急性冠综合征患者冠脉介入治疗指南-英文.ppt
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1、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 Ang
2、ina/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 m
3、illion 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
4、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 prim
5、ary 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 p
6、resentation 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
7、 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 n
8、g/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;344:18798
9、7.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 Deat
10、h,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
11、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 A
12、ntithrombotic 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 gro
13、up 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 Cons
14、ervative 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(
15、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 20
16、05;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 an
17、gina 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
18、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 angiograph
19、y 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 StrategiesA
20、n 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 patie
21、nts 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 II
22、bIIbIIb 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 angiograp
23、hy 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 therapy
24、Elevated 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.,TIM
25、I,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-asso
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