急性冠脉综合征的介入治疗

Savonitto S, et al. J Am Med Asoc 1999; 281:707-713
Anemia in NSTE ACS: ST deviation
80 75
ST deviation (%)
p <0.001
70 65 60 55 50
<8 8-<9 9-<10 10-<11 11-<12 12-<13 13-<14 14-<15 15-<16 16-<17 ≥ 17
溶栓治疗后的挽救性PCI
影响及时灌注治疗的问题
病人方面： 认识症状晚 求治晚 转运晚 转运时间方面： 4－5％急诊病人为STEMI 10％救护车有12导心电图机 要求转运到最近的医院 农村病人转运时间长
影响及时灌注治疗的问题
到达时的决策过程： 溶栓或PCI 下班、周末或节假日 到达晚、合并症、无胸痛 经济、家属问题和体制问题 执行决策的时间： 集结人员 人员、设备、器材等因素
ST Depression is a Major Predictor of Mortality in Patients Presenting with NSTE ACS
15 12 9
% mortality at 6 months1
PARAGON-A GUSTO IIb
6
3 0
No ST
1-2mm 2mm
1994
PCI
1995 1996
1997
1998 1999
2000 2001
2002 2003
2004
2005
2006
~ 5% stents
~85% stents
Drug-eluting stents
Ischemic risk
Bleeding risk
Adapted from and with the courtesy of Steven Manoukian, MD.
50 40 30 19.9 20 10 0 0/1 2 3 4 5 Number of risk factors 32.0 29.3 13.0 4.7 8.3 13.2
40.9
26.2
6/7 3.4
Population (%): 4.3
17.3
Antman EM, et al. JAMA. 2000;284:835-442. (Copyright 2000 American Medical Association. All rights reserved)
ST depression ACS
ST elevation MI treated with thrombolytics T-wave inversion ACS
30
60
90
120
150
180
Days from randomization
Granger CB et al. J Am Coll Cardiol. 1998;31:79A.
ACC/AHA UAP/NSTEMI治疗指南（2007）
UA/NSTEMI ASA, Clopidogrel if ASA Intolerant Select Management Strategy Conservative Therapy: Anticoagulant Therapy – enoxaparin or UFH or fondaparinux
PRISM-PLUS PURSUIT ESSENCE TACTICS TIMI-18
LMWH
Bivalirudin
[ Fondaparinux ]
Clopidogrel
Early invasive
REPLACE 2 CURE OASIS-5 ICTUS ISAR-REACT 2 ACUITY
SYNERGY
早期介入的益处
STEMI的急诊PCI治疗
急诊PCI的优势
急诊PCI的优势
Mortality over 6 months from Primary Coronary Angioplasty Trialists (PCAT) analysis of 11 randomized trials .
急诊PCI的优势
(95% CI) p value 1.45 (0.94-2.23) 0.093 1.27 1.0 1.11 1.04 1.07 1.04 (0.98-1.65) reference (0.93-1.33) (0.86-1.24) (0.88-1.30)
0.066
0.251
0.709
0.514
12-13
急性冠脉综合征的介入治疗
首都医科大学附属朝阳医院心脏中心 王乐丰
ACS病理变化
ACS的病理变化

Thrombus propagation. A, Left anterior descending coronary artery cut open longitudinally, showing a dark stagnation thrombosis propagating upstream from the initiating rupture/platelet-rich thrombus at the arrow. In this case the thrombus has propagated proximally up to the nearest major side branch (the first diagonal branch). B, The right coronary artery cut open longitudinally, showing a huge stagnation thrombosis propagating downstream from the initiating rupture/platelet-rich thrombus at the arrow. Unlike upstream thrombus propagation, downstream propagation may, as in this case, occlude major side branches. c = contrast medium injected postmortem; O = coronary ostium. (From Falk E: Coronary thrombosis: Pathogenesis and clinical manifestations. Am
PPCI再灌注策略
STEMI病人到达一所医院，如果有专家能够在90 分钟内进行PPCI且无禁忌征，应该首选进行PPCI。 （ I 类 A 级 证 据 水 平 ）
STEMI病人到达一所医院，它没有专家能够在90 分钟内进行PPCI，如果没有禁忌征的话，应该进 行溶栓治疗。（I类A级证据水平） 对于溶栓治疗不成功的病人，应该积极进行冠脉 造影和挽救PCI。
Mean reduction in door-to-balloon times by strategy
Strategy Having emergency medicine physicians activate the cath lab Having a single call to a central page operator activate cath lab Mean reduction in door-toballoon time (min) 8.2 13.8
10.0
百度文库
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)
Cardiol 68:28B, 1991
ACS即时处理
ACS 的治疗策略
ACS治疗的里程碑
Anti-Thrombin Rx Heparin Anti-Platelet Rx GP IIb/IIIa Aspirin blockers Treatment Strategy Conservative
TIMI risk score for UA/NSTEMI
Age >65 years
C Statistic=0.65
>3 CAD risk factors D/MI/Urg revasc (%)
c2 trend P<.001
Prior stenosis >50 %
ST deviation >2 anginal events <24 hours ASA in last 7 days Elev cardiac markers (CK-MB or troponin)
ST
ST
No ST
1-2mm 2mm
ST
ST
Kaul P, et al. J Am Coll Cardiol 2001; 38: 64-71.
ST压低患者较ST太高者危险因素更多
ST
Prior MI Prior CABG Surgery Prior PCI Prior Angina Hypertension Diabetes Hypercholesterolemia Prior CHF 20% 6% 6% 52% 41% 17% 36% 4%
Hgb (g/dL)
Anemia in NSTE ACS: Adjusted OR for CV death/MI/RI
OR >17 16-17 15-16 14-15 13-14 216 812 2130 3390 3520
Hgb (g/dL) n Adjusted OR & 95% CI for CV death/MI/RI at 30 d
Having the ED activate the cath lab while patient still en route
Expecting staff to arrive at cath lab within 20 minutes after page
15.4
19.3
Having an attending cardiologist always on site 14.6 Having staff in ED and cath lab use and receive real-time feedback Bradley EH et al. N Engl J Med 2006; 8.6
11-12 10-11 9-10 8-9 <8
2331
976 343 342 306 137
0.5 1.0 2.0 5.0
(0.81-1.34) 0.755
1.29
2.69 2.45 3.49
(0.92-1.84) 0.145
(2.01-3.60) <0.001
(1.80-3.33) <0.001
(2.35-5.20) <0.001
UAP/NSTEMI的介入治疗
ACC/AHA UAP/NSTEMI治疗指南（2007）
ACC/AHA UAP/NSTEMI治疗指南（2007）
6-month Mortality for Acute Coronary Syndromes
10% 8% 6% 4% 2% 0% 0
% Cumulative mortality at 6 months
BNP and Risk of Death in ACS
20 Q1
Mortality at 10 mo (%)
Q2
Q3
Q4
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)
ST
32% 13% 13% 78% 51% 20% 42% 8%
Savonitto S, et al. J Am Med Asoc 1999; 281:707-713.
ST压低患者较ST太高者危险因素更多
ST No. diseased vessels 0 1 2 3 (n=1864) 10% 45% 27% 18% ST (n=2170) 11% 26% 28% 36%
急诊PCI的优势
心肌Blush分级与死亡率的关系
MBG=myocardial blush grade
急诊PCI临床结果与发病时间
急诊PCI延迟时间与临床结果
急诊PCI延迟时间与临床结果
急诊PCI延迟时间与临床结果
急诊PCI延迟时间与临床结果
急诊PCI延迟时间与临床结果
急诊PCI延迟时间与临床结果