冠心病房颤危险评分.pptx

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,#,Click to edit the title text format,Click to edit the outline text format,Second Outline Level,Third Outline Level,Fourth Outline Level,Fifth Outline Level,Sixth Outline Level,Seventh Outline Level,Eighth Outline Level,Ninth Outline Level,Click to edit the title text format,Click to edit the outline text format,Second Outline Level,Third Outline Level,Fourth Outline Level,Fifth Outline Level,Sixth Outline Level,Seventh Outline Level,Eighth Outline Level,Ninth Outline Level,冠心病、房颤,临床常用危险评分,冠心病,4,1,2,3,4,5,6,就诊,检查,ECG,心肌标志物,最后诊断,UA,NQMI,QwMI,无,ST,抬高,NSTEMI,缺血性胸部不适,急性冠脉综合征,不稳定,心绞痛,ST,抬高,Libby P.et al.Circulation 2001;104:36572.,2014 AHA/ACC NSTEACS Guideline,Modified from,冠心病一级预防,ASCVD,的发生是多个危险因素复杂交互作用的共同结果。个体发生,ASCVD,的风险不仅取决于某一危险因素的水平，更取决于同时存在的危险因素的数目和水平。,国际上各种,ASCVD,防治指南均强调一级预防中,总体风险评估,和,危险分层,治疗策略的重要性。,基于预防,ASCVD,事件,获益需大于,出血,风险,的原则，,ASCVD,风险的基线评估是正确使用阿司匹林进行一级预防的前提。,针对健康人群，目前有多个心血管疾病风险评估工具可供使用,:,Framingham,，,欧洲,SCORE,和,ACC/AHA,发布的汇总队列公式等。,Framingham,研究,（,framingham heart study,，,FHS,）,始于,1948,年，最初从美国 马萨诸塞州 的,Framingham,镇上,5209,个人开始，半个多世纪里，涉及到受试者，以及此后第三代后代，且仍在持续进行；,尤其是这些受试者经历第三代后，遗传学的研究成为研究关键，这种连续数十年的跟踪研究，为医学界带来了宝贵的研究财富；堪称医学研究的典范；,全球依据,FHS,发表的文章超过,1800,余篇，不仅限于心血管领域；,提出危险因素概念；,出来了各种评分。,（,https:/www.framinghamheartstudy.org/risk-functions/index.php,）,Coronary Heart Disease,（,Hard Coronary Heart Disease(10-year risk)and Calculator,；,Coronary Heart Disease(10-year risk),；,Recurrent Coronary Heart Disease,；,Coronary Heart Disease(2-year risk)Second Event,）,score sheet for men using TC or LDL-C categories.,Peter W.F.Wilson et al.Circulation.1998;97:1837-1847,Copyright American Heart Association,Inc.All rights reserved.,CHD score sheet for women using TC or LDL-C categories.,Peter W.F.Wilson et al.Circulation.1998;97:1837-1847,Copyright American Heart Association,Inc.All rights reserved.,Estimating Risk of CHD in Men,*Note:When systolic and diastolic pressures provide different estimates for point scores,use the higher number,*Hard CHD events exclude angina pectoris,中国,ASCVD,风险模型,但以上模型高估了我国人群的心血管风险；,ASCVD,风险,.,2016,年中国,ASCVD,风险预测研究根据前瞻性队列共计,10.6,万人的最新随访数据，开发和验证了首个中国人群,10,年,ASCVD,发病风险预测模型。其对中国人群预测的准确性优于,2013 ACC/AHA,模型。,冠心病二级预防,ACS,患者存在不同的临床、,ECG,、酶或标记物特征，发生严重心血管不良预后的风险差异很大；,二分法危险分层（如正常或升高的肌钙蛋白，,ECG,正常或异常）的准确性不够；,危险分层有助于正确选择早期治疗策略,(,介入或药物,),。,ACS,患者为什么要进行风险分层评估？,“To provide more accurate prognostic information,and to target treatment more appropriately,more precise yet user friendly risk stratification is required”,临床需要更为合适、准确，并且用户友好的危险分层工具以提供更准确的预后信息和指导治疗,Fox KA,et al.BMJ 2006;333:1091.,ACS-,危险分层,临床特点,高龄、糖尿病、肾功能不全；,临床表现,（劳力性,/,静息性、发作频度 持续,/,反复缺血、,HR,、,BP,、心衰、休克、血流动力学不稳定）,心电图,ST,段偏移,(,导联数,/,幅度,),、,Wellens,综合征、,de-winter综合征、心律失常,标志物,hs-cTn,、,hsCRP,、,BNP,危险评分,GRACE,、,TIMI,；,CRUSADE,、,ACUITY,ACS,危险分层,-risk score,大部分,ACS,患者合并多种危险因素；,所以,危险评分，更为简便,，常用的,GRACE,、,TIMI,评分危险分层，有利于评估预后并指导治疗策略；,CRUSADE,、,ACUITY,等出血评分，有利于整体评估出血风险，指导抗栓药物选择及用量。,NSTEACS-,指南推荐,2014 NSTEACS Guideline,AHA/ACC,2015 NSTEACS Guideline,ESC,2016,中国非,ST,段抬高型急性冠状动脉综合征诊断和治疗指南,NSTEACS-,TIMI,评分,TIMI,评分,用来评价,ACS,患者的危险分层评分，源于,Thrombolysis in Myocardial Infarction(TIMI)Study,TIMI Risk Score Calculator for,UA/NSTEMI,和,TIMI Risk Score for,STEMI,两种,www.timi.org/index.php?page=about-timi,TIMI Risk Score for,UA/NSTEMI,www.timi.org/index.php?page=calculators,Heart J.2007;28(13):1598-660.,什么是,GRACE,研究？,目前最大规模的多国、前瞻性,注册,研究；,在,真实环境,里，不干涉现有的治疗模式，真实反映医生治疗决策和病情转归,覆盖,ACS,整个疾病谱,进行住院期间和,6,个月或者更长时间的随访,记录患者地区分布、临床表现、治疗及转归的详细资料,GRACE,主研究,亚研究,1,亚研究,2,亚研究,3,www.outcomes-umassmed.org/GRACE/,GRACE,评分是,ACS,患者危险分层及个体化治疗的有效依据,1.Eur Heart J.2007;28(13):1598-660.,2.Anderson JLet al.J Am Coll Cardiol.2007;50(7):e1-e157.,建议入院，出院，门诊随访均需行,GRACE,危险分层,NSTEACS-,GRACE,评分 手算,记录各项评分,计算总分,对应的,Y,轴数据即患者死亡风险,NSTEACS-,GRACE,评分 官网,www.gracescore.org/WebSite/WebVersion.aspx,NSTEACS-,GRACE,评分 官网,www.gracescore.org/WebSite/WebVersion.aspx,输入各种参数之后，现在,GRACE 2.0,版本还会给出除了院内和,6,个月以外，还有,1,年、,3年的发病风险等。,入院时,8,项,评估指标值：,年龄,心率,血压,血清肌酐水平,心力衰竭的,Killip,分级,入院时心脏停搏,ST,段偏离,心肌酶水平升高,GRACE,评分计算器可计算,院内,以及,出院,6,个月,时死亡以及死亡,/,心梗风险,出院及门诊,9,项,评估指标值：,年龄,心力衰竭史,心肌梗死史,心率,血压,ST,段压低,初始血清肌酐,心肌酶升高,非院内,PCI,史,NSTEACS-,GRACE,评分 计算器,2016,中国非,ST,段抬高型急性冠状动脉综合征诊断和治疗指南,2014 NSTEACS Guideline,AHA/ACC,CRUSADE,评分,www.crusadebleedingscore.org/index.html,源于,CRUSADE Quality Improvement Initiative,研究。,The CRUSADE Bleeding Score was developed using data from over,89,000 real-world,patients enrolled in the CRUSADE Quality Improvement Initiative that presented with NSTEMI.We developed(n=71,277)and validated(n=17,857)a logistic regression model to identify eight independent predictors of in-hospital major bleeding.The CRUSADE Bleeding Score was created by assigning a weighted integer to each predictor based on its coefficient in the regression model.A patients CRUSADE Bleeding Score equals the sum of the weighted scores for the independent predictors(range 1-100 points).,The purpose of CRUSADE is to help clinicians estimate a patients baseline risk of,in-hospital major bleeding,during non-ST-segment elevation myocardial infarction(,NSTEMI,).,CRUSADE,评分,www.crusadebleedingscore.org/index.html,积分越高，出血风险越大。,积分,51-91,分出血极高危，出血风险为,19.5%,；,积分,41-50,分，为出血高危，出血风险为,11.9%,；,积分,31-40,分，为出血中危，出血风险为,8.6%,；,积分,21-30,分，为出血低危，出血风险为,5.5%,；,积分,11-20,分，出血极低危，出血风险为,3.1%,；,STEMI,TIMI,Risk Score for,STEMI,GRACE,评分,尽早行急诊再灌注治疗是关键；,危险分层有助于评估预后，且对就诊较晚错过再灌注时机者有指导治疗。,Independent predictors of 30-day mortality.,David A.Morrow et al.Circulation.2000;102:2031-2037,Copyright American Heart Association,Inc.All rights reserved.,TIMI risk score for STEMI for predicting,30-day,mortality.,David A.Morrow et al.Circulation.2000;102:2031-2037,Copyright American Heart Association,Inc.All rights reserved.,TIMI risk score for STEMI for predicting,1-year,mortality(30-day survivors).,David A.Morrow et al.Circulation.2000;102:2031-2037,Copyright American Heart Association,Inc.All rights reserved.,TIMI Risk Score for STEMI summarized for printing on laminated card for clinical use.,David A.Morrow et al.Circulation.2000;102:2031-2037,Copyright American Heart Association,Inc.All rights reserved.,STEMI-,TIMI,评分,低危：,0-3,分；,中危：,4-6,分；,高危：,7-14,分。,STEMI-,GRACE,评分解读,冠心病血运重建,风险,-,获益评估,是对患者进行,血运重建治疗决策的基础,；,危险评分可以预测,心肌血运重建,手术病死率,或术后,主要不良,心脑血管,事件,；,指导医师对患者进行,风险分层,，从而为,选择适宜的,血运重建,措施,提供参考。,EuroSCORE/,1995,年确立的欧洲心血管手术危险因素评分系统,EuroSCORE,（,Euro,pean,S,ystem for,C,ardiac,O,perative,R,isk,E,valuation,）评分,，由于基于较早期的研究结果，过高估计了血运重建的死亡风险，不建议继续使用；,EuroSCORE,在,EuroSCORE,的基础上进一步完善评分项目，,2012,年发布，仍是由三方面内容组成：,患者本身因素,：年龄、性别、肌酐清除率、外周动脉疾病、神经机能障碍、既往心脏手术史、慢性肺脏疾病、活动性心内膜炎、术前危急状态、正在应用胰岛素治疗的糖尿病。,心脏相关因素,：纽约心脏协会（,NYHA,）心功能分级、,CCS,心绞痛分型、左心室功能、近期心肌梗死、肺动脉高压。,手术相关因素,：紧急外科手术是否为单纯,CABG,、胸主动脉手术。,得到以上信息后，根据改良的,logistic,公式，可以计算出,EuroSCORE,评分，其具体计算方法繁杂，简单的方法是网上下载专门计算工具，计算得分。（,手术低危组积分,0.9,中危组,0.9-1.5,高危组,1.5,）,www.euroscore.org/calc.html,SYNTAX/,评分,SYNTAX,评分：来源于大型研究,SYNTAX Trial,是根据,11,项冠状动脉造影 病变解剖特点定量评价病变的复杂程度的危险评分方法。对于病变既适于,PCI,又适于,CABG,且预期外科手术病死率低的患者，可用,SYNTAX,评分帮助制定治疗决策至今仍在临床上广泛使用。,SYNTAX,评分：是在,SYNTAX,评分的基础上，新增是否存在无保护左主干病变，并联合,6,项临床因素,(,包括年龄、肌酐清除率、左心室功能、性别、是否合并慢性阻塞性肺疾病和周围血管病,),的风险评估法，在预测左主干和复杂三支病变血运重建的远期死亡率方面，优于单纯的,SYNTAX,评分。,来自中国的研究显示，对于无保护左主干病变患者，,SYNTAX,评分预测,PCI,术后远期病死率的价值，优于,SYNTAX,评分。,评分,NERS II,评分,另一项中国的多中心研究显示，对,无保护左主干,病变患者，用整合了,临床和冠状动脉解剖学因素,的,NERS II,评分预测主要不良心脏事件,(M ACE),发生率，,优于,SYNTA X,评分,，,NERS,评分,19,分,是,MACE,独立预测因素,。,2016,中国经皮冠状动脉介入治疗指南,DAPT,时间,-,影响因素及风险评估,PRECISE-DAPT,评分,图中风险曲线为,12,个月时,DAPT,治疗的,TIMI,大,/,小出血及,TIMI,大出血。,绿色条，第一个四分位数分值（极低风险）；蓝色条，第二个四分位数分值（低风险）；紫色条，第三个四分位数分值（中等风险）；红色条，第四个四分位数分值（高风险）。,Kaplan-Meier,出血率也按照四分位数分开：,极低风险，评分,10,；,低风险，评分,11-17,；,中等风险，评分,18-24,；高风险，评分,25,。,Lancet 2017;389:102534,ESC,VKAs,的使用受到其治疗窗窄，需频繁监测和调整剂量的限制，但是当,VKAs,治疗达到足够的治疗范围内时间（,TTR,）时，在,AF,患者中能够有效地预防卒中。,临床参数有助于识别在,VKA,治疗中有可能达到适宜的,TTR,的患者。,SAMe-TT,2,R,2,评分对此进行了总结。,SAMe-TT,2,R,2,评分,The SAMe-TT,2,R,2,score can aid decision-making by identifying those patients with AF who would,do well on VKA,(,score=0-1,)or,conversely,those(ie,score,2,)who may require some intervention(s)to help them achieve acceptable anticoagulation control,Chest 2013 Nov;144(5):1555-63,ACS,合并,AF,ACS,患者房颤发病率,10-21%,，与年龄、梗死程度正相关；,加重缺血，诱发心衰，血栓栓塞；,房颤是,ACS,患者住院病死率、,30 d,病死率和,1,年病死率增加的独立预测指标；,抗栓策略,CHA,2,DS,2,-VASc,HAS-BLED,GRACE,ACS,合并,AF-,长期抗栓策略,ACS,合并,AF-,抗栓推荐,Assess ischemic and bleeding risks using validated risk predictors(e.g.,CHA,2,DS,2,-VASc,HAS-BLED),Keep triple therapy duration as short as possible;dual therapy only(oral anticoagulant and clopidogrel)may be considered in select patients,Consider a target INR of 2.02.5 when warfarin is used,Clopidogrel is the P2Y 12 inhibitor of choice,Use low-dose(,100 mg daily)aspirin,PPIs should be used in patients with a history of gastrointestinal bleeding and are reasonable to use in patients with increased risk of gastrointestinal bleeding,THANK,YOU!,