急性冠脈綜合征患者冠脈介入治療指南英文

1、,Guidelines for Coronary Intervention in ACS,Michael KY LeeQueen Elizabeth Hospital李耿淵 香港伊麗莎白醫(yī)院 SCC 2008,,Division of CardiologyDepartment of Medicine,,ACC/AHA 2007 Guidelines for the Management of Patients With

2、 Unstable Angina/Non–ST-Elevation Myocardial Infarction,,Hospitalizations in the U.S. Due to ACS,Acute Coronary Syndromes*,,1.57 Million Hospital Admissions - ACS,,UA/NSTEMI?,STEMI,,1.24 million Admissions per year,0.33

3、million Admissions per year,*Primary and secondary diagnoses. ?About 0.57 million NSTEMI and 0.67 million UA.Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69–171.,,,Primary PCI for STEMI,STEMI

4、 patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 min of first medical contact as a systems goal. STEMI patients presenting to a hospital without PCI capability, and wh

5、o cannot be transferred to a PCI center and undergo PCI within 90 min of first medical contact, should be treated with fibrinolytic therapy within 30 min of hospital presentation as a systems goal, unless fibrinolytic th

6、erapy is contraindicated.,,,,,A strategy of coronary angiography with intent toperform PCI (or emergency CABG) isrecommended in patients who have receivedfibrinolytic therapy and have:Cardiogenic shock in patients

7、< 75 years who are suitable candidates for revascularizationb. Severe congestive heart failure and/or pulmonary edema (Killip class III)c. Hemodynamically compromising ventricular arrhythmias.,Rescue PCI for STEMI

8、,,Early Risk Stratification in ACS,Use of risk-stratification models, such as the TIMI or GRACE risk score or PURSUIT risk model, can be useful to assist in decision making with regard to treatment options in patients wi

9、th suspected ACS. It is reasonable to remeasure positive biomarkers at 6- to 8-h intervals 2 to 3 times or until levels have peaked, as an index of infarct size and dynamics of necrosis.,,GRACE = Global Registry of Ac

10、ute Coronary Events; PURSUIT = Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy; TIMI = Thrombolysis In Myocardial Infarction.,,,Variables Used in the TIMI Risk Score,,The

11、TIMI risk score is determined by the sum of the presence of the above 7 variables at admission. 1 point is given for each variable. Primary coronary stenosis of 50% or more remained relatively insensitive to missing info

12、rmation and remained a significant predictor of events. Antman EM, et al. JAMA 2000;284:835–42.TIMI = Thrombolysis in Myocardial Infarction.,The TIMI Risk Score and Incidence of Adverse Ischemic Events in Patients with

13、NSTE-ACS,Reproduced with permission from Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA.. 2000;284:8

14、35-842. Copyright © 2000, American Medical Association. All rights reserved.,,,,,,,,,,,,,,,,,,,,,,4.7,8.3,13.2,19.9,26.2,40.9,0,10,20,30,40,50,0/1,2,3,4,5,6/7,Number of Risk Factors,Death, MI, or Urgent Revasculariz

15、ation (%),,,GRACE Risk Score,,The sum of scores is applied to a reference monogram to determine the corresponding all-cause mortality from hospital discharge to 6 months. Eagle KA, et al. JAMA 2004;291:2727–33. The GRAC

16、E clinical application tool can be found at www.outcomes-umassmed.org/grace. Also see Figure 4 in Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157.GRACE = Global Registry of Acute Coronary Events.,,Risk Scores,Antm

17、an EM, et al. JAMA 2000;284:835–42. Eagle KA, et al. JAMA 2004;291:2727–33. GRACE = Global Registry of Acute Coronary Events; TIMI = Thrombolysis in Myocardial Infarction.,,B-Type Natriuretic Peptide,B-type natriuretic

18、peptide (BNP): new biomarker of considerable interestBNP is a cardiac neurohormone released on ventricular myocyte stretch as proBNP, which is enzymatically cleaved to the N-terminal proBNP (NT-pro-BNP) and, subseque

19、ntly, to BNPNatriuretic peptides are strong predictors of both short- and long-term mortality in patients with STEMI and UA/NSTEMIRecommend: Measurement of BNP or NT-pro-BNP may be considered to supplement assessment

20、 of global risk in patients with suspected ACS (Class IIb, LOE: B),,Galvani M, et al. Circulation 2004;110:128–34.LOE = level of evidence.,Select Management Strategy: Initial Invasive Versus Initial Conservative Str

21、ategy,Fragmin during Instability in Coronary Artery Disease (FRISC-2),Patients within 48 h UA/NSTEMI Early inv vs conserv & dalteparin vs placebo3048 patients → dalteparin for 5–7 d → 2457 continued dalteparin/plac

22、ebo & received either inv or conserv rx strategyMeds: ASA, β-blockers unless contraindicatedNo ↓ death/MI @ 3 mo by dalteparin ↓ Death/MI @ 6 mo, 1 y & 5 y for inv strategy― Benefit confined to men, nonsmok

23、ers, and patients with ≥ 2 risk factors,,Wallentin L, et al. Lancet 2000;356:9–16 (1-year results). Lagerqvist B, et al. J Am Coll Cardiol 2001;38:41–8 (women vs men). Lagerqvist B, et al. Lancet 2006;368:998–1004 (5-y

24、r follow-up).,Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy (TACTICS-TIMI-18),2,220 patients within 24 h UA/NSTEMIEarly inv or conserv (selective invasive) strategy

25、Meds: ASA, heparin and tirofiban↓ Death, MI, and rehosp for an ACS @ 6 mo for inv strategy― Benefit in medium and high-risk patients (TnT ↑ of > 0.01 ng/mL, ST-segment deviation, TIMI risk score > 3)― No high

26、-risk features, outcomes ?― ↓ Death/MI @ 6 mo for older adults with early inv strategy― Benefit of early inv strategy for high-risk women (↑ TnT); low-risk women tended to have worse outcomes, incl ↑ risk of major bl

27、eeding,,Cannon CP, et al. N Engl J Med 2001;344:1879–87.,Third RandomizedIntervention Treatment of Angina (RITA-3),1,810 moderate-risk ACS patientsEarly inv or conserv (ischemia-driven) strategyExclusions: CK-MB >

28、2X ULN @ randomization, new Q-waves, MI w/in 1 mo, PCI w/in 1 y, any prior CABG↓ Death, MI, & refractory angina for inv strategy ― Benefit driven primarily by ↓ in refractory angina↓ Death/MI @ 5 y for early inv

29、armNo benefit of early inv strategy in women,,Fox KA, et al. Lancet 2002;360:743–51. Fox KA, et al. Lancet 2005;366:914–20 (5-y results).,RITA-3 --- 5 Year Follow-up,Fox KA, et al. Lancet 2005;366:914–20. Reprinted wit

30、h permission from Elsevier.,DeathOR 0.76 (0.58-1.00) P = 0.054,Death,,15.1%,12.1%,IntracoronaryStenting with Antithrombotic Regimen Cooling-off Study (ISAR-COOL),410 patients within 24 h intermediate-high risk UA/NSTE

31、MIVery early angio (cath median time 2.4 h) + revasc or delayed inv/“cooling off” (cath median time 86 h) strategyMeds: ASA, heparin, clopidogrel (600-mg LD) and tirofiban↓ Death/MI @ 30 d for early angio group

32、 Diff in outcome attributed to events that occurred before cath in the “cooling off” group, which supports rationale for intensive medical rx & very early angio,,Neumann FJ, et al. JAMA 2003;290:1

33、593–9. LD = loading dose.,Global Registry of Acute Coronary Events (GRACE),24,165 ACS patients in 102 hospitals in 14 countries stratified by age~ 2/3 men, but proportion ↓ with age↑ Hx angina, TIA/stroke, MI, CHF, CAB

34、G, hypertension or AF in elderly (≥65y)― Delay in seeking medical attention and NSTEMI significantly ↑ in elderly↓ Use in elderly ASA, β-blockers, lytic therapy, statins and GP IIb/IIIa inhibitors;↑ calcium antagonist

35、s and ACE inhibitorsUFH ↑ young patients; LMWHs ? across all age groupsAngio and PCI rates significantly ↓ with ↑ ageElderly patients a high-risk population for whom physicians andhealthcare systems should provide e

36、vidence-based ACS therapies,such as aggressive, early invasive strategy and key pharmacotherapies (e.g.anticoagulants, β-blockers, clopidogrel and GP IIb/IIIa inhibitors),,Avezum A, et al. Am Heart J 2005;149:67–73.,Init

37、ial Conservative Versus Initial Invasive Strategies,In initially stabilized patients, an initially conservative (i.e., a selectively invasive) strategy may be considered as a treatment strategy for UA/ NSTEMI patients (

38、without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events including those who are troponin positive. The decision to implement an initial conservative (vs. init

39、ial invasive) strategy in these patients may be made by considering physician and patient preference. An invasive strategy may be reasonable in patients with chronic renal insufficiency.,,I,I,I,,,,,,,,,,,,,IIa,IIa,IIa,

40、IIb,IIb,IIb,III,III,III,,,,I,I,I,,,,,,,,,,,,,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,,,,,,,,,,,,,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,,,,,,,,,,,,,,,,,,,,,,,,,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,Invasive versus Conservat

41、ive Treatment in Unstable coronary Syndromes (ICTUS),1,200 high-risk ACS patients Routine inv vs selective inv strategyMeds: ASA, clopidogrel, LMWH, and lipid-lowering rx; abciximab for revasc patientsNo ↓ death, MI,

42、and ischemic rehosp @ 1 y and longer-term follow-up by routine inv strategyRelatively high (47%) rate revasc actually performed in selective inv arm and lower-risk pop than in other studiesRecommendation: Initially con

43、serv (i.e., selectively inv) strategy may be considered in initially stabilized patients who have ↑ risk for events, incl troponin + (Class IIb, LOE:B),,de Winter RJ, et al. N Engl J Med 2005;353:1095–104. Hirsch A, et a

44、l. Lancet 2007;369:827–35 (follow-up study). LOE = level of evidence.,Initial Conservative Versus Initial Invasive Strategies,An early invasive strategy* is indicated in UA/NSTEMI patients who have refractory angina or

45、hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures).An early invasive strategy* is indicated in initially stabilized UA/NSTEMI patients (without serious comorbi

46、dities or contraindications to such procedures) who have an elevated risk for clinical events.,,I,I,I,,,,,,,,,,,,,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,,,,I,I,I,,,,,,,,,,,,,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,,,,,,,,

47、,,,,,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,,,,,,,,,,,,,,,,,,,,,,,,,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,*Diagnostic angiography with intent to perform revascularization.,Initial Conservative Versus Initial Invasive Strategi

48、es,An early invasive strategy* is not recommended in patients with extensive comorbidities (e.g., liver or pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh

49、 the benefits of revascularization. An early invasive strategy* is not recommended in patients with acute chest pain and a low likelihood of ACS. An early invasive strategy* should not be performed in patients who

50、will not consent to revascularization regardless of the findings.,,*Diagnostic angiography with intent to perform revascularization.,Selection of Initial Treatment Strategy: Initial Invasive Versus Conservative Strategy,

51、,,Bavry AA, et al. J Am Coll Cardiol 2006;48:1319–1325. Reprinted with permission from Elsevier. CI = confidence interval; RR = relative risk.,Relative Risk of All-Cause Mortality for Early Invasive Therapy Compared With

52、 Conservative Therapy at a Mean Follow-Up of 2 y,,Bavry AA, et al. J Am Coll Cardiol 2006; 48:1319–1325. CI = confidence interval; RR = relative risk. Reprinted with permission from Elsevier.,Relative Risk of Recurrent N

53、onfatal MI for Early Invasive Therapy Compared With Conservative Therapy at a Mean Follow-Up of 2 y,,Relative Risk of Recurrent UA Resulting in Rehosp for Early Invasive Therapy Compared With Conservative Therapy at a Me

54、an Follow-Up of 13 Months,Bavry AA, et al. J Am Coll Cardiol 2006; 48:1319–1325. Reprinted with permission from Elsevier. CI = confidence interval; RR = relative risk; UA = unstable angina.,,Initial Invasive Strategy,Eff

55、icacy and Safety ofSubcutaneous Enoxaparin in Non-Q-Wave Coronary Events (ESSENCE) trial,3,171 patients within 24 h UA/NSTEMI Enoxaparin vs UFHOther meds: ASA↓ Death, MI or recurrent angina for enox @ 14 d, 30d and 1

56、 y― minor bleeding ↑― major bleeding ?,,Cohen M, et al. N Engl J Med 1997;337:447–52. Cohen M, et al. Am J Cardiol 1998;82:19L–24L (bleeding). Goodman SG, et al. J Am Coll Cardiol 2000;36:6934–8 (1-y results).,Thro

57、mbolysis In Myocardial Ischemia trial, phase 11B (TIMI 11B),3,910 patients within 24 h UA/NSTEMIEnoxaparin vs UFHOther meds: ASA↓ Death, MI or urgent revasc for enox @ 48 h, 8 d, 14 d, & 43 d↑ major & minor b

58、leeding (inhosp) with enox,,Antman EM, et al. Circulation 1999;100:1593–601.,Superior Yield of the New strategy ofEnoxaparin, Revascularization and GlYcoprotein IIb/IIIa Inhibitors (SYNERGY),,,Ferguson JJ, et al. JAMA 2

59、004;292:45–54. Mahaffey KW, et al. Am Heart J 2005;149:S81–S90 (6 mo & 1-y results).,9,978 patients within 24 h high-risk UA/NSTEMIEnoxaparin vs UFH → early inv strategyOther meds: ASA, GP IIb/IIIa @ physician disc

60、retionEnox noninferior for death/MI @ 30 d, 6 mo 1 y↑ Major bleeding with enox― ? due to crossover to UFH @ time of PCI,SYNERGY Primary Outcomes,,Absolute Risk Reduction0.5Hazard Ratio0.9695% CI0.86–1.06p0

61、.40,,,Freedom from Death/MI,0.8,0.85,0.9,0.95,1.0,0,5,10,15,20,25,30,Days from Randomization,Kaplan Meier Curve,,UFH,,Enoxaparin,Reprinted with permission from Ferguson JJ, et al. JAMA 2004;292:45–54.,Antithrombotic Comb

62、inationUsing Tirofiban and Enoxaparin (ACUTE II),525 patients within 24 h UA/NSTEMI Enoxaparin vs UFH Other meds: ASA, tirofiban LD 0.4 mcg/kg over 30 min → 0.1 mcg/kg/minNo ↓ death/MI during first 30 d― Trend to

63、lower event rates with enoxNo ↓ major/minor bleeding,,Cohen M, et al. Am Heart J 2002;144:470–7. LD = loading dose.,INTegrilin and Enoxaparin Randomized Assessment of Acute Coronary syndrome Treatment (INTERACT),746 pat

64、ients within 24 h high-risk UA/NSTEMIEnoxaparin vs UFHOther meds: ASA, eptifibatide 180 mcg/kg IV bolus → 2.0 mcg/kg/min infusion for 48 hours↓ Death/MI for enox @ 30 d Minor bleeding - ↑ for enox @ 96 h, no diff by

65、 30 dMajor bleeding - ↓ for enox @ 96 h (1o safety endpoint),,Goodman SG, et al. Circulation 2003;107:238–44.,Aggrastat to Zocor (A to Z),3,987 patients within 24 h UA/NSTEMI on ASA & tirofibanEnoxaparin vs UFH Co

66、ronary angio in 60% of ptsNo ↓ all-cause mortality, MI or refractory ischemia w/in 7 d by enox― Nonsig trend to ↓ ischemic events with enox↑ Major bleeding with enox,,Blazing MA, et al. JAMA 2004;292:55–64.,Acute Cat

67、heterization and Urgent InterventionTriage strategY (ACUITY),Within 24 h UA/NSTEMI → heparin (enox/UFH) ± upstream GP IIb/IIIa (n=4603) vs bivalirudin (bival) ± upstream GP IIb/IIIa (n=4604) vs bival alone +

68、 provisional GP IIb/IIIa (n=4612)Compared to heparin + GP IIb/IIa:― Bival + GP IIb/IIIa noninferior for composite ischemia, major bleeding & net clinical outcomes @ 30 d― Bival alone noninferior for composite

69、 ischemia; ↓ major bleeding; ↓ net clinical outcomes @ 30 dCaution using bival alone, esp with delay to angio and high-risk features, or if early ischemic discomfort occurs after initial antithrombotic strategy implem