急性冠脈綜合征(ACS)及其治療進展培訓(xùn)課件

1、急性冠脈綜合征（ACS）及其治療進展急性冠脈綜合征（ACS）及其治療進展 急性冠狀動脈綜合征的定義和分類 定義：急性冠狀動脈綜合征(acute coronary syndomes , ACS) 是從不穩(wěn)定性心絞痛到Q波心肌梗死的一組臨床綜合征 ，通常(但并非總是)由于CAD所致，在病理生理上有很多相似之處。急性冠狀動脈綜合征的分類 ： ST段不抬高的急性冠狀動脈綜合征 非Q波心肌梗死NSTEMI（CK-MB大于正常上限的2倍） 不穩(wěn)定性心絞痛UAP（CK-MB小于正常上限的2倍） ST段抬高的急性冠狀動脈綜合征 急性Q波心肌梗死STEMI 5/982急性冠脈綜合征（ACS）及其治療進展 急性冠

2、狀動脈綜合征的定義和分類 定義：急性冠狀動脈綜合征(國際現(xiàn)狀每年: 4 million patients are admitted with unstable angina and acute MI 900,000 patients undergo PTCA with or without stent5/983急性冠脈綜合征（ACS）及其治療進展國際現(xiàn)狀每年:5/983急性冠脈綜合征（ACS）及其治療進展Ischemic Heart DiseaseevaluationBased on the patientshistory / physical examelectrocardiogramPat

3、ients are categorized into 3 groupsnon-cardiac chest painunstable anginamyocardial infarction5/984急性冠脈綜合征（ACS）及其治療進展Ischemic Heart Diseaseevaluat急性冠脈綜合征（ACS）ACS非 ST-segment抬高 ST-segment抬高不穩(wěn)定 非-Q波Q-Wave心絞痛 AMI AMIECGAcuteReperfusionHistoryPhysical Exam5/985急性冠脈綜合征（ACS）及其治療進展急性冠脈綜合征（ACS）ACS非 ST-segmen

4、t抬Acute Coronary SyndromeThe spectrum of clinical conditions ranging from:unstable anginanon-Q wave MIQ-wave MIcharacterized by the common pathophysiology of a disrupted atheroslerotic plaque5/986急性冠脈綜合征（ACS）及其治療進展Acute Coronary SyndromeThe spe5/987急性冠脈綜合征（ACS）及其治療進展5/987急性冠脈綜合征（ACS）及其治療進展STEMI和UA/N

5、STEMI病理5/988急性冠脈綜合征（ACS）及其治療進展STEMI和UA/NSTEMI病理5/988急性冠脈綜合征（不穩(wěn)定心絞痛 定義angina at rest ( 20 minutes)new-onset ( 2 months) exertional angina (at least CCSC III in severity)recent ( 2Non-Q-Wave MIclues to diagnosisProlonged chest painAssociated symptoms from the autonomic nervous systemnausea, vomiting,

6、diaphoresisPersistent ST-segment depression after resolution of chest pain 5/9810急性冠脈綜合征（ACS）及其治療進展Non-Q-Wave MIclues to diagnos5/9811急性冠脈綜合征（ACS）及其治療進展5/9811急性冠脈綜合征（ACS）及其治療進展NSTEACS誘發(fā)因素Inappropriate tachycardiaanemia, fever, hypoxia, tachyarrhythmias, thyrotoxicosisHigh afterloadaortic valve steno

7、sis, LVHHigh preloadhigh cardiac output, chamber dilatationInotropic statesympathomimetic drugs, cocaine intoxication5/9812急性冠脈綜合征（ACS）及其治療進展NSTEACS誘發(fā)因素Inappropriate tachNSTEACS預(yù)后預(yù)測因素 Presence of ST-T-wave changes with painHemodynamic deteriorationpulmonary edema, new mitral regurgitation,3rd heart

8、sound, hypotensionOther predictorsleft ventricular dysfunction, extensive CAD, age, comorbid conditions (diabetes mellitus, obstructive pulmonary disease, renal failure, malignancy) 5/9813急性冠脈綜合征（ACS）及其治療進展NSTEACS預(yù)后預(yù)測因素 Presence of ST非ST段抬高ACS（NSTEACS）Plaque disruption斑塊破裂Acute thrombosis急性血栓Vasocon

9、striction血管收縮5/9814急性冠脈綜合征（ACS）及其治療進展非ST段抬高ACS（NSTEACS）5/9814急性冠脈綜合NSTEACSpathogenesis斑塊破裂Passive plaque disruptionsoft plaque with high concentration of cholesteryl esters and a thin fibrous capActive plaque disruptionmacrophage-rich area with enzymes that may degrade and weaken the fibrous cap; pr

10、edisposing it to rupture 5/9815急性冠脈綜合征（ACS）及其治療進展NSTEACSpathogenesis斑塊破裂5/9815NSTEACS pathogenesis急性血栓Vulnerable plaquedisrupted plaque with ulcerationoccurring in 2/3 of unstable patientsthe exposed lipid-rich core abundant in cholesteryl ester is highly thrombogenic Systemic Hypercoagulable Stated

11、isrupted plaque with erosionoccurring in 1/3 of unstable patients5/9816急性冠脈綜合征（ACS）及其治療進展NSTEACS pathogenesis急性血栓5/981NSTEACS pathogenesis血管收縮the culprit lesion in response to deep arterial damage or plaque disruptionarea of dysfunctional endothelium near the culprit lesionplatelet-dependent and thr

12、ombin-dependent vasoconstriction, mediated by serotonin and thromboxane A25/9817急性冠脈綜合征（ACS）及其治療進展NSTEACS pathogenesis血管收縮5/981Risk Stratification by ECGThe risk of death or MI at 30 days is strongly related to the ECG at the time of chest pain.ST depression 10%T-wave inversion 5%No ECG changes1-2%5

13、/9818急性冠脈綜合征（ACS）及其治療進展Risk Stratification by ECGThe有以下表現(xiàn)者為高危險性：(1) 危險性隨病變血管支數(shù)、病變彌漫程度、小血管病變、閉 塞血管病變數(shù)而增高。(2) 左主干病變(3) 含血栓性病變(見圖1) (4) 病變形態(tài)復(fù)雜,行介入治療難以或無法植入支架。(見圖2) 圖1 圖2冠脈造影5/9819急性冠脈綜合征（ACS）及其治療進展有以下表現(xiàn)者為高危險性：(1) 危險性隨病變血管支數(shù)、NSTEACS治療目標(biāo)Therapeutic Goals減少心肌缺血 控制癥狀 預(yù)防心肌梗死和猝死Medical Management抗缺血 therapy抗

14、血栓 therapy5/9820急性冠脈綜合征（ACS）及其治療進展NSTEACS治療目標(biāo)Therapeutic Goals5藥物治療抗缺血 therapynitrates, beta blockers, calcium antagonists抗血栓 therapy抗血小板 therapyaspirin, ticlopidine, clopidogrel, GP IIb/IIIa inhibitors抗凝 therapy heparin, low molecular weight heparin (LMWH), warfarin, hirudin, hirulog5/9821急性冠脈綜合征（A

15、CS）及其治療進展藥物治療抗缺血 therapy5/9821急性冠脈綜合征（5/9822急性冠脈綜合征（ACS）及其治療進展5/9822急性冠脈綜合征（ACS）及其治療進展NSTEACSAnti-thrombotic Therapy不適宜溶栓“l(fā)ytic agents may stimulate the thrombogenic process and result in paradoxical aggravation of ischemia and myocardial infarction”TIMI IIIB InvestigatorsCirculation 1994; 89:1545-1

16、5565/9823急性冠脈綜合征（ACS）及其治療進展NSTEACSAnti-thrombotic Therap5/9824急性冠脈綜合征（ACS）及其治療進展5/9824急性冠脈綜合征（ACS）及其治療進展Unstable AnginaAnti-platelet Therapy阿司匹林是“金標(biāo)準(zhǔn)”irreversible inhibition of the cyclooxygenase pathway in platelets, blocking formation of thromboxane A2, and platelet aggregationin AMI, ASA reduced

17、the risk of death by 20-25%in UA, ASA reduced the risk of fatal or nonfatal MI by 71% during the acute phase, 60% at 3 months, and 52% at 2 yearsbolus dose of 160-325 mg, followed by maintenance dose of 80-160 mg/d5/9825急性冠脈綜合征（ACS）及其治療進展Unstable AnginaAnti-platelet 缺血事件發(fā)生率無阿司匹林(early 1980s)阿司匹林Aspi

18、rin + Heparin16%12%9%Incidence of death and MI5/9826急性冠脈綜合征（ACS）及其治療進展缺血事件發(fā)生率無阿司匹林(early 1980s)阿司匹林Unstable AnginaAnti-platelet TherapyClopidogrel氯比格雷CAPRIE (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events)19,000 patients randomly assigned to clopidogrel (75 mg/d) or to aspirin (32

19、5 mg/d)there was an 8.7% reduction in the combined incidence of stroke, MI, or death (P=.043)patients with MI did better with aspirinpatients with PVD or stroke did better with clopidogrelLancet 1996;348:1329-1339Circulation 1998;97:11075/9827急性冠脈綜合征（ACS）及其治療進展Unstable AnginaAnti-platelet GP IIb/III

20、a Receptor血小板聚集的最終通路Platelet activation and aggregation are early events in the development of coronary thrombosisGP IIb/IIIa receptors on activated platelets undergo a conformational change allowing recognition and binding of fibrinogenFibrinogen “acts like glue”, bridging GP IIb/IIIa receptors on

21、adjacent platelets, leading to platelet aggregation5/9828急性冠脈綜合征（ACS）及其治療進展GP IIb/IIIa Receptor血小板聚集的最終通Unstable AnginaAnti-platelet TherapyTirofiban (Aggrastat; Merk & Co.)PRISM (Platelet Receptor Inhibition for Ischemic Syndrome Management)3,200 patients with unstable angina were treated with eith

22、er heparin or tirofibanAt 48 hours, there was significant risk reduction (5.9% to 3.6%) in the rate of death, MI, or refractory ischemia. The benefit was lost at 30 days.N Engl J Med 1998;338:1498-5055/9829急性冠脈綜合征（ACS）及其治療進展Unstable AnginaAnti-platelet 5/9830急性冠脈綜合征（ACS）及其治療進展5/9830急性冠脈綜合征（ACS）及其治療進

23、展調(diào)脂治療他汀類藥物5/9831急性冠脈綜合征（ACS）及其治療進展調(diào)脂治療5/9831急性冠脈綜合征（ACS）及其治療進展急性冠脈綜合征(ACS)及其治療進展培訓(xùn)課件ACS 的治療策略進展冠脈綜合征治療策略進展主要表現(xiàn)在以下三個方面：(1) 抗血小板制劑：包括阿斯匹林,ADP受體拮抗劑(抵克力得Ticlopidine、氯吡格雷Clopidogrel )和GPb / a 受體拮抗劑(Rrepro)(2) 抗凝制劑：包括肝素、低分子肝素(LMWH)、凝血酶抑制劑(水蛭素 Hirudin )和戊聚糖鈉(3) 介入治療5/9833急性冠脈綜合征（ACS）及其治療進展ACS 的治療策略進展冠脈綜合征治

24、療策略進展主要表現(xiàn)在以下三Unstable Angina 介入治療TIMI 3B early intervention vs conservative strategy(coronary angiography within 24-48 hrs, followed by angioplasty or bypass surgery)1473 patients with UA or non-Q-wave MI were randomized, there were no difference between the groups in the rates of death or MI at 1 y

25、earCirculation 1994;89:1545-15565/9834急性冠脈綜合征（ACS）及其治療進展Unstable Angina 介入治療TIMI 3B C非ST段抬高ACS的PCI 復(fù)發(fā)靜息心絞痛 動態(tài)ST段改變：ST壓低0.1mv或一過性抬 高 0.1mv TnT、TnIC或CK-MB升高血流動力學(xué)不穩(wěn)定室速、室顫AMI后不穩(wěn)定心絞痛糖尿病 高?；颊呖赡苎杆侔l(fā)生血栓事件，進展為嚴(yán)重AMI或死亡，專家建議常規(guī)置入支架5/9835急性冠脈綜合征（ACS）及其治療進展非ST段抬高ACS的PCI 復(fù)發(fā)靜息心絞痛5/9835急性冠AMI的再灌注治療 溶栓治療 介入治療 5/9836急性

26、冠脈綜合征（ACS）及其治療進展AMI的再灌注治療 溶栓治療 再灌注策略危險和獲益 時間 靜脈溶栓5/9837急性冠脈綜合征（ACS）及其治療進展再灌注策略危險和獲益 時間 再灌注開始的時間與獲益5/9838急性冠脈綜合征（ACS）及其治療進展再灌注開始的時間與獲益5/9838急性冠脈綜合征（ACS）及ST段抬高ACS的再灌注-溶栓優(yōu)先溶栓治療： AMI患者來院3小時 不能行PCI PCI慢（D-TO-B90分鐘）5/9839急性冠脈綜合征（ACS）及其治療進展ST段抬高ACS的再灌注-溶栓優(yōu)先溶栓治療：5/9介入治療的優(yōu)點 梗塞相關(guān)血管（IRA）開通率 開通率 95% TIMI-3級率 90% 死亡率低 30天3% 腦卒中率低 再閉塞率低 適應(yīng)癥范圍廣5/9840急性冠脈綜合征（ACS）及其治療進展介入治療的優(yōu)點 5/9840急性冠脈綜合征（AST段抬高ACS的再灌注-PCI優(yōu)先PCI治療： AMI患者來院3小時 PCI條件好（D-TO-B90分鐘） 高危STEMI患者: 心源性休克或合并心衰 溶栓禁忌者 疑診AMI5/9841急性冠脈綜合征（ACS）及其治療進展ST段抬高ACS的再灌注-PCI優(yōu)先PCI治療：5ACCAHA有關(guān)