穩(wěn)定性冠心病的治療策略

穩(wěn)定性冠心病的治療策略2012-3當(dāng)前第1頁\共有59頁\編于星期四\20點(diǎn)2當(dāng)前第2頁\共有59頁\編于星期四\20點(diǎn)內(nèi)容在穩(wěn)定性冠心病治療中標(biāo)準(zhǔn)藥物治療的價值血管重建在那些患者可能獲益？如何選擇CABG或是PCI

單支、雙支病變

三支、左主干病變多支病變功能性完全血管重建選擇藥物洗脫支架還是裸金屬支架？3當(dāng)前第3頁\共有59頁\編于星期四\20點(diǎn)COURAGE:StudydesignBodenWEetal.AmHeartJ.2006;151:1173-9.BodenWEetal.NEnglJMed.2007;356:1503-16.Optimalmedicaltherapy*+PCI(n=1149)Optimalmedicaltherapy

(n=1138)AHA/ACCClassI/IIindicationsforPCI,suitablecoronaryarteryanatomy+

≥70%stenosisin≥1proximalepicardialvessel+objectiveevidenceofischemia

(or≥80%stenosis+CCSclassIIIanginawithoutprovocationtesting)Primaryoutcomes:All-causemortality,nonfatalMIFollow-up:Median4.6yearsRandomized*Intensivepharmacologictherapy+lifestyleintervention

CCS=CanadianCardiovascularSocietySecondaryoutcomes:Death,MI,stroke;ACShospitalization當(dāng)前第4頁\共有59頁\編于星期四\20點(diǎn)COURAGE:TreatmenteffectonprimaryoutcomeHR1.05(0.87-1.27)P=0.62*BodenWEetal.NEnglJMed.2007;356:1503-16.All-causedeath,MI(timetofirstevent)*UnadjustedNo.atriskMedicaltherapy 1138 1017 959 834 638 408 192 30PCI 1149 1013 952 833 637 417 200 35MedicaltherapyPCI+medicaltherapySurvivalfreeofprimaryoutcome024700.50.60.70.81.00.9Years6531當(dāng)前第5頁\共有59頁\編于星期四\20點(diǎn)6當(dāng)前第6頁\共有59頁\編于星期四\20點(diǎn)當(dāng)前第7頁\共有59頁\編于星期四\20點(diǎn)當(dāng)前第8頁\共有59頁\編于星期四\20點(diǎn)PharmacologictherapyAntiplateletAspirinClopidogrelinaccordancewithestablishedpracticestandardsDyslipidemiaSimvastatin±ezetimibe

orERniacinACEIorARBLisinoprilorlosartan-blockerERmetoprololsuccinateCalciumchannelblockerAmlodipineNitrateIsosorbide5-mononitrateBodenWEetal.AmHeartJ.2006;151:1173-9.BodenWEetal.NEnglJMed.2007;356:1503-16.當(dāng)前第9頁\共有59頁\編于星期四\20點(diǎn)內(nèi)容在穩(wěn)定性冠心病治療中標(biāo)準(zhǔn)藥物治療的價值血管重建在那些患者可能獲益？如何選擇CABG或是PCI

單支、雙支病變

三支、左主干病變多支病變功能性完全血管重建選擇藥物洗脫支架還是裸金屬支架？10當(dāng)前第10頁\共有59頁\編于星期四\20點(diǎn)11當(dāng)前第11頁\共有59頁\編于星期四\20點(diǎn)當(dāng)前第12頁\共有59頁\編于星期四\20點(diǎn)當(dāng)前第13頁\共有59頁\編于星期四\20點(diǎn)14當(dāng)前第14頁\共有59頁\編于星期四\20點(diǎn)內(nèi)容在穩(wěn)定性冠心病治療中標(biāo)準(zhǔn)藥物治療的價值血管重建在那些患者可能獲益？如何選擇CABG或是PCI

單支、雙支病變

三支、左主干病變多支病變功能性完全血管重建選擇藥物洗脫支架還是裸金屬支架？15當(dāng)前第15頁\共有59頁\編于星期四\20點(diǎn)ProximalLADdisease,medicine,PTCAorCABG

（MASStrial）1724301.41.42.82.81.49.7420328298P=0.0002P=0.006NSNSP=0.019P<0.01P<0.01Eventrateatf-up(%)Huebetal.JAmCollCardiol1995;26:1600-1605SingleCenter,randomizedtrialStableangina,proximalLADsignificantlesion<12mminlength,nopriorMI,nototalocclusion,nopriorCABGorangioplasty.n=214:Medicaln=72;BAn=72;LIMAn=70當(dāng)前第16頁\共有59頁\編于星期四\20點(diǎn)穩(wěn)定性冠心病血運(yùn)重建策略SilberS,TCT2010當(dāng)前第17頁\共有59頁\編于星期四\20點(diǎn)內(nèi)容在穩(wěn)定性冠心病治療中標(biāo)準(zhǔn)藥物治療的價值血管重建在那些患者可能獲益？如何選擇CABG或是PCI

單支、雙支病變

三支、左主干病變

多支病變功能性完全血管重建選擇藥物洗脫支架還是裸金屬支架？18當(dāng)前第18頁\共有59頁\編于星期四\20點(diǎn)71%enrolled

(N=3,075)AllPtswithdenovo3VDand/orLMdisease(N=4,337)Treatmentpreference(9.4%)ReferringMDorpts.refused

informedconsent(7.0%)Inclusion/exclusion(4.7%)Withdrewbeforeconsent(4.3%)Other(1.8%)Medicaltreatment(1.2%)TAXUSn=903PCIn=198CABGn=1077CABGn=897nof/un=4285yrf/un=649PCIallcapturedw/followupCABG2500750w/f/uvsTotalenrollmentN=3075Stratification:

LMandDiabetesTwoRegistryArmsRandomizedArmsn=1800TwoRegistryArmsN=1275RandomizedArmsN=1800HeartTeam(surgeon&interventionalist)PCIN=198CABGN=1077AmenableforonlyonetreatmentapproachTAXUS*N=903

CABGN=897vsAmenableforbothtreatmentoptionsStratification:

LMandDiabetesLM33.7%3VD66.3%LM34.6%3VD65.4%DM28.5%NonDM71.5%NonDM71.8%DM28.2%23USSites62EUSites+SYNTAXTrialDesign當(dāng)前第19頁\共有59頁\編于星期四\20點(diǎn)PatientProfiling

LocalHeartteam(surgeon&interventionalcardiologist)assessedeachpatientinregardsto:Patient’soperativerisk(EuroSCORE&Parsonnetscore)Coronarylesioncomplexity(newlydevelopedSYNTAXscore)ThegoaloftheSYNTAXscoreistoprovideatooltoassistphysiciansintheirrevascularizationstrategiesforpatientswithhighrisklesionsSianosetal,EuroIntervention2005;1:219-227Valgimiglietal,AmJCardiol2007;99:1072-1081Serruysetal,EuroIntervention2007;3:450-459CoronarytreesegmentsbasedontheclassificationproposedbytheAHAandmodifiedfortheARTSstudyCirculation1975;51:31-3&SeminIntervCardiol1999;4:209-19Leamanscore,Circ1981;63:285-299LesionsclassificationACC/AHA,Circ2001;103:3019-3041Bifurcationclassification,CCI2000;49:274-283CTOclassification,JAmCollCardiol1997;30:649-656TortuosityThrombusBifurcationTotalOcclusion3VesselLeftMainDominanceCalcificationNumber&locationoflesionsSYNTAXscore當(dāng)前第20頁\共有59頁\編于星期四\20點(diǎn)MACCEto12MonthsP=0.0015*061210200MonthsSinceAllocationCumulativeEventRate(%)ITTpopulation12.1%

17.8%EventRate±1.5SE.*Fisher’sExactTestTAXUS*

(N=903)CABG

(N=897).SerruysPW,atTCT2008當(dāng)前第21頁\共有59頁\編于星期四\20點(diǎn)SYNTAXTrial

AdverseEventsto12Months

ITTpopulationEventRate±1.5SE,*FisherexacttestAllDeathRevascularizationCVA(Stroke)MyocardialInfarctionTAXUS*(N=903)CABG(N=897).SerruysPW,atTCT2008當(dāng)前第22頁\共有59頁\編于星期四\20點(diǎn)當(dāng)前第23頁\共有59頁\編于星期四\20點(diǎn)SabikJF,TCT2010當(dāng)前第24頁\共有59頁\編于星期四\20點(diǎn)Patient1Patient1Patient2Patient2SYNTAXSCORE21SYNTAXSCORE52LCx70-90%LAD70-90%RCA270-90%RCA370-90%LM99%LCx100%LAD99%RCA100%Thereis‘3-vesseldisease’and‘3-vesseldisease’當(dāng)前第25頁\共有59頁\編于星期四\20點(diǎn)SYNTAXTrial,MACCEto12Months

LeftMainSubsetP=0.44*061220400MonthsSinceAllocationCumulativeEventRate(%)13.6%

15.8%

TAXUS

(N=357)CABG

(N=348)Eventrate±1.5SE,*FisherexacttestITTpopulation當(dāng)前第26頁\共有59頁\編于星期四\20點(diǎn)P=0.2026.8%22.3%0CumulativeEventRate(%)2040Before1year*13.7%vs15.8%P=0.441-2years*7.5%vs10.3%P=0.222-3years*5.2%vs5.7%P=0.780123624MonthsSinceAllocationTAXUS

(N=357)CABG

(N=348)MACCEto3Years

LMSubsetCumulativeKMEventRate±1.5SE;log-rankPvalue;*BinaryratesSerruysP,TCT2010當(dāng)前第27頁\共有59頁\編于星期四\20點(diǎn)CABGPCIPvalueDeath6.0%2.6%0.21CVA4.1%0.9%0.12MI2.0%4.3%0.36Death,CVAorMI11.0%6.9%0.26Revasc.13.4%15.4%0.69MonthsSinceAllocationCumulativeEventRate(%)P=0.33LeftMainTAXUS

(N=118)CABG

(N=104)MACCEto3YearsbySYNTAXScoreTercileLowScores(0-22)18.0%23.0%MonthsSinceAllocationCumulativeEventRate(%)0122440020301036Site-reportedData;ITTpopulationCumulativeKMEventRate±1.5SE;log-rankPvalue>>><<當(dāng)前第28頁\共有59頁\編于星期四\20點(diǎn)CABGPCIPvalueDeath12.4%4.9%0.06CVA2.3%1.0%0.46MI3.3%5.0%0.63Death,CVAorMI15.6%10.8%0.29Revasc.14.0%15.9%0.75P=0.90LeftMainTAXUS

(N=103)CABG

(N=92)MACCEto3YearsbySYNTAXScoreTercile

IntermediateScores(23-32)23.4%23.4%MonthsSinceAllocationCumulativeEventRate(%)0122440020301036Site-reportedData;ITTpopulationCumulativeKMEventRate±1.5SE;log-rankPvalue>>><<當(dāng)前第29頁\共有59頁\編于星期四\20點(diǎn)P=0.003LeftMainTAXUS

(N=135)CABG

(N=149)MACCEto3YearsbySYNTAXScoreTercile

LeftMainSYNTAXScore3337.3%21.2%LeftMainMonthsSinceAllocationCumulativeEventRate(%)0122440020301036CABGPCIPvalueDeath7.6%13.4%0.10CVA4.9%1.6%0.13MI6.1%10.9%0.18Death,CVAorMI15.7%20.1%0.34Revasc.9.2%27.7%<0.001Site-reportedData;ITTpopulationCumulativeKMEventRate±1.5SE;log-rankPvalue><<<<當(dāng)前第30頁\共有59頁\編于星期四\20點(diǎn)ESC穩(wěn)定性冠心病血運(yùn)重建策略(2010)SilberS,TCT2010當(dāng)前第31頁\共有59頁\編于星期四\20點(diǎn)

血運(yùn)重建策略的制定應(yīng)由多學(xué)科完成32當(dāng)前第32頁\共有59頁\編于星期四\20點(diǎn)一站式雜交手術(shù)（MIDCAB+PCI）對部分三支或左主干病變可能是一選擇ThefirstHybridOperatingRoominAsiawasbuiltatFuwaiHospitalin2007.33新技術(shù)、新理念呼喚新的治療策略當(dāng)前第33頁\共有59頁\編于星期四\20點(diǎn)內(nèi)容在穩(wěn)定性冠心病治療中標(biāo)準(zhǔn)藥物治療的價值血管重建在那些患者可能獲益？如何選擇CABG或是PCI

單支、雙支病變

三支、左主干病變

多支病變功能性完全血管重建選擇藥物洗脫支架還是裸金屬支架？當(dāng)前第34頁\共有59頁\編于星期四\20點(diǎn)Angiography-guidedPCIFFR-guidedPCIMeasureFFRinallindicatedstenosesStentallindicatedstenosesStentonlythosestenoseswithFFR≤0.80RandomizationIndicateallstenoses≥50%consideredforstentingPatientwithstenoses≥50%inatleast2ofthe3majorepicardialvessels1-yearfollow-upFLOWCHART當(dāng)前第35頁\共有59頁\編于星期四\20點(diǎn)

FAMEstudy:ProceduralResultsANGIO-groupN=496FFR-groupN=509P-valueProceduretime(min)70±4471±430.51Contrastagentused(ml)302±127272±133<0.001Materialsusedatprocedure(US$)60075332<0.001Lengthofhospitalstay(days)3.7±3.5

3.4±3.30.05stentsperpatient2.7±1.21.9±1.3<0.001當(dāng)前第36頁\共有59頁\編于星期四\20點(diǎn)FFR-guided30days2.9%90days3.8%180days4.9%360days5.3%Angio-guidedabsolutedifferenceinMACE-freesurvivalFAMEstudy:Event-freeSurvival當(dāng)前第37頁\共有59頁\編于星期四\20點(diǎn)

ANGIO-groupN=496FFR-groupN=509P-valueEventsat1year,No(%)Death,MI,CABG,orrepeat-PCI91(18.4)67(13.2)0.02Death15(3.0)9(1.8)0.19Deathormyocardialinfarction55(11.1)37(7.3)0.04CABGorrepeatPCI47(9.5)33(6.5)0.08Totalno.ofMACE113760.02AdverseEventsat1year當(dāng)前第38頁\共有59頁\編于星期四\20點(diǎn)

PCI應(yīng)用的適當(dāng)性（美國注冊資料），全美1091所醫(yī)院PCI500154例急癥PCI占71.1%STEMI20.6%，NSTEMI21.1%，高危UA29.3%非急癥PCI占28.9%適當(dāng)性急癥PCI：適當(dāng)98.6%非急癥PCI：適當(dāng)50.4%，不肯定38.0%

不適當(dāng)11.6%

無心絞痛53.8%

無創(chuàng)檢查屬低危71.6%

藥物治療不適當(dāng)（≤1種藥物）95.8%

ChanP.JAMA2011；306:53當(dāng)前第39頁\共有59頁\編于星期四\20點(diǎn)

PCIsinChina當(dāng)前第40頁\共有59頁\編于星期四\20點(diǎn)內(nèi)容在穩(wěn)定性冠心病治療中標(biāo)準(zhǔn)藥物治療的價值血