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武汉亚洲心脏病医院朱国英多支血管病变血运重建单纯球囊扩张(PTCA)时代多个临床试验结果有利于CABG◼CABG完全血运重建率高◼PCI再次血运重建率高10090807060500601201802403003
60Days%Death/MI/CABG/Re-PTCACABRI:CABG(91%)CABRI:PTCA(59%)32%14%EventfreesurvivalMyrosyprophecyARTS2:ElutingSTENT(95%)A
RTS2:CABG(90%)CABRI:1994ARTS:1999ARTS2:2003,FREEDOMARTS:CABG(89%)ARTS:STENT(75%)-5%AndreasGruentzig’sLec
ture,ESC2000Amsterdam1009080706050060120180240300360Days%Death/MI/CABG/Re-PTCACABRI:CABG(91%)CABRI:PTC
A(59%)32%14%EventfreesurvivalMyrosyprophecyARTS2:ElutingSTENT(95%)ARTS2:CABG(90%)CABRI:1994ARTS:1999ARTS2:2003,FREEDOMARTS:CABG(89%)ARTS:STE
NT(75%)-5%AndreasGruentzig’sLecture,ESC2000AmsterdamCurrentTrialsofCABGvs.DESSYNTAXFREEDOMCOMBATSYNTAXTrialDesignSYNTAX是多支血管血运重建的里程碑
研究⚫第一个随机、对照临床研究⚫设计基础:—回顾分析了2003–2004年104家医疗中心的血运重建(CABG或PCI)—12,072例患者:1/3为左主干,2/3为三支病变—治疗策略:2/3选择CABG,
1/3选择PCISYNTAX是多支血管病变治疗策略真实世界的研究PatientCharacteristics(1)RandomizedCohortPatientCharacteristics(2)RandomizedCohortAll–CauseDeathto12Month
sMyocardialinfarctionto12MonthsAll–CauseDeath/CVA/MIto12MonthsSymptomaticGraftOcclusion&StentThrombosist
o12MonthsMACCEto12MonthsRepeatRevascularizationto12MonthsCVAto12Months12MonthLMSubgroupMACCERates12MonthLMSubgroupMACCERatesOutcomeaccordingtoDiabeti
cStatusConclusionsPatientProfilingThereis‘3-vesseldisease’and‘3-vesseldisease’研究结果:12月MACE-SYNTAXSCOREP
atrickW.Serruys:—对于合并左主干冠心病患者:DES和CABG的有效性和安全性相近似—对于采用SYNTAX计分系统评估的低计分组和中等计分组的左主干合并单支、双支或三支病变患者:DES是更为合理的治疗选择—对于高计分(≥
33分)组左主干合并多支病变患者:CABG是较为合理的治疗选择SYNTAX的意义⚫PatrickSerruys评论:—首次比较了DES和CABG对复杂、疑难病变患者的影响—PCI和CABG对主要终点事件的影响未分胜负—结果显示PCI和CABG都能改善预后⚫PetrWidimsky评论
:—研究结果对外科和介入医生皆大欢喜—对于左主干和三支病变患者,需心内科和外科共同决定治疗策略—患者应参与治疗决策,选择开胸手术还是承担再次血管重建的风险SYNTAX的意义SYNTAXSTEMI的血运重建方式ST段抬高心肌梗死溶栓直接PCI溶栓后PCICAB
G74.52.261078977212151305101520253035直接PCI和溶栓疗法的比较—23个随机研究的汇萃分析(n=7739)PTCAKeeleyE.etal.,Lancet2003;361:13-20.P=0.0002P=0.0003P<0.0001P<0.0001
P<0.0001P=0.0004P=0.032P<0.0001DeathDeath,noSHOCKdataReMIRec.IschTotalStrokeHem.StrokeMajorBleedDeathMICVAF
ibrinolysis(%)EventsDES能否常规用于直接PCI?HarmonizingOutcomeswithRevascularizationandStentsinAMI3602ptswithSTE
MIwithsymptomonset≤12hoursEmergentangiography,followedbytriageto…PrimaryPCICABG–MedicalRx–UFH+GPIIb/IIIainhibitor(abciximabor
eptifibatide)Bivalirudinmonotherapy(±provisionalGPIIb/IIIa)Aspirin,thienopyridineR1:13000ptseligibleforstentrandomizationR3:1Bareme
talEXPRESSstentPaclitaxel-elutingTAXUSstentClinicalFUat30days,6months,1year,andthenyearlythrough5yea
rs;angioFUat13monthsStentRandomizationHypothesesInpatientswithSTEMIundergoingprimaryPCI,theuseofpaclitaxel-elutingTAXUSstentsratherth
anbaremetalEXPRESSstentswillbe:–Efficacious,asevidencedbyreducedratesofischemia-driventargetlesionrevasculariz
ationat1-yearandangiographicbinaryrestenosisat13months;and–Safe,withnon-inferiorratesofthecompositemeasureofdeath,reinfarction,ste
ntthrombosisorstrokeat1-yearHorizonsEnrollment-CentersUSA(57)(1)Spain(6)UK(2)NorwayPoland(9)Germany(16)Aus
tria(5)(3)NetherlandsItaly(2)Argentina(12)Israel(10)3,602ptsrandomizedat123centersin11countriesbetweenMarch25th,2005andMay7th,2007TA
XUSDESN=2257EXPRESSBMSN=749Randomized1yearFUN=2186(96.9%)N=715(95.5%)•••Withdrew••••••LosttoFU•••18537
27R3:1HarmonizingOutcomeswithRevascularizationandStentsinAMI3006ptseligibleforstentrand.PrimaryMedicalRx193PrimaryCABG62Deferre
dPCI2IndexPCI,noteligible-PTCAonly119-Stented220UFH+GPI(n=1802)Bivalirudin(n=1800)R1:13602ptswithSTEMI93.1%ofallstentedptswererandomized
22572132209820691868749697675658603NumberatriskTAXUSDESEXPRESSBMSPrimaryEfficacyEndpoint:IschemicTLRIschemicTLR(%)012345678910TimeinMonths0123456789
1011127.5%4.5%Diff[95%CI]=-3.0%[-5.1,-0.9]HR[95%CI]=0.59[0.43,0.83]P=0.002TAXUSDES(n=2257)EXPRESSBMS(n=749)IschemicTVR(%)0123
45678910TimeinMonths012345678910111222572119207820451848749695669650598NumberatriskTAXUSDESEXPRESSBMS8.7%5.8%
Diff[95%CI]=-3.0%[-5.2,-0.7]HR[95%CI]=0.65[0.48,0.89]P=0.006TAXUSDES(n=2257)EXPRESSBMS(n=749)SecondaryEfficacyEndpoint:IschemicTV
RPrimarySafetyEndpoint:SafetyMACE*SafetyMACE(%)012345678910TimeinMonths012345678910111222572115208620571856749697683672619NumberatriskTAXUSD
ESEXPRESSBMSTAXUSDES(n=2257)EXPRESSBMS(n=749)8.1%8.0%Diff[95%CI]=0.1%[-2.1,2.4]HR[95%CI]=1.02[0.76,1.36]PNI=0.01PSup=0.92
*SafetyMACE=death,reinfarction,stroke,orstentthrombosisOne-YearAll-CauseMortalityMortality(%)012345TimeinMonths01234567
8910111222572180216121471949749716712702648NumberatriskTAXUSDESEXPRESSBMSTAXUSDES(n=2257)EXPRESSBMS(n=749)3.5%3.5%HR[95%CI
]=0.99[0.64,1.55]P=0.98One-YearDeathorReinfarctionDeathorMI(%)012345678TimeinMonths01234567891011122257214021102
0831882749703689678625NumberatriskTAXUSDESEXPRESSBMSTAXUSDES(n=2257)EXPRESSBMS(n=749)7.0%6.8%HR[95%CI]
=0.97[0.70,1.32]P=0.83StentThrombosis(ARCDefiniteorProbable)22382122209820781884744701694683629NumberatriskTAXUSDESEXPRESSBMSStentTh
rombosis(%)01234TimeinMonths0123456789101112TAXUSDES(n=2238)EXPRESSBMS(n=744)3.4%3.1%HR[95%CI]=0.92[0.58,1.45]P=0.72Angi
ographicFollow-upTAXUSDESN=1348EXPRESSBMSN=452RandomizedEligibleN=1308N=4411800consecutiveeligibleptsassigne
dto13monthangiographicFU**Randomizedinstentarm;stentproceduresuccessful(DS<10%,TIMI-3flow,≤NHLBItypeAperi-
stentdissection);nostentthrombosisorCABGw/i30days4011•••DiedbeforeangioFU•••N=942(72.0%)N=307(69.6%)CompletedAngioFU366134•AngioFUnotperformed
•••Notreceived/analyzable••••••Outofwindow••••283140N=911N=293Analyzed•••Lesions•••1081332BinaryAnalysisSegmentRestenosisat13MonthsPatientandLesionLe
velAnalysis*RR[95%CI]=0.44[0.33,0.57]P<0.0001*ITT:Includesallstentrandomizedlesions,whetherornotastentwasimplanted,andwhetheror
notnonstudystentswereplaced**AnylesionwithrestenosisperptrestenosisRR[95%CI]=0.44[0.33,0.57]P<0.0001Major2endpointA
ngiographicLateLossat13MonthLesionswithStentsImplantedP<0.0001P<0.0001±0.42±0.54±0.64±0.70P=0.18P=0.07±0.56±0.
64±0.47±0.50BinaryAngiographicRestenosisat13MonthsLesionswithStentsImplantedRR[95%CI]=0.42[0.32,0.54]P<0.0001RR[95%CI]=
0.39[0.29,0.52]P<0.0001P=0.13P=0.42ConclusionsInthislarge-scale,prospective,randomizedtrialofptswithSTEMIundergoingprimarysten
ting,theimplantationofpaclitaxel-elutingTAXUSstentscomparedtobaremetalEXPRESSstentsresultedin:–Asignificant41%reductioninthe1-yearprimaryefficac
yendpointofischemia-drivenTLR,andasignificant56%reductioninthe13monthmajorsecondaryefficacyendpointofbinaryrestenosis–Noninferiorratesofth
eprimarycompositesafetyendpointofallcausedeath,reinfarction,stentthrombosisorstrokeat1-yearConclusionsThelon
g-termsafetyandefficacyprofileofpaclitaxel-elutingTAXUSstentscomparedtobaremetalEXPRESSstentsinSTEMIwil
lbedeterminedbytheongoing5yearfollow-upofpatientsrandomizedintheHORIZONS-AMItrial慢性稳定型心绞痛PCI?—什么时候需要血运重建?—哪些病人需要血运重建?ACC/AHA/SCAI2007年PCI指南
推荐:⚫病变血管供应大面积心肌(ⅠB)⚫供应中等面积心肌(ⅡaB)⚫供应小面积心肌或无缺血症状(ⅢC)慢性稳定型心绞痛PCI推荐血运重建治疗策略:⚫病变血管供应较大面积心肌的患者⚫症状发作频繁且有加重趋势的患者⚫药物治疗效果欠佳
的患者慢性稳定型心绞痛PCI武汉亚洲心脏病医院2007AHA/ACC/SCAI/ACS/ADA2007学术公告:⚫强调置入DES后双重抗血小板治疗至少12个月⚫接受双重抗血小板治疗的病人,各种择期手术应推迟1年⚫若无法推迟,置入DE
S的病人宜考虑在围手术期继续服用阿司匹林Intervention2009What’sNext?