急性冠脉综合征评估及危险分层

1
0
0.4% RcTnT Neg AND CRP <1.55 N=277 RcTnT(early +) OR CRP >1.55 N=129 RcTnT(early +) AND CRP >1.55 N=22
Morrow DA, et al. J Am Coll Cardiol. 1998;31:1460-1465.
STEMI with fibrinolytics T-wave inversion
TIMI Risk Score for UA/NSTEMI: 7 Independent Predictors
• Aged ≥65 years • ≥3 CAD risk factors • Prior CAD (stenosis >50%) • Aspirin in last 7 days
TIMI Risk Score For UA/NSTEMI
• Age >65 years • >3CAD Risk Factors D/MI/Urg Revasc (%) • Prior Stenosis >50 % • ST deviation • >2 Anginal events <24 hours • ASA in last 7 days • Elev Cardiac Markers (CK-MB or troponin) 50 40 30 19.9 20 10 0 0/1 2 3 4 5 Number of Risk Factors 32.0 29.3 13.0 6/7 3.4 4.7 8.3 13.2
Progressive mechanical obstruction
Dynamic obstruction Inflammation/ infection
Braunwald E. Circulation. 1998;98:2219-2222.
Secondary UA (b MVO2)
GUSTO IIb: Correlation of 6-Month Mortality With Baseline ECG Findings in Patients With ACS
OPUS-TIMI 16 6
30-Day Mortality Relative Risk
6
TACTICS-TIMI 18 14 12
P=.014
P<.001
13
5 4 3 2 1 1 0
67 150 155 78
3.5
10 8 5.7
1.8
6 4 2 0 1
504 717
2.1
324 90
0
1 2 3 No. of Elevated Biomarkers
OPUS-TIMI 16 6
14
30-Day Mortality Rel Risk
6 5 4 3 2 1 1 1.8
TACTICS-TIMI 18
P=.014 30 Day Mortality (%)
P=.001
13
12 10 8 6 4 2 0 1 2.1 5.7
Troponin
P=.007
Months
Months
Lindahl B, et al. N Engl J Med. 2000;343:1139-1147. (with permission)
Risk Stratification With CRP and Troponin T
10 9 8 14-Day Mortality (%) 7 6 5 4 3 2 4.7% Chi Square: P=.0007 9.1%
P<.001 P=.004 P<.001 P<.001
49.6
50%
Event Rate at 1 year (%)
35.1
40% 30% 20%
4.9 10.7 7.1 4.1 24.4 21.0 10.8 19.5
10% 0%
6.5 3.9
Death
MI
Death/MI
Death/MI/RI
Scirica BM, et al. Am J Cardiol. 2002;90:303-305. (with permission)
Days After Randomization
de Lemos JA, et al. N Engl J Med. 2001;345:1014-1021. (with permission)
BNP and Risk of Death in ACS
20 Q1 Q2 Q3 Q4
Mortality at 10 mo (%)
Troponin I (TnI), C-Reactive Protein (CRP), and B-type Natriuretic Peptide (BNP) as Determinants of 30-Day Mortality Risks in Acute Coronary Ischemia: A Multimarker Approach
Acute Coronary Syndromes
Evaluation and Risk Stratification
New Terminology in ACS
Plaque Rupture
Stable Angina Unstable Angina Non– Q-wave MI Q-wave MI
Old term
White Blood Cell Count vs Mortality
20%
30-Day Mortality
15%
10%
5%
0
0
5
10
WBC Count (x103)
15
20
Cannon CP, et al. Am J Cardiol. 2001;87:636-639. (with permission)
New term Atherothrombosis
Daysweeks
UA/NSTEMI Minuteshours
STEMI
Antithrombotic Therapy
Thrombolysis Primary PCI
ACS, acute coronary syndrome; MI, myocardial infarction; UA, unstable angina; NSTEMI, non–ST-segment elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction; PCI, percutaneous coronary intervention. Cannon CP. J Thromb Thrombolysis. 1995;2:205-218.
0
1 2 3 No. of Elevated Biomarkers
Sabatine M, et al. Circulation. 2002;105:1760-1763. (with permission)
Braunwald Etiologic Classification of UA
Nonocclusive thrombus on pre-existing plaque
No. Studies:
6.7
1.9
3634 1849 737 322
Death
13
Death/MI
6
Heidenreich PA, J Am Coll Cardiol. 2001;38:478-485.
TIMI IIIB: Troponin I Levels Predict Mortality In UA/NSTEMI
10 ST ACS Cumulative Mortality (%) 8 6 4 2 0 0 30 60 90 120 150 180 Days From Randomization
GUSTO, Global Use of Strategies To Open Occluded Arteries in Acute Coronary Syndromes; ECG, electrocardiogram; ACS, acute coronary syndrome; STEMI, ST-segment elevation myocardial infarction. Savonitto S, et al. JAMA. 1999;281:707-713. (with permission)
TRS 0-2
TRS 3-4ຫໍສະໝຸດ TRS 5-7Prognostic Value of Troponin T or I in ACS: A Meta-analysis
25
Neg RR 3.9 (2.9-5.3) RR 3.8 (2.6-5.5)
20.8
20 15
%
Pos (Trop I + T)
10 6.4 5 0
• >2 anginal events in ≤24 hours
• ST deviation
• Elevated cardiac markers (CK-MB or troponin)
TIMI, thrombosis in myocardial infarction; UA, unstable angina; NSTEMI, non–ST-segment elevation myocardial infarction; CAD, coronary artery disease. Antman EM, et al. JAMA. 2000;284:835-842.
Mortality at 42 Days (% of Patients)
8
7.5
6.0
6
3.7
4
3.4 1.7
2
1.0
831
0
174
0.4 to <1.0
148
134
50
5.0 to <9.0
67
>9.0
0 to <0.4
1.0 to <2.0 2.0 to <5.0
Risk Ratio
Cardiac Troponin I (ng/ml)
B-type Natriuretic Peptide (BNP) and Mortality in ACS Patients
10 Quartile 4 (n=630)
8
P<.001
Mortality (%)
6
Quartile 3 (n=632) 4 Quartile 2 (n=632) 2 Quartile 1 (n=631) 0 0 50 100 150 200 250 300
P=.02
15
P<.0001
P=.001
10
5
0
ST MI 825 Non-ST MI 565 Unstable Angina 1133
de Lemos JA, et al. N Engl J Med. 2001;345:1014-1021. (with permission)
Multimarker Approach: Troponin I, CRP, and BNP to Predict 30-Day Mortality in ACS
CRP
Cumulative Probability of Death (%)
20 CRP >10mg/l (n=309) 20 Troponin T >0.60 µg/l (n=377) P=.001 CRP 2-10mg/l (n=294) 10 P=.29 10 Troponin T 0.60-0.59 µg/l (n=367) P=.001 CRP <2mg/l (n=314) Troponin T <0.60 µg/l (n=173) 0 0 6 12 18 24 30 36 42 48 0 0 6 12 18 24 30 36 42 48
C Statistic=0.65 c2 trend P<.001
40.9
26.2
Population (%): 4.3
17.3
Antman EM, et al. JAMA. 2000;284:835-442. (with permission)
TIMI Risk Score vs Prognosis in Unselected Patients (TIMI 3 Registry)
1.0 1.8 3.5 3.9 6.2 7.8
Antman EA, et al. N Engl J Med. 1996;335:1342-1349. (with permission)
Predictive Value of Troponin T and hs-CRP for Mortality from ACS in FRISC Substudy