非ST抬高ACS的風(fēng)險(xiǎn)評(píng)估及介入時(shí)機(jī)選擇培訓(xùn)教學(xué)課件

1、非ST段抬高急性冠脈綜合征風(fēng)險(xiǎn)評(píng)估及介入時(shí)機(jī)選擇ACS的病理生理基礎(chǔ)CK- MB or TroponinTroponin elevated or notAdapted from Michael DaviesAdapted from Michael Davies ACS 無持續(xù)ST段抬高 ACS 伴持續(xù)ST段抬高ACS的臨床分型ACSST 段持續(xù)抬高的 ACS無 ST 段抬高的 ACScTnT ( cTnI ) 0.1g/L或CK-MB正常上限的2倍cTnT ( cTnI ) 0.1g/L 或CK-MB50%) 7 天內(nèi)已服用阿斯匹林史24 小時(shí)內(nèi)心絞痛發(fā)作2 次ST段 改變心肌標(biāo)志物 (CK-

2、MB or 肌鈣蛋白)升高預(yù)測(cè)30和1年死亡率Antman EM, et al. JAMA. 2000;284:835-442. (with permission)TIMI積分與死亡、心梗、急診血管再建術(shù)復(fù)合終點(diǎn)的關(guān)系Population (%):4.78.313.219.926.240.9010203040500/123456/7TIMI 積分4.317.332.029.313.03.4C Statistic=0.65c2 trend P.001死亡/心梗/再血管化（）P.001P=.004P.001P.001Scirica BM, et al. Am J Cardiol. 2002;90:

3、303-305. (Copyright 2002, with permission from Excerpta Medica, Inc.)TIMI 3研究中 TIMI 積分與預(yù)后的關(guān)系TRS 0-2TRS 3-4TRS 5-70%10%20%30%40%50%DeathMIDeath/MIDeath/MI/RIEvent Rate at 1 year (%)CRUSADE出血危險(xiǎn)評(píng)分表Note: Heart rate is truncated 90 mL/min; Prior Vascular disease is defined as prior PAD or stroke預(yù)測(cè)因子范圍分值基

4、線血球壓積(%)15-3030-6060-9090-1201203935281770心率 (bpm) 7071-8081-9091-100101-110111-120 121013681011性別MaleFemale08有CHF征象 NoYes07既往血管性疾病NoYes06糖尿病NoYes06收縮壓 (mm Hg) 9091-100101-120121-180181-200 2011085135總分值：100CRUSADE出血評(píng)分系統(tǒng)推導(dǎo)人群71，277例患者驗(yàn)證人群17，857例嚴(yán)重出血發(fā)生率隨出血風(fēng)險(xiǎn)評(píng)分的逐漸增加而增高 危險(xiǎn)N最低分值最高分值出血% 極低危19,4861203.1% 低

5、危12,54521305.5% 中危11,53031408.6% 高危 10,961415011.9% 極高危15,210519119.5%基于CRUSADE出血危險(xiǎn)評(píng)分，患者按照五分位數(shù)進(jìn)行出血危險(xiǎn)分層評(píng)估 CRUSADE出血危險(xiǎn)評(píng)分越高，患者的出血風(fēng)險(xiǎn)越高CRUSADE 出血危險(xiǎn)分層評(píng)估p0.001 testing for trend注: 抗栓治療包括抗血小板(阿司匹林或氯吡格雷), 抗凝劑、或GP IIb/IIIa抑制劑 大出血風(fēng)險(xiǎn)抗栓藥物聯(lián)用越多，出血風(fēng)險(xiǎn)越高1.93.12.65.55.38.46.712.019.913.5出血風(fēng)險(xiǎn)0510152025大出血 (%)非常低低中等高非常高

6、2 種抗栓治療2 種抗栓治療*N = 50,969N = 5,931*p140肌鈣蛋白（Tn）隨時(shí)間改變新發(fā)或推測(cè)可能新發(fā)ST段壓低延遲侵入治療（25-72h內(nèi)）無上述表現(xiàn)的糖尿病患者腎功能不全（GFR60ml/min/1.73m2）左室收縮功能減退（EF140有創(chuàng)治療標(biāo)準(zhǔn)（二）次要標(biāo)準(zhǔn) 糖尿病 腎功能異常（GFR60ml/min/1.73m2） 左心室功能降低（LVEF 60, ischemic EKG or biomarker AND suitable for revascularizationRANDOMIZE*Early InvasiveCoronary angiography as

7、soon as possible (no later than 24 hours) followed by PCI or CABGDelayed InvasiveCoronary angiography any time 36 hrs followed by PCI or CABGASA, clopidogrel, GP IIb/IIIa antagonist as per routine practice*Center chose randomization ratio 1:1, 1:2 or 2:1 Early: DelayedExcludedContraindication for LM

8、WH or high risk of bleeding or not a suitable candidate for revascularizationFollow-up at 30 days and 6 monthsOutcomesPrimary Composite of Death, new MI or Stroke at 6 mo.SecondaryComposite of: Death, new MI or refractory ischemiaDeath, new MI, stroke, refractory ischemia or repeat revascularization

9、StrokeStudy Flow ChartTIMACS Stand AloneN=1,398TIMACSTotalN=3,031TIMACS OASIS 5N=1,633+30 Day and 6 month Follow-up 3,029Lost to Follow-up: 4Participating CountriesNorth America 650South America 442Europe 1065Asia 846Australia 28TIMACS Steering CommitteeA. Avezum BrazilC. Morillo - ColumbiaJ-P. Bass

10、and FranceL. Piegas BrazilW. Boden USAJ. Probstfield USAJ. Col BelgiumS. Qiao - ChinaR. Diaz ArgentinaH-J Rupprecht GermanyD. Faxon USAP. G. Steg FranceC. Granger USAJ-F. Tanguay-CanadaC. Joyner - CanadaP. Widimsky Czech RepM. Kenda SloveniaJ. Varigos AustraliaS. Mehta - CanadaS. Yusuf - CanadaT. Mo

11、ccetti SwitzerlandJ. Zhu ChinaCriteria for Crossover from Delayed Group to Early GroupRefractory ischemiaNew MIHemodynamic instabilityCrossover from Early to Delayed: 11.9%Crossover from Delayed to Early: 25% Interventions and TimingEarlyN=1,593DelayedN=1,438Coronary Angiography (%)97.695.5Median ti

12、me (h iqr)14 (3-21)50 (41-81)PCI (%)59.655.0Median time (h iqr)16 (3-23)52 (41-101)CABG (%)14.713.6Median time (d iqr)7.7 (4.7-17.4)10.8 (6.7-19.8)Iqr=interquartile rangePrimary and Secondary OutcomesEarlyN=1,593DelayedN=1,438HR 95% CIPDeath, MI, Stroke9.711.40.850.68-1.060.15Death, MI, refractory i

13、schemia9.613.10.720.58-0.890.002Death, MI, Stroke, refractory ischemia + repeat intervention16.719.70.840.71-0.990.039Death4.96.00.810.60-1.110.19MI4.85.80.830.61-1.140.25Stroke1.31.40.900.48-1.680.74Ref. Ischemia1.03.30.300.17-0.53= 3 g/dL2.32.6Transfusion 2 U2.22.9Pre-specified SubgroupsOverallAge

14、 =65FemaleMaleNo ST deviationST deviationNo elevated markerElevated MarkerGRACE 0-140GRACE =1413031129317361052197615231508668236320709619.76.512.39.79.87.611.710.59.57.714.10.4630.5400.7220.4230.00970.85 ( 0.68 - 1.06 )0.98 ( 0.64 - 1.52 )0.83 ( 0.64 - 1.07 )0.77 ( 0.54 - 1.12 )0.89 ( 0.68 - 1.18 )

15、0.88 ( 0.62 - 1.26 )0.81 ( 0.61 - 1.07 )1.00 ( 0.62 - 1.60 )0.81 ( 0.63 - 1.04 )1.14 ( 0.82 - 1.58 )0.65 ( 0.48 - 0.88 )NCharacteristicHR (95% CI)Interaction p-Value0.330.50.71.001.52.03.0Early better Delayed better Hazard Ratio (95% CI)Early%11.4 6.514.812.310.98.714.310.511.76.721.6Delayed% GRACE

16、Risk Score: Primary OutcomeHR 1.1495% CI 0.82-1.58P=0.43 HR 0.6595% CI 0.48-0.88P=0.005Interaction P=0.0097Low/Int RiskGRACE Score = 140N=961Death, MI or Stroke at 6 mo.ConclusionsOverall, we found no significant difference between an early and a delayed invasive strategy for prevention of death, MI

17、 or stroke (primary outcome).However, in the subgroup at highest risk (GRACE score 140), an early invasive strategy was superior to a delayed invasive strategy for prevention of death, MI or strokeThe early invasive strategy also had a large impact on reducing the rate of refractory ischemia by 70%.

18、There were no significant differences in major bleeding or other safety concerns between the two strategiesImplicationsMost patients with ACS can be managed safely with either an early or a delayed invasive strategyIn a subset of patients at highest risk (GRACE score140), early intervention is super

19、ior and these patients should be taken to the cath lab as early as possibleIn all other patients, the decision regarding timing of intervention can depend on other factors, such as cath lab availability and economic considerations.薈萃分析包括ABORD、ELISA、ISAR-COOL和 TIMACS、OPTIMA、PURSUIT、ACUITY七項(xiàng)臨床試驗(yàn) 納入137

20、62例NST-ACS患者比較早期介入（24h）和延遲介入（24h）Rajpurohit N, Catheter Cardiovasc Interv. 2013,81:223-31 死亡或心肌梗死死亡心肌梗死大出血結(jié)論該薈萃分析表明NSTEMI患者的早期介入策略30天臨床療效不劣于延遲介入策略早期介入策略大出血事件明顯下降該薈萃僅有TIMACS和PURSUIT研究有高?；颊邤?shù)據(jù)，因此未能對(duì)高危亞組進(jìn)行分析介入時(shí)機(jī) NSTE-ACS患者早期介入治療心血管獲益增加 基于危險(xiǎn)分層，指南對(duì)NSTE-ACS患者推薦介入治療時(shí)間進(jìn)一步前移3,4Neumann FJ et al. JAMA 2003;290:1593-1599.Mehta SR et al. NEJM 2009;360:2165-75 Amsterdam EA, et al. Circulation. 2014 Sep