【文档说明】非ST段抬高急性ACS的诊断治疗NSTEACS临床指南解读课件.ppt，共(83)页，3.835 MB，由小橙橙上传

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北京朝阳医院BeijingChaoyangHospital非ST段抬高急性ACS的诊断治疗------NSTEACS临床指南解读首都医科大学附属北京朝阳医院心脏中心杨新春北京朝阳医院BeijingChaoyangHospital概况急性冠脉综

合征图谱STElevationMINonSTElevationACSECG–STCK-MBTroponinCRP,IL-6,TNFa,PAI1,NF-KB,CD40,COX-2ECG-STStableAnginaUnstableAnginaNon-QwaveMIQwav

eMI北京朝阳医院BeijingChaoyangHospital急性冠脉综合征Presumedprognosis:veryhighriskofin-hospitaldeathTreatmentgoal:preventdeath

byrestoringcoronarybloodflowFibrinolytictherapyDirectPCIPresumedprognosis:lowriskofin-hospitaldeath,unlessMIdevelopsTreatmentgoal:stabilizewi

thaspirinheparin&monitorforMIdevelopment+Cardiacenzymes–CardiacEnzymesScheduledPCIManagemedicallyLow-riskfeaturesHigh-risk

featuresACS患者6个月死亡率0%2%4%6%8%10%0306090120150180DaysfromrandomizationT-waveinversionST-segmentdepressionST-segmentelevationT-waveinv

ersionACSSTACSGrangerCBetal.JAmCollCardiol.1998;31:79A.STMIwithfibrinolyticsSTEMI&NSTEMI冠状动脉病变支数的比较No.diseasedvesselsST(n=1864)ST(n=2170)010%11%1

45%26%227%28%318%36%SavonittoS,etal.JAmMedAsoc.1999;281:707-713.北京朝阳医院BeijingChaoyangHospital病因及病理北京朝阳医院BeijingChaoyangHospital急性冠脉综合征的病理机制⚫易损斑

块因破裂、侵蚀、钙化结节等因素引起血栓形成⚫血栓形成可以形成阻塞性(15%)或非阻塞性(85%)的血栓⚫阻塞状态取决于血栓形成的速度与体内自溶的平衡北京朝阳医院BeijingChaoyangHospital血小板聚集形成血栓血小板的粘

附和激活血流中的正常血小板血小板粘附于损伤的内皮表面并被激活血小板内皮细胞内皮下腔血小板粘附到内皮下腔血小板血栓北京朝阳医院BeijingChaoyangHospital非ST段抬高的ACSResultsfromcross-

linkingofplateletsbyfibrinogenatplateletreceptorsGPIIb-IIIaatsiteofplaqueruptureplateletfibrinogenRupturedplaqueGPIIb-IIIa冠脉被富含血小板的血栓部分堵塞Unobstru

ctedlumenthrombusArterywall北京朝阳医院BeijingChaoyangHospitalST段抬高AMIResultsfromstabilizationofaplateletaggregateatsiteofplaquerupturebyfibrinmeshplatele

tRBCfibrinmeshGPIIb-IIIa冠脉被血栓完全堵塞北京朝阳医院BeijingChaoyangHospital危险分层北京朝阳医院BeijingChaoyangHospital肌钙蛋白T对预后的影响:荟萃分析1.96.76.420.8051015202

5DeathDeath/MI%RR3.9(2.9-5.3)RR3.8(2.6-5.5)No.Studies:136NegPos(TropI+T)36341849737322HeidenreichPA,JAmCollCardiol.

2001;38:478-485.北京朝阳医院BeijingChaoyangHospitalWBCCount(x103)30-DayMortality0510152005%10%15%20%白细胞计数和死亡率的关系CannonCP,etal.A

mJCardiol.2001;87:636-639.(withpermission)北京朝阳医院BeijingChaoyangHospital肌钙蛋白I(TnI),C反应蛋白(CRP),以及脑钠肽(BNP)水平与30天死亡率的关系OPUS-TIMI1611.83.5601234

560123No.ofElevatedBiomarkers30-DayMortalityRelativeRiskTACTICS-TIMI1812.15.713024681012140123No.ofElevat

edBiomarkersP=.014P<.001671501557850471732490SabatineM,etal.Circulation.2002;105:1760-1763.(withpermission)北京朝阳医院BeijingChaoyangHosp

italGUSTOIIb:ACS患者基础ECG改变与6个月死亡率的关系CumulativeMortality(%)02468100306090120150180DaysFromRandomizationT-waveinversionSTACSS

TEMIwithfibrinolyticsGUSTO,GlobalUseofStrategiesToOpenOccludedArteriesinAcuteCoronarySyndromes;ECG,electrocardiogram;ACS

,acutecoronarysyndrome;STEMI,ST-segmentelevationmyocardialinfarction.SavonittoS,etal.JAMA.1999;281:707-713.(withpermission)北京朝阳医院BeijingChao

yangHospital北京朝阳医院BeijingChaoyangHospital北京朝阳医院BeijingChaoyangHospitalTIMI,thrombosisinmyocardialinfarcti

on;UA,unstableangina;NSTEMI,non–ST-segmentelevationmyocardialinfarction;CAD,coronaryarterydisease.AntmanEM,etal.JAM

A.2000;284:835-842.非ST段抬高ACS的TIMI积分评价年龄≥65years≥3冠心病危险因素继往冠心病史(狭窄>50%)7天内已服用阿斯匹林史≤24小时内心绞痛发作>2次

ST改变心肌标志物升高(CK-MBor肌钙蛋白)TIMI积分5-7，为高危病人北京朝阳医院BeijingChaoyangHospitalAntmanEM,etal.JAMA.2000;284:835-442.(withpermission)Popu

lation(%):4.78.313.219.926.240.9010203040500/123456/7D/MI/UrgRevasc(%)NumberofRiskFactors4.317.332.029.313.03.4CStatist

ic=0.65c2trendP<.001TIMI积分与死亡、心梗、急诊血管再建术复合终点的关系北京朝阳医院BeijingChaoyangHospital治疗－－基于循征医学的证据药物治疗早期介入治疗北京朝阳医院Beijing

ChaoyangHospitalVascularDamageInflammationMyocyteNecrosisAcceleratedAtherosclerosisHemodynamicStressHbA1cBloodglucoseCrClMicroalbuminuriaTropon

inBNP,NT-proBNPhs-CRP,CD40LMorrowDA,etal.Circulation.2003;108:250-252.MultimarkerStrategyinACS北京朝阳医院BeijingChaoyangHospit

alAge653CADriskfactors(FHx,HTN,chol,DM,activesmoker)STdeviation0.5mmcardiacmarkersRecent(24H)sever

eanginaHISTORICALPRESENTATIONRISKSCORE=TotalPoints(0-7)KnownCAD(stenosis50%)ASAuseinpast7days0/123456/7RISKSCORERISKOFCARDIACEVENTS(%)BY14DAYSINTIMI

11B*33571219AntmanetalJAMA2000;284:835-8421111111TIMIRISKSCOREforUA/NSTEMIPOINTSDEATHORMIDEATH,MIORURGENT

REVASC5813202641*Entrycriteria:UAorNSTEMIIdefinedasischemicpainatrestwithinpast24H,withevidenceofCAD(STsegment

deviationor+marker)北京朝阳医院BeijingChaoyangHospitalACS的治疗目标病理生理改变治疗进程ACS(非阻塞性)斑块破裂血栓形成减少血栓负荷限制血栓进展促进斑块愈合和内环境稳定AMI(阻塞性)血栓性

阻塞开通阻塞性血管限制损伤范围北京朝阳医院BeijingChaoyangHospital症状提示急性冠脉综合征评价12导联ECE慢性稳定性心绞痛可能ACS确定ACS药物治疗抗凝治疗阻滞剂非心脏病诊断其它可疑疾病诊断北京朝阳医院Bei

jingChaoyangHospital评价再灌注症状提示急性冠脉综合征可疑ACS确诊ACSNSTEACSSTEACSECG无特异改变心肌标志物阴性ST-T改变胸痛持续心肌标志物阳性血流动力学不稳定观察、随访证实ACS收入院急性

心肌缺血路经门诊随访北京朝阳医院BeijingChaoyangHospitalUA/NSTEMI的急性期处理抗缺血治疗⚫吸氧、卧床、ECG监测⚫硝酸酯类⚫-阻滞剂⚫ACEIUA,unstableangina;NSTEMI,non-ST

-segmentelevationmyocardialinfarction;ECG,electrocardiogram;ACE,angiotensin-convertingenzyme.BraunwaldE,etal.JAmCollCardiol.2000;36:

970-1062.抗栓治疗抗血小板治疗抗凝治疗北京朝阳医院BeijingChaoyangHospitalNSTEMI的药物治疗首选用药抗缺血治疗低分子肝素(LMWH)阿司匹林/赛氯匹啶/氯比格雷次选用药GPIIbIIIa阻滞剂替代治疗凝血酶抑制剂其他ACS的抗缺血治疗Earlybe

nefitReductionischaemiaEarlybenefitPreventionDeath/MISustainedEffectofEarlybenefitAdditionalLong-termDeath/MIBetablockersABBANitratesC(-)(-)(

-)CaAntagonistsBB(-)(-)Aspirin(-)AAAThienopyridinesBBBBIIb/IIIareceptorsblockersAAAAUnfractionatedheparinCB(-)(-)LWMHA

AACDirectantithrombins(-)AA(-)RevascularizationAAAA北京朝阳医院BeijingChaoyangHospitalPossible（可疑）ACS阿斯匹林阿

斯匹林+IV肝素Heparin+GPIIb/IIIa拮抗剂高危或拟行介入治疗者氯吡格雷阿斯匹林+低分子肝素or静脉肝素Likely/Definite（可能或确定）ACS氯吡格雷*ClassIIa:enoxaparinpreferred

overUFHunlessCABGplannedwithin24hours.ACC,AmericanCollegeofCardiology;AHA,AmericanHeartassociation;ACS,acute

coronarysyndrome;PCI,percutaneouscoronaryintervention;SQLMWH,subcutaneouslowmolecular-weightheparin;IV,intravenous.Braunwald

E,etal.JAmCollCardiol.2000;36:970-1062.ACC/AHA推荐的抗栓治疗（I类指征）北京朝阳医院BeijingChaoyangHospital17.16.5*PlaceboASA05101520Patients(%)Uns

tableAngina25.011.0*ASA01020303.31.9*ASA0123411.89.4*ASA051015AcuteMIAspirin在ACS中的应用*P<.0001DeathorMI*P=.003Reocclusion*P=.01

2MI*P<.001DeathN=3973995134198587860085878600MI,myocardialinfarction;ASA,acetylsalicylicacid;RISC,ResearchonInStabili

tyinCoronaryarterydisease.RISCGroup.Lancet.1990;336:827-830.RouxS,etal.JAmCollCardiol.1992;19:671-677.ISIS-2.Lancet.

1988;2:349-360.PlaceboPlaceboPlacebo氯吡格雷•对阿斯匹林禁忌的患者，作为替代药物单独应用•与阿斯匹林联用,改善急性期和远期预后•介入治疗中应用CUREPCICURE0.000.020.040.0

60.080.100.120.14CumulativeHazardRateClopidogrel+ASA*369Placebo+ASA*MonthsofFollow-Up11.4%9.3%20%RRRP<0.001N=12,562012

*IncombinationwithstandardtherapyTheCURETrialInvestigators.NEnglJMed.2001;345:494-502.一级终点事件-MI/Stroke/CVDeathPlac

ebo+ASA*N=6303Clopidogrel+ASA*N=6259Majorbleeding2.7%3.7%**Life-threateningbleeding1.8%2.2%†Non-life-threateningbleeding0.9%1.5%‡Minorbleeding2

.4%5.1%§EndPoint*Incombinationwithstandardtherapy**P=0.001;†P=NS;‡P=0.002;§P<0.001.TheCURETrialInvestigators.NEnglJMed.2001;

345:494-502.CURE–出血并发症0.150.100.050.00100200300400Daysoffollow-up12.6%8.8%31%RRRP=0.002N=2658Clopidogrel+ASA

*Placebo+ASA*CumulativeHazardRate*IncombinationwithstandardtherapyMehta,SR.etalfortheCURETrialInvestigat

ors.Lancet.August2001.CompositeofcardiovasculardeathorMIfromrandomizationtoendoffollow-upPCI–CURE长期随访结果北京

朝阳医院BeijingChaoyangHospitalRR:Death/MIASAAlone68/655=10.4%Heparin+ASA55/698=7.9%BBBBBBB0.1110SummaryR

elativeRisk0.67(0.44-0.1.02)TherouxRISCCohen1990ATACSHoldrightGurfinkel肝素的应用：ComparisonofHeparin+ASAvsASAAlo

neASA,acetylsalicylicacid;RISC,ResearchonInStabilityinCoronaryarterydisease;ATACS,AntithromboticTherapyinAcuteCompanySyndromes;RR,re

lativerisk;MI,myocardialinfarction.OlerA,etal.JAMA.1996;276:811-815.(withpermission)低分子肝素（LMWH）LMWHismorereliabl

e&willprobablyreplaceUFHasprimarytherapy,withattentiontoincreasedbleedingrisk低分子肝素可替代普通肝素作为首选治疗BetterOutcomeORBetterPatencyFRAXIS0.93AS

SENT-PlusTIMI11B0.85AMI-SKESSENCE0.80HART-20123456789081624324048566472%PtsHoursfromRandomizationUFHENOX5.2%4.2%

RRR18%P=0.217.3%5.5%RRR24%P=0.03ESSENCETIMI11B普通肝素和依诺肝素的比较：TIMI11BvsESSENCE：Death/MI/UrgentRevasc.AntmanEMetal,Circulation1999Oc

t12;100(15):1602-80.512OVERALLESSENCETIMI11BUFH(%)Enox(%)O.R.FavorsENOXFavorsUFHHeterogeneity:AllP=NS1.01.5严重出血事件1.21.11.11.3OR(95

CI)P1.52(0.86-2.69)NS0.91(0.47-1.78)NS1.23(0.80-1.89)NSAntmanEMetal,Circulation1999Oct12;100(15):1602-8ACC/AHA有关NSTE-ACS低分子肝素应用指南•在应用阿斯匹林和/或

氯吡格雷以外，应用皮下注射低分子肝素或静脉注射普通肝素抗凝•Initialanticoagulationwithsubcut.LMWHorIVUFH,inadditiontoASA+/-clopidogrel(ClassI;EvidenceA)凝血酶抑制剂的地位尚未确定，仍有待更多证据支持•水蛭

素•BIVALIRUDIN北京朝阳医院BeijingChaoyangHospital血小板糖蛋白（GP）IIb/IIIa受体拮抗剂Abciximab阿昔单抗ReoproTirofiban替罗非班Eptifibatide依替巴肽Lamifiban拉米非班

Xemilofiban珍米洛非班Sibrafiban西拉非班Orbofiban奥波非班Lefradafiban来达非班Integrelin引替瑞林Fradafiban夫雷非班GPIIbIIIa受体拮抗剂GPIIbIIIa受体拮抗剂改善ACS患者临床预后(Death&MIrate

)(4Pstudies)StudyNORGPIIbIIIaIPlaceboPPRISM+7d19150.584.9%8.3%0.006PRISM+30d19150.738.7%11.9%0.03PUR

SUIT7d109460.8910.1%11.6%0.02PURSUIT30d109460.9214.2%15.7%0.04PARAGONA22820.8910.3%11.7%0.48PARAGONB52200.9010.

6%11.5%0.32GPIIbIIIaInhibitorsACS介入治疗中应用EPIC2099Abciximab8.312.8EPILOG2792Abciximab5.311.7EPISTENT1603Abciximab5.

310.8(stentarmsonly)IMPACT-II4010Eptifibatid9.511.4ESPRIT2064Eptifibatide6.810.4RESTORE2141Tirofiban8.010.5OddsRatioTrialNAgentIIb/IIIaControl(

95%CI)30-DayDeath,MI,UrgentRevascularization%0.00.51.02.0PresentedatAHAScientificSessionsNov.15,2000北京朝阳医院BeijingChaoyangHospi

tal早期介入治疗中应用GPIIbIIIaInhibitors的益处30天Death/MI/InterventionCombinationofAspirin,Thienopyridines,GPIIbIIIaAntagonists&UH联合应用阿斯匹林、噻氯匹

定、GPIIbIIIa拮抗剂和普通肝素ESPRIT研究eptifibatide180+180µg/kgbolus(boluses10minapart)2.0µg/kg-mininfusionx18-24°+heparin60U/kgbolus(ACT200-300sec)placeb

o+heparin60U/kgbolus(ACT200-300sec)vs.试验设计ASA,thienopyridine<24°;randomizationincathlabelective(non-urgent)stentPCI

48hour,30day,6month,1yearfollow-upprimaryendpoint:48°death,MI,urgentTVR,thromboticbailoutkeysecondarye

ndpoint(30d):death,MI,urgentTVRkeysecondaryendpoint(6m,1y):death,MI11.5%7.4%0%5%10%15%placebo(n=1024)eptifibatide(n=1040)6个月时的死亡/

MI事件P=0.001537%log-rankstatisticcumulativeeventrate(%)1年时死亡/MI/TVR0510152025024681012placeboeptifibatide24%RRRp=0.006822

.1%17.5%cumulativeeventrate(%)months1年时糖尿病患者的TVR05101520024681012diabetes-placebodiabetes-eptifibatidenodiabetes-placebonodiabetes-eptifibatide

16.1%18.1%11.6%10.4%cumulativeeventrate(%)months=2.0%10%RRp=NS=1.2%11%RRp=NSCombinationofLMWH&GPIIbIIIaInhibitorsinAcuteCoronar

ySyndrome联合应用低分子肝素和GPIIbIIIa拮抗剂INTERACT研究TheINTERACTStudy试验设计746patientsUA/NSTEMIChestpain>10minwithin24hr0.5mmSTSegmentdepression/t

ransientelevationPositivecardiacmarkers(CK-MBortroponin)180/2.0doseeptifibatidefor48hrsASA160mginitially→80-325mgdailyTreatmentGroupAUFH70IU/kgbo

lus/0.15U/kg-hr(aPTT50-70sec)(n=366)TreatmentGroupB1.0mg/kgq12enoxaparin(n=380)Endpoints:Primary-Major/MinorTIMIBleedingSecondary

-D/MI/recurrentischemia-STsegmentmonitoringGoodmanetal,ACC200225.1%14.1%0%5%10%15%20%25%30%UFHEnoxap

arinP=0.00020-48HoursINTERACT:96小时内缺血事件25.9%12.7%0%5%10%15%20%25%30%UFHEnoxaparinP=0.000148-96HoursGoodmanetal,ACC20

02n=346n=357n=320n=3228.5%5.3%0%2%4%6%8%10%UFHEnoxaparinP=0.083AllINTERACT30天严重出血事件5.5%2.9%0%2%4%6%8%10%UFHEnoxaparinP=0.

079Non-CABGRelatedTIMIScale(LMWHtrials)Goodmanetal,ACC2002INTERACT:结论联合应用依替巴肽和依诺肝素较联合应用普通肝素可以：降低严重出血事件降低死亡及再发MI降低缺血发作Goodmanetal,ACC2002早期介

入治疗？！VANQWISHTrialVAHospitalsStudy:ManagementpostNon-QwaveMIBodenWE:PresentedattheACCScientificSessions1997,AnaheimCACombinedEndp

ointDeathRatesNon-fatalMIRatesPercent0510152025005101551015Discharge12moInvasiveConservativeDischarge12moDis

charge12mop=0.004p=0.05p=0.007p=0.025北京朝阳医院BeijingChaoyangHospital048121607142128354249%ofPatientsDeathorMIP=NS12.2%10.8%EarlyConservativeEarly

InvasiveWeeksAndersonHVetal.,JACC1995;26:1643-1650.TIMIIIIBOneYearResults北京朝阳医院BeijingChaoyangHospital北京朝阳医院Beiji

ngChaoyangHospitalFRISCII-DeathorMIat6monthsPatientsEligibleforRevascularizationLancet1999;354:708-15p=0.03

1北京朝阳医院BeijingChaoyangHospital北京朝阳医院BeijingChaoyangHospital北京朝阳医院BeijingChaoyangHospital北京朝阳医院BeijingChaoy

angHospitalTable3.TACTICS-CardiacEventsat30days0123456Time(months)048121620%PatientsCONSINVO.R0.7895%CI(0.62,0.97)p=0.02519.

4%15.9%TACTICS-TIMI18研究6个月初级终点事件Death,MI,RehospforACSat6Months14.524.216.914.3051015202530TnT-TnT+(%)CONSINVTACTICS-TIMI18研究中根据

肌钙蛋白T分组观察TnTcutpoint=0.01ng/ml(54%ofPtsTnT+)6个月时的Death,MI,RehospACS事件发生率OR=0.52*p<0.001InteractionP<0.001p=NS*N=41

4N=396N=463N=49511.820.312.816.119.530.605101520253035Low0-2Intermed.3-4High5-7Death/MI/ACSRehosp(%)TIMIRiskSco

reCONS根据TIMI积分分组观察:6个月结果%ofPts:25%60%15%INVOR=0.75CI(0.57,1.00)OR=0.55CI(0.33,0.91)北京朝阳医院BeijingChao

yangHospitalTACTICS-TIMI18:结论ACS早期介入治疗，先期应用GPIIb/IIIainhibitor（替罗非班），可以：1显著减少主要心血管事件2在肌钙蛋白阳性和TIMI积分危险分层中高危的患者中尤为明显3低危患者获益不明显北京朝阳医院BeijingChaoyangHo

spital北京朝阳医院BeijingChaoyangHospital北京朝阳医院BeijingChaoyangHospital北京朝阳医院BeijingChaoyangHospital北京朝阳医院BeijingChaoy

angHospital北京朝阳医院BeijingChaoyangHospital北京朝阳医院BeijingChaoyangHospital北京朝阳医院BeijingChaoyangHospitalNS

TE-ACS早期介入治疗和保守治疗的荟萃分析RCTNFUINSVCONSVPTIMI3B14731yr10.712.20.42VANQWISH9201yr24.218.40.028MATE2012yr13.912.00.8DANAMI10082yr9.21

4.80.08FRISCII24571yr10.414.10.008TACTICS2200.5yr7.39.50.05OVERALL727111.3%12.8%RR0.87(p.0584)ACC/AHA对NSTE-ACS早期介入治疗的建议（ClassI–EvidenceA)Thesuperior

ityofanearlyinvasivemanagementstrategyisemphasizedinthemanagementofhighriskpts,(STdepression,(+)biomark

ers&recurrentischemia对高危患者（ST段压低，血清生化标记物＋，反复缺血发作），强调早期介入干预的益处ACS研究未来的方向对病因和病理机制的进一步研究更加精确的早期诊断和危险分层建立更加合理的联合用药方案合适患者采

取更加积极的介入治疗：非ST段抬高ACS的急诊介入治疗（immediatePCI）？对不稳定斑块的早期检出和处理北京朝阳医院BeijingChaoyangHospital谢谢！北京朝阳医院BeijingChaoyangHospital