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IsearlyinvasivetheanswerforACSDr.BenHeMD/PhD/FSCAI/FAPSICDirectorofCardiologyDepartmentRenjiHospitalAffiliatedtoShanghaiJiaotonguniversity編輯課件Isearlyinvasivetheanswerf1PathophysiologyofAcuteCoronarySyndrome編輯課件PathophysiologyofAcuteCoron2ACSisanImportantManifestationofAtherothrombosis11.CannonCP.JThrombThrombolysis1995;2:205–218.AntithrombotictherapyStableanginaUANon-

Q-waveMIThrombolysisprimaryPCIQ-waveMIMinutes–

hoursDays–weeksSTEMIUA/NSTEMIAtherothrombosisNewtermOldtermPlaque

rupture編輯課件ACSisanImportantManifestat3編輯課件編輯課件4RelationofTIMIriskscoreandMACErate編輯課件RelationofTIMIriskscorean5HottopicinACSIsearlyinvasivesuperiortoconservativestrategyinACS?Shouldinvasivebedeferredforcoolingoff?

Whatistheoptimaltimeforinvasive?編輯課件HottopicinACS編輯課件6編輯課件編輯課件7OptimalStrategyforUA/NSTEMITIMIIIIB2005ConservativeInvasiveVANQWISHFRISCIITACTICS-

TIMI18RITA-3編輯課件OptimalStrategyforUA/NSTEMI8FRICS-II:highriskgetmore編輯課件FRICS-II:highriskgetmore編輯9TIMI-18:highriskgetmore編輯課件TIMI-18:highriskgetmore編輯課10RITA-3:1&3yrsoutcome編輯課件RITA-3:1&3yrsoutcome編輯課件11RITA-3:5yrsoutcome編輯課件RITA-3:5yrsoutcome編輯課件12編輯課件編輯課件13編輯課件編輯課件14編輯課件編輯課件15In2005,ItseemswefoundanswerInACS,earlyinvasivesuperiortoearlyconservativeThisisparticulartrueinhighriskpatients編輯課件In2005,Itseemswefoundansw16ESCGuideline2005編輯課件ESCGuideline2005編輯課件17編輯課件編輯課件18Istheproblemsettled?編輯課件Istheproblemsettled?編輯課件19ICTUSDesigned編輯課件ICTUSDesigned編輯課件20編輯課件編輯課件21編輯課件編輯課件22編輯課件編輯課件23編輯課件編輯課件24編輯課件編輯課件25編輯課件編輯課件264yrsICTUSLancet2007;369:827-835However,mostofselectiveptswereperformedPCISo,thelong-termf/uresultsdonotinflectInv/Consstrategy編輯課件4yrsICTUSLancet2007;369:274yrsICTUSLancet2007;369:827-835編輯課件4yrsICTUSLancet2007;369:28ICTUS’scriticism

LibertydefinitionofMI(only1*ULN)causingtheearlyMIincreaseinearlyinvasivegroup3yrsrevascularizationratewasequalin2group(81%PCI)1yearmortalityrateinACSinbotharmareverylow(2.5%),Isitarealhighrisk?編輯課件ICTUS’scriticismLibertydefi29EvenputICTUSintopool,Inv>Cons編輯課件EvenputICTUSintopool,Inv30InvvsCons/AllcausedeathHighrisk?編輯課件InvvsCons/AllcausedeathHi31編輯課件編輯課件32編輯課件編輯課件332007ESCGuidelineUrgentCoronaryangiographyisrecommendedinPtswithrefractoryorrecurrentanginaassociatedwithdynamicSTdeviation,heartfailure,lifethreateningarrhythmias,orhaemodynamicinstability(I-C)Early(<72h)angiographyfollowedbyrevascularization(PCIorCABG)inpatientswithintermediatetohighriskfeaturesisrecommended(I-A)編輯課件2007ESCGuidelineUrgentCoron34MonocyteLDL-CAdhesion

moleculeMacrophageFoamcellOxidized

LDL-CPlaqueruptureSmoothmuscle

cellsCRP2編輯課件MonocyteLDL-CAdhesion

molecul35ISAR-COOLTrial編輯課件ISAR-COOLTrial編輯課件36ISAR-COOLAntithromboticRegimen編輯課件ISAR-COOLAntithromboticRegim37編輯課件編輯課件38ISAR-COOL編輯課件ISAR-COOL編輯課件39編輯課件編輯課件40編輯課件編輯課件41編輯課件編輯課件42WhatistheoptimaltimeforPCI?編輯課件WhatistheoptimaltimeforP43編輯課件編輯課件44MethodsforOptimaltrial編輯課件MethodsforOptimaltrial編輯課件45ResultsofOptimaltrial編輯課件ResultsofOptimaltrial編輯課件46ConclusionfromOptimaltrial編輯課件ConclusionfromOptimaltrial編47What’sthedifferencebetweenISAR-Cool&Optimal?2.5vs84+0.5vs25-編輯課件What’sthedifferencebetween48TimetoCoronaryAngiographyandOutcomesAmongPatientsWithHigh-RiskNon–ST-Segment–ElevationAcuteCoronarySyndromes:ResultsFromtheSYNERGYTrial

PierluigiTricoci,MD,MHS,PhD;YuliyaLokhnygina,PhD;LisaG.Berdan,PA-C,MHS;StevenR.Steinhubl,MD;DietrichC.Gulba,MD;HarveyD.White,MD;NealS.Kleiman,MD;PhilipE.Aylward,MD;AnatolyLanger,MD;RobertM.Califf,MD;JamesJ.Ferguson,MD;ElliottM.Antman,MD;L.KristinNewby,MD,MHS;RobertA.Harrington,MD;ShaunG.Goodman,MD;KennethW.Mahaffey,MDDivisionofCardiology,DukeClinicalResearchInstitute,Durham,NC編輯課件TimetoCoronaryAngiographya49Background2007ACC/AHAGuidelinesforNSTEACSrecommendtheuseofanearlyinvasivestrategyforhigh-riskpatientsRandomizedclinicaltrialsonearlyvs.conservativestrategyuseddifferenttimingofcardiaccatheterizationOptimaltimingofcardiaccatheterizationinNSTEACSnotyetestablished(expeditedvs.deferred)ExpeditedcatheterizationincreasinglyadoptedintheUS編輯課件Background2007ACC/AHAGuideli50StudyObjectiveToevaluatetheassociationbetweentimefromhospitaladmissiontocardiaccatheterizationandadverseoutcomesamonghigh-riskpatientswithNSTEACStreatedwithanearlyinvasivestrategy(cardiaccatheterization<48hofhospitaladmission)編輯課件StudyObjectiveToevaluatethe51StudyPopulationPatientsrandomizedintheSYNERGYtrial

Ischemicsymptoms<24handatleast2of3high-riskfeatures

Age>60yearsST-segmentdepressionortransientelevationPositivetroponinand/orCK-MBUseofcoronaryangiographyinSYNERGY10,027ptsrandomizedintheSYNERGYtrial9,188ptsunderwentcardiaccatheterization6,352ptsunderwentcardiaccatheterization<48h編輯課件StudyPopulationPatientsrando52AdjustedEstimatesof30-dayDeath/MIRates(with95%CI).0.0編輯課件AdjustedEstimatesof30-dayD53LandmarkAnalysis:AdjustedORof30-dayDeath/MI(with95%CI)編輯課件LandmarkAnalysis:AdjustedOR54AdjustedEstimatesofIn-hospitalTransfusionRates

(with95%CI)編輯課件AdjustedEstimatesofIn-hospi55StudyLimitationsNon-randomizedobservationalanalysisPropensity-basedmodelsusedtodealwithlackofrandomizationTimetocathisapost-baselineand“dynamic”variableStatisticalmethodologiesattemptedtoaddresstheseissues

EventsfromhospitaladmissiontorandomizationnotavailableEventsunlikelypriortorandomizationMyocardialinfarctioninthefirsthoursfollowingthehospitalizationismoredifficulttoadjudicate編輯課件StudyLimitationsNon-randomize56ConclusionsfromSynergy-1Observationalanalysisamonghigh-riskNSTEACSpatientsenrolledintheSYNERGYtrialtreatedwithanearlyinvasivestrategyReducedtimetocardiaccatheterizationwasassociatedwithdecreasedprobabilityof30-daydeath/MIandnochangesinbleedingNosignalssuggestingbenefitsofdelayingthecardiaccatheterizationwereobserved編輯課件ConclusionsfromSynergy-1Obs57ConclusionsfromSynergy-2RandomizedclinicaltrialstoestablishoptimaltimingofcatheterizationinNSTEACSareneededbutchallengingDelayingcathisproblematicforhospitaladoptingexpeditedcathstrategyLagfromhospitalizationtorandomizationmayconfoundactualtimetocatheterizationintervalsEarlyre-MIadjudicationcomplexWell-designedobservationalstudiesmaybeofvalueinthedebateonoptimaltimingofcardiaccatheterizationamongNSTEACSpatients編輯課件ConclusionsfromSynergy-2Ran58Conclusion&ProspectiveACS,earlyinvasiveissuperiortoearlyconservativeinmostPtsespeciallyhighriskImmediateinvasivestrategyisrecommendedinveryhighrisk(instabilityofhemodynamicorelectricity)Inhighriskpts,short-term(24hrs)cooling-offmaybebenefited(butnomorethan48hs)Inlowrisk,espinwomen,earlyconservativecanbechosenNewantiplateletdrugmaychangepractice編輯課件Conclusion&ProspectiveACS,e59Thankyouforyourattention編輯課件Thankyouforyourattention編輯60IsearlyinvasivetheanswerforACSDr.BenHeMD/PhD/FSCAI/FAPSICDirectorofCardiologyDepartmentRenjiHospitalAffiliatedtoShanghaiJiaotonguniversity編輯課件Isearlyinvasivetheanswerf61PathophysiologyofAcuteCoronarySyndrome編輯課件PathophysiologyofAcuteCoron62ACSisanImportantManifestationofAtherothrombosis11.CannonCP.JThrombThrombolysis1995;2:205–218.AntithrombotictherapyStableanginaUANon-

Q-waveMIThrombolysisprimaryPCIQ-waveMIMinutes–

hoursDays–weeksSTEMIUA/NSTEMIAtherothrombosisNewtermOldtermPlaque

rupture編輯課件ACSisanImportantManifestat63編輯課件編輯課件64RelationofTIMIriskscoreandMACErate編輯課件RelationofTIMIriskscorean65HottopicinACSIsearlyinvasivesuperiortoconservativestrategyinACS?Shouldinvasivebedeferredforcoolingoff?

Whatistheoptimaltimeforinvasive?編輯課件HottopicinACS編輯課件66編輯課件編輯課件67OptimalStrategyforUA/NSTEMITIMIIIIB2005ConservativeInvasiveVANQWISHFRISCIITACTICS-

TIMI18RITA-3編輯課件OptimalStrategyforUA/NSTEMI68FRICS-II:highriskgetmore編輯課件FRICS-II:highriskgetmore編輯69TIMI-18:highriskgetmore編輯課件TIMI-18:highriskgetmore編輯課70RITA-3:1&3yrsoutcome編輯課件RITA-3:1&3yrsoutcome編輯課件71RITA-3:5yrsoutcome編輯課件RITA-3:5yrsoutcome編輯課件72編輯課件編輯課件73編輯課件編輯課件74編輯課件編輯課件75In2005,ItseemswefoundanswerInACS,earlyinvasivesuperiortoearlyconservativeThisisparticulartrueinhighriskpatients編輯課件In2005,Itseemswefoundansw76ESCGuideline2005編輯課件ESCGuideline2005編輯課件77編輯課件編輯課件78Istheproblemsettled?編輯課件Istheproblemsettled?編輯課件79ICTUSDesigned編輯課件ICTUSDesigned編輯課件80編輯課件編輯課件81編輯課件編輯課件82編輯課件編輯課件83編輯課件編輯課件84編輯課件編輯課件85編輯課件編輯課件864yrsICTUSLancet2007;369:827-835However,mostofselectiveptswereperformedPCISo,thelong-termf/uresultsdonotinflectInv/Consstrategy編輯課件4yrsICTUSLancet2007;369:874yrsICTUSLancet2007;369:827-835編輯課件4yrsICTUSLancet2007;369:88ICTUS’scriticism

LibertydefinitionofMI(only1*ULN)causingtheearlyMIincreaseinearlyinvasivegroup3yrsrevascularizationratewasequalin2group(81%PCI)1yearmortalityrateinACSinbotharmareverylow(2.5%),Isitarealhighrisk?編輯課件ICTUS’scriticismLibertydefi89EvenputICTUSintopool,Inv>Cons編輯課件EvenputICTUSintopool,Inv90InvvsCons/AllcausedeathHighrisk?編輯課件InvvsCons/AllcausedeathHi91編輯課件編輯課件92編輯課件編輯課件932007ESCGuidelineUrgentCoronaryangiographyisrecommendedinPtswithrefractoryorrecurrentanginaassociatedwithdynamicSTdeviation,heartfailure,lifethreateningarrhythmias,orhaemodynamicinstability(I-C)Early(<72h)angiographyfollowedbyrevascularization(PCIorCABG)inpatientswithintermediatetohighriskfeaturesisrecommended(I-A)編輯課件2007ESCGuidelineUrgentCoron94MonocyteLDL-CAdhesion

moleculeMacrophageFoamcellOxidized

LDL-CPlaqueruptureSmoothmuscle

cellsCRP2編輯課件MonocyteLDL-CAdhesion

molecul95ISAR-COOLTrial編輯課件ISAR-COOLTrial編輯課件96ISAR-COOLAntithromboticRegimen編輯課件ISAR-COOLAntithromboticRegim97編輯課件編輯課件98ISAR-COOL編輯課件ISAR-COOL編輯課件99編輯課件編輯課件100編輯課件編輯課件101編輯課件編輯課件102WhatistheoptimaltimeforPCI?編輯課件WhatistheoptimaltimeforP103編輯課件編輯課件104MethodsforOptimaltrial編輯課件MethodsforOptimaltrial編輯課件105ResultsofOptimaltrial編輯課件ResultsofOptimaltrial編輯課件106ConclusionfromOptimaltrial編輯課件ConclusionfromOptimaltrial編107What’sthedifferencebetweenISAR-Cool&Optimal?2.5vs84+0.5vs25-編輯課件What’sthedifferencebetween108TimetoCoronaryAngiographyandOutcomesAmongPatientsWithHigh-RiskNon–ST-Segment–ElevationAcuteCoronarySyndromes:ResultsFromtheSYNERGYTrial

PierluigiTricoci,MD,MHS,PhD;YuliyaLokhnygina,PhD;LisaG.Berdan,PA-C,MHS;StevenR.Steinhubl,MD;DietrichC.Gulba,MD;HarveyD.White,MD;NealS.Kleiman,MD;PhilipE.Aylward,MD;AnatolyLanger,MD;RobertM.Califf,MD;JamesJ.Ferguson,MD;ElliottM.Antman,MD;L.KristinNewby,MD,MHS;RobertA.Harrington,MD;ShaunG.Goodman,MD;KennethW.Mahaffey,MDDivisionofCardiology,DukeClinicalResearchInstitute,Durham,NC編輯課件TimetoCoronaryAngiographya109Background2007ACC/AHAGuidelinesforNSTEACSrecommendtheuseofanearlyinvasivestrategyforhigh-riskpatientsRandomizedclinicaltrialsonearlyvs.conservativestrategyuseddifferenttimingofcardiaccatheterizationOptimaltimingofcardiaccatheterizationinNSTEACSnotyetestablished(expeditedvs.deferred)ExpeditedcatheterizationincreasinglyadoptedintheUS編輯課件Background2007ACC/AHAGuideli110StudyObjectiveToevaluatetheassociationbetweentimefromhospitaladmissiontocardiaccatheterizationandadverseoutcomesamonghigh-riskpatientswithNSTEACStreatedwithanearlyinvasivestrategy(cardiaccatheterization<48hofhospitaladmission)編輯課件StudyObjectiveToevaluatethe111StudyPopulationPatientsrandomizedintheSYNERGYtrial

Ischemicsymptoms<24handatleast2of3high-riskfeatures

Age>60yearsST-segmentdepressionortransientelevationPositivetroponinand/orCK-MBUseofcoronaryangiographyinSYNERGY10,027ptsrandomizedintheSYNERGYtrial9,188ptsunderwentcardiaccatheterization6,352ptsunderwentcardiaccatheterization<48h編輯課件StudyPopulationPatientsrando112AdjustedEstimatesof30-dayDeath/MIRates(with95%CI).0.0編輯課件AdjustedEstimatesof30-dayD113LandmarkAnalysis:AdjustedORof30-dayDeath/MI(with95%CI)編輯課件LandmarkAnalysis:AdjustedOR114AdjustedEstimatesofIn-hospitalTransfusionRates

(with95%CI)編輯課件AdjustedEstimatesofIn-hospi115StudyLimitationsNon-randomizedobservationalanalysisPropensity-basedmodelsusedtodealwithlackofrandomizationTimetocathisapost-baselineand“dynamic”variableStatisticalmethodologiesattemptedtoaddresstheseissues

EventsfromhospitaladmissiontorandomizationnotavailableEventsunlikelypriortorandomizationMyocardialinfarctioninthefirsthours

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