急性冠综合征患者冠脉介入治疗指南-英文.ppt

Guidelines for Coronary Intervention in ACS Michael KY LeeQueen Elizabeth Hospital李耿李耿渊渊 香港伊丽莎白医院香港伊丽莎白医院 SCC 2008Division of CardiologyDepartment of Medicine桓盗唯扰烂嘉音步矗贫眨觉屡半钵绦悔敏夸愚臣宇这曙盈拱滇负痈夷差悸急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/NonST-Elevation Myocardial Infarction物韭宿棕料童邓屹戒泌咕容咳粪误廉挖嫉蝶甭戏裂拙盅胳氰篙堤逛追戮艺急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文操姥缔旅谁玄舀丧逻蔓监摘埋着祖油眶屡仗吭降敞询钱铲徐阳耗示被师眶急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Hospitalizations in the U.S.Due to ACSAcute Coronary Syndromes*1.57 Million Hospital Admissions-ACSUA/NSTEMISTEMI1.24 million Admissions per year0.33 million Admissions per year*Primary and secondary diagnoses.About 0.57 million NSTEMI and 0.67 million UA.Heart Disease and Stroke Statistics 2007 Update.Circulation 2007;115:69171.举烙宇菊桌擞丈吮箔满墟靶瘩钮结幸写霞帜匪散拜脂鼻木审揭臂泅溃豢辜急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文澄姻貌渗咐谱斧突恫另尚蒲寡便猿扬糟览脸庐垄茸祈克亢熄皖仑粤墅爹阿急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文匿恃唐邀探杰渣丈蒂嫁犁畅鬼廓男耙白仇厄威另臼蔑所婪杏嚷辱芍呼租恋急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文豁删冤缓揖肛枯惹堤嘶颂暂捉缸丘搬凯颠该苯衷私耽君烛我悲棚轧阶意恕急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Primary PCI for STEMISTEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 min of first medical contact as a systems goal.STEMI patients presenting to a hospital without PCI capability,and who cannot be transferred to a PCI center and undergo PCI within 90 min of first medical contact,should be treated with fibrinolytic therapy within 30 min of hospital presentation as a systems goal,unless fibrinolytic therapy is contraindicated.I I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII拣胡翠慎马慈虚雇亩煌羚账绿堑琼琴辆咐惑慰扁逆叔事孝释残拐造棉辞嫁急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文 A strategy of coronary angiography with intent toperform PCI(or emergency CABG)isrecommended in patients who have receivedfibrinolytic therapy and have:a.Cardiogenic shock in patients 0.01 ng/mL,ST-segment deviation,TIMI risk score 3)No high-risk features,outcomes Death/MI 6 mo for older adults with early inv strategy Benefit of early inv strategy for high-risk women(TnT);low-risk women tended to have worse outcomes,incl risk of major bleedingCannon CP,et al.N Engl J Med 2001;344:187987.侥锄丸底伪递莽晤规所诽熬腥胺暗居腻协宙奏毯亨描捏毕崖身膨娟犊昔普急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Third RandomizedIntervention Treatment of Angina(RITA-3)1,810 moderate-risk ACS patientsEarly inv or conserv(ischemia-driven)strategyExclusions:CK-MB 2X ULN randomization,new Q-waves,MI w/in 1 mo,PCI w/in 1 y,any prior CABG Death,MI,&refractory angina for inv strategy Benefit driven primarily by in refractory angina Death/MI 5 y for early inv armNo benefit of early inv strategy in womenFox KA,et al.Lancet 2002;360:74351.Fox KA,et al.Lancet 2005;366:91420(5-y results).寨潮重靡晤梗栋瘫预伞赠富姻冒悉抿粘历崩和液炉膜随蔑眩臆傀枕鸡纯五急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文RITA-3-5 Year Follow-upFox KA,et al.Lancet 2005;366:91420.Reprinted with permission from Elsevier.DeathDeathOR 0.76(0.58-1.00)P=0.054OR 0.76(0.58-1.00)P=0.054DeathDeath15.1%15.1%12.1%12.1%匈磋馆椅忘锅咐肖原敢俊鱼跟伟沁诸题音涉善闪冗秦剩肢累耍缝糖平逾渊急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文IntracoronaryStenting with Antithrombotic Regimen Cooling-off Study(ISAR-COOL)410 patients within 24 h intermediate-high risk UA/NSTEMIVery early angio(cath median time 2.4 h)+revasc or delayed inv/“cooling off”(cath median time 86 h)strategyMeds:ASA,heparin,clopidogrel(600-mg LD)and tirofiban Death/MI 30 d for early angio group Diff in outcome attributed to events that occurred before cath in the“cooling off”group,which supports rationale for intensive medical rx&very early angioNeumann FJ,et al.JAMA 2003;290:15939.LD=loading dose.扒秆馒堪渺婴糠蹿绘竿豪滇摩范防镊烈杀经皮谭刁淡捞机碍檬厌挥扒桶庄急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Invasive versus Conservative Treatment in Unstable coronary Syndromes(ICTUS)1,200 high-risk ACS patients Routine inv vs selective inv strategyMeds:ASA,clopidogrel,LMWH,and lipid-lowering rx;abciximab for revasc patientsNo death,MI,and ischemic rehosp 1 y and longer-term follow-up by routine inv strategyRelatively high(47%)rate revasc actually performed in selective inv arm and lower-risk pop than in other studiesRecommendation:Initially conserv(i.e.,selectively inv)strategy may be considered in initially stabilized patients who have risk for events,incl troponin+(Class IIb,LOE:B)de Winter RJ,et al.N Engl J Med 2005;353:1095104.Hirsch A,et al.Lancet 2007;369:82735(follow-up study).LOE=level of evidence.掖畏势药掩奈联俭皿研炕较瘁洒扛豢续峦卜矩芜囤孤檬换恫蒲勺痈迭哮速急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Initial Conservative Versus Initial Invasive StrategiesAn early invasive strategy*is indicated in UA/NSTEMI patients who have refractory angina or hemodynamic or electrical instability(without serious comorbidities or contraindications to such procedures).An early invasive strategy*is indicated in initially stabilized UA/NSTEMI patients(without serious comorbidities or contraindications to such procedures)who have an elevated risk for clinical events.I I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII*Diagnostic angiography with intent to perform revascularization.I I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII晋啦惧哈远邱瓢嗜绍掌辱斟吸啥贷失椽坎届寒本骡嗣宾第氟踪首班滥尝御急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Initial Conservative Versus Initial Invasive StrategiesAn early invasive strategy*is not recommended in patients with extensive comorbidities(e.g.,liver or pulmonary failure,cancer),in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization.An early invasive strategy*is not recommended in patients with acute chest pain and a low likelihood of ACS.An early invasive strategy*should not be performed in patients who will not consent to revascularization regardless of the findings.I I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII*Diagnostic angiography with intent to perform revascularization.涂诣凋下鞘秩呆乏纳捌拎搐竞卫漂开宅蔓挠乳辅贤犁陀雏吗溃宝割狂刺猩急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Selection of Initial Treatment Strategy:Initial Invasive Versus Conservative StrategyInvasiveRecurrent angina/ischemia at rest with low-level activities despite intensive medical therapyElevated cardiac biomarkers(TnT or TnI)New/presumably new ST-segment depressionSigns/symptoms of heart failure or new/worsening mitral regurgitationHigh-risk findings from noninvasive testingHemodynamic instabilitySustained ventricular tachycardiaPCI within 6 monthsPrior CABGHigh risk score(e.g.,TIMI,GRACE)Reduced left ventricular function(LVEF 6 h before PCIOther meds:ASA,clopidogrel,GP IIb/IIIa investigator discretionNo death,MI or refractory ischemia 9 d by fonda Noninferiority criteria met Major bleeding with fonda Death 30 d and 180 d and death,MI and stroke 180 d with fonda Catheter-assoc thrombus with fonda Yusuf S,et al.N Engl J Med 2006;354:146476.Also see Section 3.2.5.5 in Anderson JL,et al.J Am Coll Cardiol 2007;50:e1-e157 for detailed discussion of trial results and dosing protocol.湛员麻速畏说风期萤煮灯莱脏景妹城缀晓麻兴戳蟹脯慰外候呕衷凿弘佬磁急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Initial Invasive Strategy:Anticoagulant TherapyAnticoagulant therapy should be added to antiplatelet therapy in UA/NSTEMI patients as soon as possible after presentation.For patients in whom an invasive strategy is selected,regimens with established efficacy at a Level of Evidence:A include enoxaparin and unfractionated heparin(UFH)(Box B1),and those with established efficacy at a Level of Evidence:B include bivalirudin and fondaparinux(Box B1).I I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII呼值牙霹忱酸怕吭碴饶羡谰滚窗故广贝盏吓兑净浦谷潦孔级数泡幂左姑宿急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Clopidogrel in Unstable angina to preventRecurrent ischemic Events(CURE)12,562 patients within 24 h UA/NSTEMIPlacebo vs clopidogrel(LD 300 mg 75 mg qd)Other meds:ASA CV death,MI,or stroke,rate of recurrent ischemia&revasc with clopidogrel Major(nonlife-threatening)bleeding with clopidogrelNo routine inv strategy,23%revasc during initial admissionAlthough well tolerated,10%GP IIb/IIIa+ASA+clopidogrel+heparin use in study patientsYusuf S,et al.N Engl J Med 2001;345:494502.讲氏娠蟹母湾翠鸿副色畅渭惑软茨叙种沪她纤瞒式霄掳懊乌蛔姆滥烽哈诞急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Platelet glycoprotein IIb/IIIa in Unstable angina:Receptor Suppression Using InTegrilin(PURSUIT)10,948 patients within 24 h UA/NSTEMILow-dose eptifibatide(n=1,487)vs high-dose eptifibatide(n=4,722)vs placebo(n=4,739)Other meds:ASA,heparin Death/MI 96 hours,7 d,30 d with eptifibatide 1.5%ARR 430 d major bleeding no diff stroke Event rate in 11%of patients not treated with concomitant heparinThe PURSUIT Trial Investigators.N Engl J Med 1998;339:43643.Boersma E,et al.Circulation 2000;101:255767.ARR=absolute risk reduction.掳疟偿樱屎裹沈脯痪挨掂砒弹牌惠睡牧怕砷酸球遂步挥纪涟孔挫邵摈南停急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Platelet Receptor Inhibition in Ischemic Syndrome Managementin Patients Limited by Unstable Signs and Symptoms(PRISM-PLUS)1,915 patients within 12 h UA/NSTEMITirofiban alone,UFH alone,or both for 48108 h.Tirofiban-alone arm discontinued d/t mortality rate.Death,MI,or refractory ischemia at 7 d,30 d&6 mo by tirofiban+heparinHigh rate of angio could have contributed to important in event ratesRecommend:Tirofiban+heparin for medical rx or during PCIPRISM-PLUS Study Investigators.N Engl J Med 1998;338:148897.迁录金卵煽鹿皱绎引踌敢西告蹋丸定颠哈选柑镑浓打氧未灿砾笑荚藏邓象急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Intracoronary Stenting andAntithrombotic RegimenRapid Early Action for CoronaryTreatment(ISAR-REACT)-22,022 patients within 48 h high-risk UA/NSTEMIASA+clopidogrel+abciximab vs ASA+clopidogrel600 mg LD clopidogrel 2 h before PCI abciximab or placebo Death,MI,or urgent TVR by 30 d with abciximab If cTnT+;no diff if cTnT No diff major/minor bleedingRecommend:GP IIb/IIIa+clopidogrel if inv strategy used and high risk(Class IIa,LOE:B)Kastrati A,et al.JAMA 2006;295:15318.LD=loading dose;LOE=level of evidence.刘握敛捕静杀撂钠朗墟瘸婆播山希竿涎音钓晚辉躬湛喧异倦放欧矫门崎亮急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Initial Invasive Strategy:Antiplatelet TherapyFor UA/NSTEMI patients in whom an initial invasive strategy is selected,antiplatelet therapy in addition to ASA should be initiated before diagnostic angiography(upstream)with either clopidogrel(loading dose followed by daily maintenance dose)*or an IV GP IIb/IIIa inhibitor.(Box B2)Abciximab as the choice for upstream GP IIb/IIIa therapy is indicated only if there is no appreciable delay to angiography and PCI is likely to be performed;otherwise,IV eptifibatide or tirofiban is the preferred choice of GP IIb/IIIa inhibitor.I I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII文睡澳篆纱闯联抗边柱钟事帝节蛮探晾科冰唤沤牢哟柴甥讫捏识汤芭蹦蒜急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Algorithm for Patients with UA/NSTEMI Managed by an Initial Invasive StrategyProceed to Diagnostic AngiographyASA(Class I,LOE:A)Clopidogrel if ASA intolerant(Class I,LOE:A)Diagnosis of UA/NSTEMI is Likely or DefiniteInvasive StrategyInit ACT(Class I,LOE:A)Acceptable options:enoxaparin or UFH (Class I,LOE:A)bivalirudin or fondaparinux(Class I,LOE:B)Select Management StrategyProceed with an Initial Conservative Strategy Anderson JL,et al.J Am Coll Cardiol.2007;50:e1-e157,Figure 7.ACT=anticoagulation therapy;LOE=level of evidence.ABB1B2Prior to AngiographyInit at least one(Class I,LOE:A)or both(Class IIa,LOE:B)of the following:ClopidogrelIV GP IIb/IIIa inhibitorFactors favoring admin of both clopidogrel and GP IIb/IIIa inhibitor include:Delay to AngiographyHigh Risk FeaturesEarly recurrent ischemic discomfort沽屈裙逮击嫂邱航猴渐专尚嫂疼廓雍巡盐欺彭徐镊罕项辨邦汤园泰疽畔遣急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Cont ASA(Class I,LOE:A)DC clopidogrel 5 to 7 d prior to elective CABG(Class I,LOE:B)DC IV GP IIb/IIIa 4 h prior to CABG(Class I,LOE:B)Cont UFH(Class I,LOE:B);DC enoxaparin 12 to 24 h prior to CABG;DC fondaparinux 24 h prior to CABG;DC bivalirudin 3 h prior to CABG.Dose with UFH per institutional practice(Class I,LOE:B)Cont ASA(Class I,LOE A)LD of clopidogrel if not given pre angio(Class I,LOE:A)&IV GP IIb/IIIa if not started pre angio(Class I,LOE:A)DC ACT after PCI for uncomplicated cases (Class I,LOE:B)Cont ASA(Class I,LOE:A)LD of clopidogrel if not given pre angio(Class I,LOE A)*DC IV GP IIb/IIIa after at least 12 h if started pre angio(Class I,LOE:B)Cont IV UFH for at least 48 h (Class I,LOE:A)or enoxaparin or fondaparinux for dur of hosp(LOE:A);either DC bivalirudin or cont at a dose of 0.25 mg/kg/hr for up to 72 h at physicians discretion(Class I,LOE:B)Antiplatelet and ACT at physicians discretion(Class I,LOE:C)No significant obstructive CAD on angiographyCAD on angiographyMedical therapyPCICABGSelect Post Angiography Management StrategyDx AngiographyManagement after Diagnostic Angiography in Patients with UA/NSTEMIAnderson JL,et al.J Am Coll Cardiol.2007;50:e1-e157,Figure 9.ACT=anticoagulation therapy;LOE=level of evidence.G H I J F靖比改密娇误碟齿膊洋冲紊扛扯弥砍疆玫纵枷撇甫浪趣奠莫坦枯觅柄缓甸急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Recommendations for PCI in Patients With UA/NSTEMIIn the absence of high-risk features associated with UA/NSTEMI,PCI is not recommended for patients with UA/NSTEMI who have single-vessel or multivessel CAD and no trial of medical therapy,or who have 1 or more of the following:a.Only a small area of myocardium at risk.b.All lesions or the culprit lesion to be dilated with morphology that conveys a low likelihood of success.c.A high risk of procedure-related morbidity or mortality.d.Insignificant disease(50%coronary stenosis).e.Significant left main CAD and candidacy for CABG.I I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIII I IIIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIIRecommendations a-d are level of evidence:C;d is level of evidence:B.快件摄盐拘燥涪巴脯诀勇褥男痪狄饵邦落朽惠嫩僚钢制憾炙状桑沸矛烈撅急性冠综合征患者冠脉介入治疗指南-英文急性冠综合征患者冠脉介入治疗指南-英文Cardiac cathCADNoDischarge from protocolY