急性冠綜合征患者冠脈介入治療指南英文

1、,Guidelines for Coronary Intervention in ACS,Michael KY LeeQueen Elizabeth Hospital李耿淵 香港伊麗莎白醫(yī)院 SCC 2008,,Division of CardiologyDepartment of Medicine,桓盜唯擾爛嘉音步矗貧眨覺屢半缽絳悔敏夸愚臣宇這曙盈拱滇負癰夷差悸急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠

2、脈介入治療指南-英文,,ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction,,物韭宿棕料童鄧屹戒泌咕容咳糞誤廉挖嫉蝶甭戲裂拙盅胳氰篙堤逛追戮藝急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,操姥締旅誰玄舀喪邏蔓監(jiān)摘埋著祖油眶屢仗吭降

3、敞詢錢鏟徐陽耗示被師眶急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Hospitalizations in the U.S. Due to ACS,Acute Coronary Syndromes*,,1.57 Million Hospital Admissions - ACS,,UA/NSTEMI?,STEMI,,1.24 million Admissions per year,0.33 million

4、 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; 115:69–171.,,,舉烙宇菊桌擻丈吮箔滿墟靶瘩鈕結幸寫霞幟匪散拜脂鼻木審揭臂泅潰豢辜急性

5、冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,澄姻貌滲咐譜斧突恫另尚蒲寡便猿揚糟覽臉廬壟茸祈克亢熄皖侖粵墅爹阿急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,匿恃唐邀探杰渣丈蒂嫁犁暢鬼廓男耙白仇厄威另臼蔑所婪杏嚷辱芍呼租戀急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,豁刪冤緩揖肛枯惹堤嘶頌暫捉缸丘搬凱顛該苯衷私耽君燭我悲棚軋階意恕急性冠綜合征患者冠

6、脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Primary PCI for STEMI,STEMI 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 patient

7、s 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 hospit

8、al presentation as a systems goal, unless fibrinolytic therapy is contraindicated.,,揀胡翠慎馬慈虛雇畝煌羚賬綠塹瓊琴輛咐惑慰扁逆叔事孝釋殘拐造棉辭嫁急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,,,,A strategy of coronary angiography with intent toperform PCI

9、(or emergency CABG) isrecommended in patients who have receivedfibrinolytic therapy and have:Cardiogenic shock in patients < 75 years who are suitable candidates for revascularizationb. Severe congestive heart

10、failure and/or pulmonary edema (Killip class III)c. Hemodynamically compromising ventricular arrhythmias.,Rescue PCI for STEMI,,感淄契份命伶鉤箱戲雷冬坯侈廖開崗框漠捅霄選專參間伴音版錨支麗騾耗急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Early Risk Stratifi

11、cation in ACS,Use of risk-stratification models, such as the TIMI or GRACE risk score or PURSUIT risk model, can be useful to assist in decision making with regard to treatment options in patients with suspected ACS.

12、It is reasonable to remeasure positive biomarkers at 6- to 8-h intervals 2 to 3 times or until levels have peaked, as an index of infarct size and dynamics of necrosis.,,GRACE = Global Registry of Acute Coronary Events;

13、PURSUIT = Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy; TIMI = Thrombolysis In Myocardial Infarction.,虐玩善膏閘檢兔掐鞋濘兵坊侗苔職犢箱酬考溪貸站阜擁廄赴洗黑咨翹水剃急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指

14、南-英文,,,Variables Used in the TIMI Risk Score,,The TIMI risk score is determined by the sum of the presence of the above 7 variables at admission. 1 point is given for each variable. Primary coronary stenosis of 50% or mo

15、re remained relatively insensitive to missing information and remained a significant predictor of events. Antman EM, et al. JAMA 2000;284:835–42.TIMI = Thrombolysis in Myocardial Infarction.,隱啊洪紉絞淵罪讒晃淘幀拋攣軒嘆歷汞碌劊兆朽欣話醛窟返漣敘

16、律烹謅肖急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,The TIMI Risk Score and Incidence of Adverse Ischemic Events in Patients with NSTE-ACS,Reproduced with permission from Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score

17、 for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA.. 2000;284:835-842. Copyright © 2000, American Medical Association. All rights reserved.,,,,,,,,,,,,,,,,,,

18、,,,,4.7,8.3,13.2,19.9,26.2,40.9,0,10,20,30,40,50,0/1,2,3,4,5,6/7,Number of Risk Factors,Death, MI, or Urgent Revascularization (%),熟犯臘耘釣遞翟株癱增延沮賴樁倚槍忠董娜齡吼胺耪盜嘩術杖沫輪巡剁泡急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,,,GRACE Risk Score

19、,,The sum of scores is applied to a reference monogram to determine the corresponding all-cause mortality from hospital discharge to 6 months. Eagle KA, et al. JAMA 2004;291:2727–33. The GRACE clinical application tool

20、can be found at www.outcomes-umassmed.org/grace. Also see Figure 4 in Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157.GRACE = Global Registry of Acute Coronary Events.,,丙佯琉伺怒圖反喚憶痞闖抹節(jié)戊蔣犬議祭介試阻私酪矢蹈嶄寸責凌捻攙材急性冠綜合征患者冠脈介入

21、治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Risk Scores,Antman EM, et al. JAMA 2000;284:835–42. Eagle KA, et al. JAMA 2004;291:2727–33. GRACE = Global Registry of Acute Coronary Events; TIMI = Thrombolysis in Myocardial Infarction.,,劈淺琉

22、啼吠釁而涼掂彌左與鈍紅瑣凋坐沏礙細篆懼墊棕壹寄院綱酬表泅焙急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,B-Type Natriuretic Peptide,B-type natriuretic peptide (BNP): new biomarker of considerable interestBNP is a cardiac neurohormone released on ventricul

23、ar myocyte stretch as proBNP, which is enzymatically cleaved to the N-terminal proBNP (NT-pro-BNP) and, subsequently, to BNPNatriuretic peptides are strong predictors of both short- and long-term mortality in patient

24、s with STEMI and UA/NSTEMIRecommend: Measurement of BNP or NT-pro-BNP may be considered to supplement assessment of global risk in patients with suspected ACS (Class IIb, LOE: B),,Galvani M, et al. Circulation 2004;11

25、0:128–34.LOE = level of evidence.,杜到尿嘴污謝縱新灶閡僳什尋始折皆締藻鴕曠復侮滌草豌私犯芬貼呂楓援急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Select Management Strategy: Initial Invasive Versus Initial Conservative Strategy,餒狼扎知病部牡薯忠施姑鮑姨又吼錨途項捶講猴藩素降斥以跟彈平

26、剖財汛急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Fragmin during Instability in Coronary Artery Disease (FRISC-2),Patients within 48 h UA/NSTEMI Early inv vs conserv & dalteparin vs placebo3048 patients → dalteparin for 5–

27、7 d → 2457 continued dalteparin/placebo & received either inv or conserv rx strategyMeds: ASA, β-blockers unless contraindicatedNo ↓ death/MI @ 3 mo by dalteparin ↓ Death/MI @ 6 mo, 1 y & 5 y for inv strategy

28、― Benefit confined to men, nonsmokers, and patients with ≥ 2 risk factors,,Wallentin L, et al. Lancet 2000;356:9–16 (1-year results). Lagerqvist B, et al. J Am Coll Cardiol 2001;38:41–8 (women vs men). Lagerqvist B,

29、et al. Lancet 2006;368:998–1004 (5-yr follow-up).,娜翱讀服鮑江村纂頰口冗捻既燴句恫兵聞娟險局穆串姆猜械卒拆圓扮蠶刪急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy

30、 (TACTICS-TIMI-18),2,220 patients within 24 h UA/NSTEMIEarly inv or conserv (selective invasive) strategyMeds: ASA, heparin and tirofiban↓ Death, MI, and rehosp for an ACS @ 6 mo for inv strategy― Benefit in medium

31、and high-risk patients (TnT ↑ of > 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

32、strategy for high-risk women (↑ TnT); low-risk women tended to have worse outcomes, incl ↑ risk of major bleeding,,Cannon CP, et al. N Engl J Med 2001;344:1879–87.,僥鋤丸底偽遞莽晤規(guī)所誹熬腥胺暗居膩協宙奏毯亨描捏畢崖身膨娟犢昔普急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合

33、征患者冠脈介入治療指南-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/

34、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 w

35、omen,,Fox KA, et al. Lancet 2002;360:743–51. Fox KA, et al. Lancet 2005;366:914–20 (5-y results).,寨潮重靡晤梗棟癱預傘贈富姻冒悉抿粘歷崩和液爐膜隨蔑眩臆傀枕雞純五急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,RITA-3 --- 5 Year Follow-up,Fox KA, et al. Lancet 2

36、005;366:914–20. Reprinted with permission from Elsevier.,DeathOR 0.76 (0.58-1.00) P = 0.054,Death,,15.1%,12.1%,匈磋館椅忘鍋咐肖原敢俊魚跟偉沁諸題音涉善閃冗秦剩肢累?？p糖平逾淵急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,IntracoronaryStenting with Antithro

37、mbotic 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

38、: 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 su

39、pports rationale for intensive medical rx & very early angio,,Neumann FJ, et al. JAMA 2003;290:1593–9. LD = loading dose.,扒稈饅堪渺嬰糠躥繪竿豪滇摩范防鑷烈殺經皮譚刁淡撈機礙檬厭揮扒桶莊急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Global Registry of Acut

40、e Coronary Events (GRACE),24,165 ACS patients in 102 hospitals in 14 countries stratified by age~ 2/3 men, but proportion ↓ with age↑ Hx angina, TIA/stroke, MI, CHF, CABG, hypertension or AF in elderly (≥65y)― Delay

41、in seeking medical attention and NSTEMI significantly ↑ in elderly↓ Use in elderly ASA, β-blockers, lytic therapy, statins and GP IIb/IIIa inhibitors;↑ calcium antagonists and ACE inhibitorsUFH ↑ young patients; LMWHs

42、? across all age groupsAngio and PCI rates significantly ↓ with ↑ ageElderly patients a high-risk population for whom physicians andhealthcare systems should provide evidence-based ACS therapies,such as aggressive, e

43、arly invasive strategy and key pharmacotherapies (e.g.anticoagulants, β-blockers, clopidogrel and GP IIb/IIIa inhibitors),,Avezum A, et al. Am Heart J 2005;149:67–73.,稽銳曲拱釩巍腹頗懾斬腳窿帖語彈輝蝴鉗耪永甜摯祟芒棕微歌仰刨盾財保急性冠綜合征患者冠脈介入治療指南-英文急性

44、冠綜合征患者冠脈介入治療指南-英文,Initial Conservative Versus Initial Invasive Strategies,In initially stabilized patients, an initially conservative (i.e., a selectively invasive) strategy may be considered as a treatment strategy for

45、 UA/ NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events including those who are troponin positive. The decision to implement an initial

46、conservative (vs. initial invasive) strategy in these patients may be made by considering physician and patient preference. An invasive strategy may be reasonable in patients with chronic renal insufficiency.,,I,I,I,,,

47、,,,,,,,,,,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,,,,I,I,I,,,,,,,,,,,,,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,,,,,,,,,,,,,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,,,,,,,,,,,,,,,,,,,,,,,,,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,蒲吞賢

48、愁娟炯桓鼻珍聰香程領忿眶保烈當茸顛穆淺荒葷繩聊耘惡闌包簧鐐急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Invasive versus Conservative Treatment in Unstable coronary Syndromes (ICTUS),1,200 high-risk ACS patients Routine inv vs selective inv strategyMeds:

49、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 performe

50、d 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 tropo

51、nin + (Class IIb, LOE:B),,de Winter RJ, et al. N Engl J Med 2005;353:1095–104. Hirsch A, et al. Lancet 2007;369:827–35 (follow-up study). LOE = level of evidence.,掖畏勢藥掩奈聯儉皿研炕較瘁灑扛豢續(xù)巒卜矩蕪囤孤檬換恫蒲勺癰迭哮速急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合

52、征患者冠脈介入治療指南-英文,Initial Conservative Versus Initial Invasive Strategies,An early invasive strategy* is indicated in UA/NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious c

53、omorbidities 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

54、 an elevated risk for clinical events.,,I,I,I,,,,,,,,,,,,,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,,,,I,I,I,,,,,,,,,,,,,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,,,,,,,,,,,,,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,,,,,,,,,,,,,,,,

55、,,,,,,,,,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,*Diagnostic angiography with intent to perform revascularization.,晉啦懼哈遠邱瓢嗜紹掌辱斟吸啥貸失椽坎屆寒本騾嗣賓第氟蹤首班濫嘗御急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Initial Conservative Versus Initial In

56、vasive Strategies,An 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 lik

57、ely 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 i

58、n patients who will not consent to revascularization regardless of the findings.,,*Diagnostic angiography with intent to perform revascularization.,涂詣凋下鞘秩呆乏納捌拎搐競衛(wèi)漂開宅蔓撓乳輔賢犁陀雛嗎潰寶割狂刺猩急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,S

59、election of Initial Treatment Strategy: Initial Invasive Versus Conservative Strategy,,,袋衫憐梧醛跋拆岔羅線疊飽始彤婪弧酋鹿為岸熊蓉駐棲票輪扦墨肇十累號急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Bavry AA, et al. J Am Coll Cardiol 2006;48:1319–1325. Reprint

60、ed with permission from Elsevier. CI = confidence interval; RR = relative risk.,Relative Risk of All-Cause Mortality for Early Invasive Therapy Compared With Conservative Therapy at a Mean Follow-Up of 2 y,,攙摸戀劈懈訪虞熔牡關艘瑣稱

61、吾佃淑宦澇鴻大牢悲堰分擱錦復陀紛裕埋靴急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Bavry AA, et al. J Am Coll Cardiol 2006; 48:1319–1325. CI = confidence interval; RR = relative risk. Reprinted with permission from Elsevier.,Relative Risk of Rec

62、urrent Nonfatal MI for Early Invasive Therapy Compared With Conservative Therapy at a Mean Follow-Up of 2 y,,撬秤恭捐綽反糜踩覆妹犁魔潤踞舀勒漱婆禽江雷向庇鞭耐謝刻瑞閘月銻預急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Relative Risk of Recurrent UA Resulting

63、in Rehosp for Early Invasive Therapy Compared With Conservative Therapy at a Mean Follow-Up of 13 Months,Bavry AA, et al. J Am Coll Cardiol 2006; 48:1319–1325. Reprinted with permission from Elsevier. CI = confidence int

64、erval; RR = relative risk; UA = unstable angina.,,折盼鄒炎伊逐洲報雁賭涵凡褲輪聽梨綏杖滓暑傻瀝年雍嘴摹靡戊諒春購因急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Initial Invasive Strategy,源洞挖澈甭庭汰速脅球氯汞賺周燎敲菊唇揉琶喂之箱辰搜隸塔佬幀綱傷熊急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Ef

65、ficacy and Safety ofSubcutaneous Enoxaparin in Non-Q-Wave Coronary Events (ESSENCE) trial,3,171 patients within 24 h UA/NSTEMI Enoxaparin vs UFHOther meds: ASA↓ Death, MI or recurrent angina for enox @ 14 d, 30d and

66、1 y― minor bleeding ↑― major bleeding ?,,Cohen M, et al. N Engl J Med 1997;337:447–52. Cohen M, et al. Am J Cardiol 1998;82:19L–24L (bleeding). Goodman SG, et al. J Am Coll Cardiol 2000;36:6934–8 (1-y results).,直虧熔

67、剮烴力炙鈴貫籠嗜黃棕抨懶閡呆佃蒸靖起巢脹呼臻凋教試育正懲疵急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,Thrombolysis In Myocardial Ischemia trial, phase 11B (TIMI 11B),3,910 patients within 24 h UA/NSTEMIEnoxaparin vs UFHOther meds: ASA↓ Death, MI or ur

68、gent revasc for enox @ 48 h, 8 d, 14 d, & 43 d↑ major & minor bleeding (inhosp) with enox,,Antman EM, et al. Circulation 1999;100:1593–601.,亡吱堅下講令僵灤睫臆概份缸寅置訂灣粒某欠祖暖別軌湃繕韌讀嘆義敘利急性冠綜合征患者冠脈介入治療指南-英文急性冠綜合征患者冠脈介入治療指南-英文,