IIIa inhibitor include:,Delay to Angiography,High Risk Features,Early recurrent ischemic discomfort,ACS治疗原则专题知识,第34页,Initiate clopidogrel(Class I,LOE:A),Consider adding IV eptifibatide or tirofiban(Class IIb,LOE:B),Conservative Strategy,Initiate A/C Rx(Class I,LOE:A):Acceptable options,:,enoxaparin,or UFH(Class I,LOE:A)or fondaparinux(Class I,LOE:B),but enoxaparin or fondaparinux are preferable(Class IIA,LOE:B),Select Management Strategy,ASA(Class I,LOE:A),Clopidogrel if ASA intolerant(Class I,LOE:A),Diagnosis of UA/NSTEMI is Likely or Definite,Algorithm for Patients with UA/NSTEMI Managed by an Initial Conservative Strategy,Proceed with Invasive Strategy,(Continued),Anderson JL.J Am Coll Cardiol.In press.Figure 8,C2,C1,A,ACS治疗原则专题知识,第35页,Evidence for Primary PCI as,Treatment of Choice for STEMI ACS,ACS治疗原则专题知识,第36页,Summary of 23 Randomized Trials,(n=7739),p=0.0003,p0.0001,p=0.0004,p0.0001,OR=0.57,Keeley&Grines Lancet,PCI,Lytic,Risk Reduction,Death28%,Death/MI/CVA43%,Primary PCI:,The Preferred Reperfusion Strategy,ACS治疗原则专题知识,第37页,Primary,Transfer,Facilitated&Rescue PCI for STEMI,Primary PCI,(PPCI),Direct to CVL for PCI reperfusion therapy,Transfer PCI,Pts transferred from hospitals without PCI facilities(,no,lysis,)to a PCI centre,Facilitated PCI,Patients receiving thrombolysis*followed by intentional PCI,Rescue PCI,PCI after failed thrombolysis(at 90 mins),*,Thrombolysis may be Pre-hospital,ACS治疗原则专题知识,第38页,ACS治疗原则专题知识,第39页,ACS治疗原则专题知识,第40页,Door-To-Balloon(DTB)Time&Choice of Reperfusion Therapy in STEMI,Sx onset 60 min,Sx onset 3 hrs 12hr:,No lysis but PCI may still be beneficial,ACS治疗原则专题知识,第41页,Evidence for Pre-Hospital Thrombolysis,for Early(2 Hour)STEMI,ACS治疗原则专题知识,第42页,Evidence to support Transfer to PCI Centers from,Hospitals without PCI facilities for STEMI ACS,ACS治疗原则专题知识,第43页,Evidence Against Facilitated PCI for STEMI ACS,ACS治疗原则专题知识,第44页,Evidence for Resue PTCA after failed fibrinolysis(RESCUE I trial),PTCA,No PTCA,P=0.001,12,6,0,62,36,24,48,0.6,0.7,0.8,0.9,1.0,Time,(weeks),Ellis,Am Heart J;139:1046,A.II.030,%Survival,ACS治疗原则专题知识,第45页,Options for Patients with Prolonged Transfer Times,Full dose fibrinolytic with elective transfer or for rescue,Full dose fibrinolytic with routine transfer and rescue as needed,Primary PCI(no matter how long it takes),Facilitated PCI,All of the above:Depending on the time of day and which cardiologist is on call!,ACS治疗原则专题知识,第46页,ESC Guidelines for STEMI,ACS治疗原则专题知识,第47页,LATE RECANALIZATION OF,INFARCT-RELATED ARTERY,BENEFITS,RISKS,Prevention of remodellingRisks of PCI,&improved LV function,Decreased Vent.Arryhthm.Risk of Restenosis,Enhance collaterals,ACS治疗原则专题知识,第48页,ACS,临床策略,体格检验，,ECG,，试验室检验,连续,ST,段抬高,非连续,ST,段抬高,诊疗不明确,溶栓，,PCI,肝素（,LMWH,，,UFH,），,ASA,，,氯吡格雷，,beta,阻滞剂，硝酸盐,ASA,高危,低危,GP IIb/IIIa,冠脉造影,第,2,次肌钙蛋白测定,阳性,两次阴性,运动试验，冠脉造影,PCI,，,CABG,或依据临床及造影结果选择治疗方案,NST-AMI ACS Task Force,ESC,ACS治疗原则专题知识,第49页,AMI,治疗关键：心肌再灌注治疗,时间就是心肌,尽早，充分，连续开通与梗死相关血管,药品抗栓治疗（抗凝和抗血小板）,ACS治疗原则专题知识,第50页,THANK,YOU,ACS治疗原则专题知识,第51页,