冠心病治疗-2008.ppt

Prof.Yean L.Lim AMProfessor&Director,Center for Cardiovascular TherapeuticsWestern HealthUniversity of MelbourneQianjiang PCI MeetingHangzhou,1 Aug 2008CAD Therapy 2008PCI for CAD:2008 ConsiderationsRevascularization Therapy for CAD,Who&When?If Revascularization indicated,PCI or CABG?If PCI,DES or BMS?Complex PCI Strategy(STEMI,LM,MVD,Diabetic,Bifurcation CTO)“Treats Patients Not Lesions”Stable Angina:Maximal Medical Therapy,deferred PCI穩定心絞穩定心絞痛痛:药物治疗後介入药物治疗後介入ACS:Early PCI,especially High-Risk Pts急性冠脈綜合症急性冠脈綜合症:介入介入(高危高危)+葯物治疗葯物治疗治病人治病人 不只治病変不只治病変PCI for CAD:2008 ConsiderationsRevascularization therapy for CAD,Who&When?If Revascularization indicated,PCI or CABG?If PCI,DES or BMS?Complex PCI Strategy(STEMI,LM,MVD,Diabetic,Bifurcation CTO)Which Revascularization?Vessel&Lesion Factors(Lesion Complexity)Patient Factors(Diabetes,Renal)Secondary Factors(Costs,Culture)Immediate Risk&Long-term BenefitSVD,Suitable Lesion(s)PCI Technically FeasibleIncomplete Revasc,TLRMVD,PCI Risk CABGComplete RevascBetter Long-term ResultPCICABGPre-DES PCI vs CABG(Angina Relief)Pre-DES PCI vs CABG(Mortality)DES PCI vs CABG(Mortality)DES PCI vs CABG(MACCE)DES PCI vs CABG in MVDHospital&Doctors Clinical Outcomes Matter PCI for CAD:2008 ConsiderationsRevascularization therapy for CAD,Who&When?If Revascularization indicated,PCI or CABG?If PCI,DES or BMS?Complex PCI Strategy(STEMI,LM,MVD,Diabetic,Bifurcation CTO)BMS or DES Safety Risk of Late Stent Thrombosis,Death,MI StettlerStettler C.,et al.,Lancet 2007;370:937-48.C.,et al.,Lancet 2007;370:937-48.Efficacy of DESReduced Target Lesion RevascularizationNetwork AnalysisHR 0.70Windecker S,ACC 2008 ChicagoPCI for CAD:2008 ConsiderationsRevascularization therapy for CAD,Who&When?If Revascularization indicated,PCI or CABG?If PCI,DES or BMS?Complex PCI Strategy(STEMI,LM,MVD,Diabetic,Bifurcation CTO)Kastrati ACC 2008Clopidogrel600mg as early as possible could be helpfulAbciximabstill needed for high-risk ptsFacilitationUpstream GP2b3a Inhibitorno clinical benefit over in labFull-dose fibrinolyticsHarmfulHalf-dose lytic+GP2b3a InhHarmfulPrimary PCI for STEMI STEMI介入特点介入特点 多取岀 少放入BMS or DES for Primary PCI for STEMIWhen to use DES for PPCIEarly onset STEMIHigh risk of restenosisAfter Thrombo-aspirationAfter Pre-dilatationUNPROTECTED LEFT MAIN LESIONUnprotected LM:PCI or CABGFuture of PCI for CADPCI Milestones:1977:POBA1990:BMS2000:DES2008:?Bioabsorbable DESOCT of BVS stent:Normal vessel function after 2 yearsP.Serruys,Great Minds Symposium,Cairns,July 2008Conclusion Early PCI for ACS but deferred PCI for Stable Early PCI for ACS but deferred PCI for Stable Angina,unless large reversible ischemic burden Angina,unless large reversible ischemic burden presentpresentPCI for all who need revascularization except PCI for all who need revascularization except Diabetics,ULM or when where CABG is Diabetics,ULM or when where CABG is contraindicated or unavailablecontraindicated or unavailableThrombus aspiration followed by Thrombus aspiration followed by stentingstenting(?DES)(?DES)for Primary PCI for eligible STEMIfor Primary PCI for eligible STEMIPCI for CTO should not be based only on anatomyPCI for CTO should not be based only on anatomyBioabsorbableBioabsorbable stentsstents?Next PCI breakthrough?Next PCI breakthrough Thank You