不稳定型心绞痛和非段抬高心梗的治疗.ppt
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1、Acute Coronary Syndromes:Management of UA/NSTEMIOverview of 2003 Updates to the Overview of 2003 Updates to the ACC/AHA Guideline for UA/NSTEMIACC/AHA Guideline for UA/NSTEMIAssess likelihood of CADRisk stratificationTarget therapy:more aggressive treatment in higher-risk patientsAnti-ischemic,antit
2、hrombotic therapyInvasive vs conservative strategyDischarge planning(risk factor modification and long-term medical therapy)ACC/AHA,American College of Cardiology/American Heart Association;UA,unstable angina;NSTEMI,nonST-segment elevation myocardial infarction.Braunwald E,et al.J Am Col.Cardiol.200
3、0;36:970-1062.Acute Management of UA/NSTEMIAcute Management of UA/NSTEMIAnti-Ischemic TherapyAnti-Ischemic TherapyOxygen,bed rest,ECG monitoringOxygen,bed rest,ECG monitoringNitroglycerinNitroglycerin-BlockersBlockersACE inhibitorsACE inhibitorsUA,unstable angina;NSTEMI,non-ST-segment elevation myoc
4、ardial infarction;ECG,electrocardiogram;ACE,angiotensin-converting enzyme.Braunwald E,et al.J Am Coll Cardiol.2000;36:970-1062.Antithrombotic TherapyAntithrombotic TherapyAntiplatelet therapyAntiplatelet therapyAnticoagulant therapyAnticoagulant therapyPossible Possible ACSACSAspirinAspirinAspirinAs
5、pirin+IV HeparinIV Heparin+IV Platelet IV Platelet GP IIb/IIIa GP IIb/IIIa AntagonistAntagonistDefinite ACS With Definite ACS With Invasive Strategy Invasive Strategy(Catheterization/PCI)(Catheterization/PCI)or High Risk(IIa)*or High Risk(IIa)*ClopidogrelClopidogrelAspirinAspirin+SQ LMWH*SQ LMWH*oro
6、rIV HeparinIV HeparinLikely/Definite Likely/Definite ACSACSClopidogrelClopidogrel*Class IIa:enoxaparin preferred over UFH unless CABG planned within 24 hours.ACC,American College of Cardiology;AHA,American Heart association;ACS,acute coronary syndrome;PCI,percutaneous coronary intervention;SQLMWH,su
7、bcutaneous low molecular-weight heparin;IV,intravenous.Braunwald E,et al.J Am Coll Cardiol.2000;36:970-1062.ACC/AHA Class I Recommendations for ACC/AHA Class I Recommendations for Antithrombotic Therapy*Antithrombotic Therapy*17.117.16.5*6.5*PlaceboPlaceboASAASA0 05 5101015152020Patients(%)Patients(
8、%)Unstable AnginaUnstable Angina 25.025.011.0*11.0*ASAASA0 01010202030303.33.31.9*1.9*ASAASA0 01 12 23 34 411.811.89.4*9.4*ASAASA0 05 510101515Acute MIAcute MIAspirin in Acute Coronary SyndromesAspirin in Acute Coronary Syndromes*P P.0001.0001Death or MIDeath or MI*P P=.003=.003ReocclusionReocclusio
9、n*P P=.012=.012MIMI*P P.001.001DeathDeathN=3973995134198587860085878600MI,myocardial infarction;ASA,acetylsalicylic acid;RISC,Research on InStability in Coronary artery disease.RISC Group.Lancet.1990;336:827-830.Roux S,et al.J Am Coll Cardiol.1992;19:671-677.ISIS-2.Lancet.1988;2:349-360.PlaceboPlace
10、boPlaceboPlaceboPlaceboPlaceboAspirin in Acute Coronary SyndromesAspirin in Acute Coronary Syndromes12.912.93.9*3.9*ASAASA0 05 51010151511.911.93.3*3.3*ASAASA0 05 51010151512.912.96.2*6.2*ASAASA0 05 5101015152.22.21.3*1.3*ASAASA0 00.50.51 11.51.52 22.52.5UA/NSTEMIUA/NSTEMIPrimary Primary PreventionP
11、reventionStable Stable AnginaAngina*P P.0001.0001MIMI*P P=.0003=.0003MIMI*P P=.008=.008Death or MIDeath or MI*P P=.012=.012Death or MIDeath or MIN=1103411037155178279276118121MI,myocardial infarction;ASA,acetylsalicylic acid;RISC,Research on InStability in Coronary artery disease;ISIS-2,Second Inter
12、national Study of Infarct Survival.PHS.N Engl J Med.1989;321:129-35.Ridker PM,et al.AJC.1991;114:835-839.Cairns JA,et al.N Engl J Med.1985;313:1369-1375.Theroux P,et al.N Engl J Med.1988;319:1105-1111.PlaceboPlaceboPlaceboPlaceboPlaceboPlaceboPlaceboPlaceboPatients(%)Patients(%)Indirect Comparisons
13、of ASA Doses on Indirect Comparisons of ASA Doses on Vascular Events in High-Risk PatientsVascular Events in High-Risk Patients*Odds reduction.Treatment effect P.0001.ASA,acetylsalicylic acid.Adapted with permission from BMJ Publishing Group.Antithrombotic Trialists Collaboration.BMJ.2002;324:71-86.
14、0.50.51.01.01.51.52.02.0500-1500 mg500-1500 mg3434 19 19160-325 mg160-325 mg1919 26 2675-150 mg75-150 mg1212 32 3275 mg162 mg/d162 mg/d(n=2179)(n=2179)Primary end pointPrimary end point16.416.418.618.6Death,MI,strokeDeath,MI,stroke6.26.26.16.1DeathDeath2.82.81.71.7MIMI2.02.02.12.1StrokeStroke2.12.12
15、.82.8Urgent hospital careUrgent hospital care9.59.510.610.6Urgent resuscitationUrgent resuscitation7.37.310.010.0Internal bleedingInternal bleeding2.42.43.33.3Any bleedingAny bleeding11.111.115.415.4TransfusionTransfusion1.01.02.02.0ClopidogrelClopidogrel+ASA+ASA(N=6259)(N=6259)PlaceboPlacebo+ASA+AS
16、A*(N=6303)(N=6303)CURE:Major Bleeding at 1 year by ASA DoseCURE:Major Bleeding at 1 year by ASA Dose 200 mg(N=4110)3.7%4.9%P value for trend.0001.0009*P=.0001.P=.0009.Adapted from Peters RJG,et al.Circulation.2003;108:1682-1687.ASA DoseASA DoseRR:RR:Death/MIDeath/MIASA Alone ASA Alone 68/655=10.4%68
17、/655=10.4%Heparin+ASA Heparin+ASA 55/698=7.9%55/698=7.9%B BB BB BB BB BB BB B0.10.11 11010Summary Relative RiskSummary Relative Risk0.67(0.44-0.1.02)0.67(0.44-0.1.02)TherouxTherouxRISCRISCCohen 1990Cohen 1990ATACSATACSHoldrightHoldrightGurfinkelGurfinkelComparison of Heparin+ASA vs ASA AloneComparis
18、on of Heparin+ASA vs ASA AloneASA,acetylsalicylic acid;RISC,Research on InStability in Coronary artery disease;ATACS,Antithrombotic Therapy in Acute Company Syndromes;RR,relative risk;MI,myocardial infarction.Oler A,et al.JAMA.1996;276:811-815.(with permission)TIMI,Thrombosis in Myocardial Infarctio
19、n;ESSENCE,Efficacy and Safety of Subcutaneous Enozapam in NonQ-Wave Coronary Events;UHF,unfractionated heparin;ENOX,enoxaparin;MI,myocardial infarction;OR,odds ratio.Antman EM,et al.Circulation.1999;100:1602-1608.(with permission)TIMI TIMI IIIIB/ESSENCE Metanalysis:B/ESSENCE Metanalysis:Enoxaparin v
20、s Unfractionated HeparinEnoxaparin vs Unfractionated Heparin8.6 7.1 0.82(0.69-0.97)18 .026.5 5.2 0.79(0.65-0.96)21 .025.3 4.1 0.77(0.62-0.95)23 .021.81.4 0.80(0.55-1.16)20 .24 0.512Day281443UFH(%)ENOX(%)OR(95 CI)Favors ENOXFavors UFHPORDeath or MI%0123456789081624324048566472Patients(%)Hours from Ra
21、ndomization7.3%5.5%RRR 24%P=.026UFH(n=1957)ENOX(n=1953)UHF,unfractionated heparin;ENOX,enoxaparin;RRR,relative risk ratio.Antman EM.Circulation.1999;100:1593-1601.(with permission)TIMI TIMI IIIIB:Early Phase B:Early Phase Death/MI/Urgent RevascDeath/MI/Urgent Revasc0123456789081624324048566472Patien
22、ts(%)Hours from Randomization7.3%5.5%RRR 24%P=.026UFH(n=1957)ENOX(n=1953)UFHUFHEnoxaparinEnoxaparinP PP P=.03=.03=.03=.03Major Bleeds96 HoursMajor Bleeds96 HoursMajor Bleeds96 HoursMajor Bleeds96 HoursINTERACT:Enoxaparin vs Unfractionated INTERACT:Enoxaparin vs Unfractionated Heparin With GP IIb/III
23、a InhibitorsHeparin With GP IIb/IIIa InhibitorsGoodman SG,et al.Circulation.2003;107:238-244.Death/MI30 DaysDeath/MI30 DaysDeath/MI30 DaysDeath/MI30 DaysP PP P=.031=.031=.031=.031UFHUFHEnoxaparinEnoxaparinPercentPercentA-Phase Study DesignA-Phase Study DesignUA/UA/NSTEMINSTEMIFinal A Final A visit 3
24、0 visit 30 days days RandomizeRandomize-24-24 hourshours Chest painChest pain Min 0 hourMin 0 hourMax 120 hourMax 120 hourTirofiban Tirofiban+ASA+ASA Hour 0Hour 0Aggressive or conservativeAggressive or conservativecare per local practicecare per local practice2026202619611961ENOXENOX1mg/kg q12 hr1mg
25、/kg q12 hrUFHUFHWeight-adjustedWeight-adjustedZ ZZ Z Treat&Evaluate Treat&Evaluate for Z-Phasefor Z-Phase2018201819521952398739871 1 endpoint endpoint 7 days7 daysBlazing M.presented at ACC 2003.0 01010202030300 02 24 46 68 810101212UFHUFHEnoxaparinEnoxaparinUFHUFHENOXENOXDays From RandomizationDays
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