单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,非ST段抬高急性冠脉综合征诊治策略,厦门大学附属中山医院厦门心脏中心王 焱,ACS住院患者NSTE-ACS vs STEMI,National Center for Health Statistics.2001.,ACS,2.3 million,hospital admissions,ACS,(230万/年 ACS住院患者）,UA/NSTEMI,1.43 million,admissions per year,（143万/年患者占63%）,STEMI,829,000,admissions per year,（82.9万/年患者占36%）,ACS主要发病机理,动脉粥样硬化斑块-不稳定或破裂,血栓形成,炎症,细胞,少量平滑肌,细胞,激活的巨噬细胞,血栓,The“Vulnerable Plaque Paradigm易损斑块的特征,Non-vulnerable plaque(非易损斑块),纤维组织局部阻塞血流，但不易引起血凝块及心脏事件。,Vulnerable Plaque易损斑块,富含脂质核、纤维帽薄、边缘炎症反响明显，易于破裂。,ACS的病理生理根底,CK-MB or Troponin,Troponin elevated or not,Adapted from Michael Davies,Adapted from Michael Davies,ACS 无持续ST段抬高,ACS 伴持续ST段抬高,ACS的临床分型,ACS,ST 段持续抬高的 ACS,无 ST 段抬高的 ACS,cTnT(cTnI,)0.1g/L,或,CK-MB,正常上限的2倍,cTnT(cTnI),0.1g/L,或,CK-MB,正常上限的2倍,STEMI,NSTEMI,UA,解决血管壁问题,延缓斑块形成,稳定易损斑块,减少血栓形成,减少急性心脏事件,NSTE-ACS 防治措施,解决血管腔问题,恢复正常管腔,再狭窄,改善心肌供血,提高生活质量,外 膜,lipid core,脂肪核,血栓,延缓斑块发展,稳定斑块,抗炎作用,减少,血栓形成,改善,内皮功能,非ST段抬高ACS的治疗,抗血小板治疗,抗凝治疗,抗缺血治疗,调脂治疗,介入治疗,冠脉搭桥,抗栓不溶栓,抗血小板、抗凝,PCI？！,临床疑诊ACS时的治疗处理 ESC Guidelines 2002,Physical examination,Echocardiogram,ECG monitoring,Blood samples,Thrombolysis,PCI,No persistent,Segment,elevation,Gp2b/3a,CAG,Low risk,High risk,Positive,Twice negative,Stress test,CAG,ASA,Clopidogrel,Heparin(s),Betablockers,Nitrates,Persistent ST,Segment elevation,Second troponin measurement,PCI or CABG or medical management depending upon clinical and angiographics features,最初评价,胸痛的性质、详细的查体,确定CAD的可能性,ECGV3R-5R，V7-9,血化验TnT或I、CK、CK-MB、Cr等,诊 断,常规血生化，特别包括Tn T或I,监测心电ST段的变化,超声心动图检查,如需排除主动脉夹层，做MRI；,排除肺栓塞行CT或核素检查,观察对抗缺血治疗的效果,评定危险记分,评价出血的危险性,NSTE-ACS危险分层,Stable,Angina,Unstable,Angina,Non-Q,Wave MI,Q-WaveMI,Non-ST,Elevation ACS,ST ElevationMI,Positive markers identify high-risk patients,CRP,Troponin,CK-MB,ECG-ST,ECG-ST,NSTE-ACS危险分层,临床因素,年龄,原有基础的左室功能,冠脉解剖,糖尿病,心绞痛的病史特点,心电图或动态心电图,心肌缺血的表现,ST段和T波改变,肌钙蛋白,反应蛋白,纤维蛋白肽,BNP或NTproBNP,NSTE-ACS危险分层方法 -早期,CAG的意义,早期冠脉造影目的：,提供病变范围和分布、狭窄程度和部位、是否适合血管重建术等。,早期冠脉造影,-一种有创的危险分层方法,-可提高预后分层的可靠性,-是制定治疗方案的有效方法：,没有病变可迅速出院,罪犯病变适合 PCI 者可立即介入治疗加快出院,左主干病变、复杂病变伴左室功能不全者迅速 CABG,-发现可能从早期血管重建术中获益的高危病人,NSTE-ACS 治疗策略选择保守策略 vs 介入策略,保守策略：,先药物干预使病情稳定，所谓 冷却期cooling-off phase)，,对药物控制不满意者考虑行CAG,早期介入干预策略：,对ACS患者常规进行早期CAG检查，,然后决定血运重建方式,ACC/AHA：治疗的选择一,有创治疗：,1.尽管充分药物治疗仍发生静息或低水平活动心绞痛；,2.TnT或TnI升高；,3.新出现的ST压低；,4.HF体征和病症或新出现或加重的二尖瓣返流；,5.无创检查有高危的证据；,6.持续性室速；,7.六个月内曾PCI；,8.先前CABG；,9.危险积分属高危TIMI，GRACE；,10.左心室功能降低LVEF40%I(A),ACC/AHA：治疗的选择二,保守治疗：,计分属低危险TIMI，GRACE,无高危特征的患者或医生选择,2007-ESC介入治疗,紧急Urgent,1.患者出现持续性或反复胸痛，伴有或不伴有ST改变2mm或深的倒置T波，抗缺血治疗效果不好,2.出现心衰临床病症或血流动力学不稳定,3.致命性心律失常VF、VT,早期72小时,1.Tn T或I,2.动态ST或T改变有病症或无病症,3.糖尿病,4.肾功能异常GFR60ml/min/1.73m2,5.左心室功能降低LVEF40%,6.堵塞后心绞痛,7.有MI病史,8.6个月内行PCI,有CABG史,9.中高GRACE危险记分,不做或择期做,无再发胸痛,无心衰的体征,无新的ECG改变就诊6-12小时,TnT 或I正常就诊6-12小时,ESC血运重建,造影没有显著病变药物治疗,造影有显著病变：单支病变处理罪犯病变；多支：PCI或CABG的选择应个体化,有些仅处理罪犯病变以后再择期外科,提倡介入术前应用GPIIb/IIIa拮抗剂,如方案搭桥，波立维应停用5天,0.2,0.5,1,2,5,Favors Invasive,Favors Conservative,Odds Ratio,Death or MI,OR 0.82,P=0.001,Trial,TIMI 3B,VANQWISH,MATE,FRISC II,TACTICS,RITA 3,TOTAL,Mehta SR et al.,JAMA,2005;293:2908-17,5.1%,8.1%,27.2%,28.0%,12.0%,8.9%,4.3%,11.4%,4.0%,5.3%,7.4%,10.9%,VINO,4.8%,14.8%,Inv,Cons,7.4%,11.0%,Invasive Management of UA/NSTEMI Meta-analysis:,Death/MI at 17 mo.F/U,Study,Mortality during hospitalization,Mortality after discharge,Cons(%),Inv(%),Odds Ratio,95%CI,TIMI 3B,3.3,2.8,0.1,0.2,0.5,1,2,5,10,Favors Routine,Favors Selective,VANQWISH,11.7,13.4,MATE,6.9,10.0,FRISC II,3.0,1.2,TACTICS,2.8,1.9,VINO,9.4,1.6,RITA 3,7.3,5.2,Subtotal,1.1,1.8,TIMI 3B,1.9,2.2,VANQWISH,1.3,4.5,MATE,3.3,0.9,FRISC II,0.9,1.1,TACTICS,0.7,1.4,VINO,4.5,1.6,RITA 3,0.7,1.6,Subtotal,3.8,4.9,Mehta SR et al.,JAMA,2005;293:2908-17,OR 1.60,P=0.007,OR 0.76,P=0.01,Invasive Rx in ACS:Early and Late Mortality,Overall,12.2,14.4,Trials 1999,9.4,12.4,Troponin+ve,10.0,14.0,Troponin ve,6.7,7.4,Any Marker+ve,14.7,17.4,Any Marker-ve,7.7,8.5,Favors Invasive,Favors Conservative,0.5,1,2,Trial,Inv,(%),Cons,(%),Odds Ratio,P value,0.001,0.82,0.40,0.90,0.012,0.82,0.42,0.89,0.001,0.69,0.0001,0.73,0.92,0.99,*TIMI 3B,VANQWISH and MATE,FRISC II,TACTICS,VINO,RITA 3,Data by troponin status available only in FRISC II,TACTICS,RITA 3,Invasive Management of UA/NSTEMI,Meta-analysis:Subgroups,Mehta SR et al.,JAMA,2005;293:2908-17,Death or MI,at Follow up,UA/NSTEMI：早期介入策略的益处 FRISC II试验,Lancet 1999,Vol 354,Invasive,(n=1222),Non,-,invasive,(n=1226),Risk,radio,P,Death,/,MI,or both,113(9.4%),148(12.1%),0.78,0.031,MI,94(7.8%),124(10.1%),0.77,0.045,Death,23(1.9%),36(2.9%),0.65,0.10,注：2457例 ACS患者(随访6个月),UA/NSTEMI：早期介入策略的益处 FRISC II试验,Probability of Death/MI,Conservative(,保守治疗),Invasive(介入治疗),0.14,0.12,0.10,0.08,0.06,0.04,0.02,0,0 30 60 90 120 150 180,Time since start of open phase(days),FRISC II Investigators.,Lancet.,1999;354:708-715.,Dalteparin(达肝素),12.1%,9.4%,360,180,90,30,0,Probability of Death,.04,.03,.02,.01,0,Non-Invasive(n=1235),Invasive(n=1222),InvasiveNoninvasive RR(95%CI),2.2%4.0%0.56(0.35-0.89)p=0.018,Wallentin,Lancet 2000,FRISC-II Mortality at One-Year Invasive Vs.Conservative Management Strategies,FRISC II:5 Year Outcomes,End point