ACS是否应该早期介入治疗PPT课件

1、第1页/共60页ACS is an Important Manifestation of Atherothrombosis11. Cannon CP. J Thromb Thrombolysis 1995; 2: 205218.AntithrombotictherapyStable anginaUANon-Q-wave MIThrombolysisprimary PCIQ-wave MIMinutes hoursDaysweeksSTEMIUA/NSTEMIAtherothrombosisNew termOld termPlaquerupture第2页/共60页第3页/共60页Relation

2、 of TIMI risk score and MACE rate第4页/共60页Hot topic in ACS1.Is early invasive superior to conservative strategy in ACS?2.Should invasive be deferred for cooling off? What is the optimal time for invasive?第5页/共60页第6页/共60页Optimal Strategy for UA/NSTEMITIMI IIIB2005ConservativeInvasiveVANQWISHFRISC IITA

3、CTICS-TIMI 18RITA-3第7页/共60页FRICS-II: high risk get more第8页/共60页TIMI-18: high risk get more第9页/共60页RITA-3: 1&3 yrs outcome第10页/共60页RITA-3: 5yrs outcome第11页/共60页第12页/共60页第13页/共60页第14页/共60页In 2005,It seems we found answer1.In ACS, early invasive superior to early conservative2.This is particular true i

4、n high risk patients第15页/共60页ESC Guideline 2005第16页/共60页第17页/共60页Is the problem settled?第18页/共60页ICTUS Designed第19页/共60页第20页/共60页第21页/共60页第22页/共60页第23页/共60页第24页/共60页第25页/共60页4 yrs ICTUS Lancet 2007;369:827-835However, most of selective pts were performed PCISo, the long-term f/u results do not infle

5、ct Inv/Cons strategy 第26页/共60页4 yrs ICTUS Lancet 2007;369:827-835第27页/共60页ICTUSs criticism Liberty definition of MI (only 1*ULN) causing the early MI increase in early invasive group 3yrs revascularization rate was equal in 2 group(81%PCI) 1year mortality rate in ACS in both arm are very low(2.5%),I

6、s it a real high risk?第28页/共60页Even put ICTUS into pool, Inv Cons第29页/共60页Inv vs Cons/All cause death High risk?第30页/共60页第31页/共60页第32页/共60页2007 ESC Guideline Urgent Coronary angiography is recommended in Pts with refractory or recurrent angina associated with dynamic ST deviation, heart failure, lif

7、e threatening arrhythmias, or haemodynamic instability (I-C) Early(72h) angiography followed by revascularization (PCI or CABG) in patients with intermediate to high risk features is recommended (I-A)第33页/共60页MonocyteLDL-CAdhesion moleculeMacrophageFoam cellOxidizedLDL-CPlaque ruptureSmooth muscle c

8、ellsCRP2第34页/共60页ISAR-COOL Trial第35页/共60页ISAR-COOL Antithrombotic Regimen第36页/共60页第37页/共60页ISAR-COOL第38页/共60页第39页/共60页第40页/共60页第41页/共60页What is the optimal time for PCI?第42页/共60页第43页/共60页Methods for Optimal trial第44页/共60页Results of Optimal trial第45页/共60页Conclusion from Optimal trial第46页/共60页Whats th

9、e difference between ISAR-Cool & Optimal?2.5 vs 84 + 0.5 vs 25 -第47页/共60页Time to Coronary Angiography and Outcomes Among Patients With High-Risk NonST-SegmentElevation Acute Coronary Syndromes: Results From the SYNERGY Trial Pierluigi Tricoci, MD, MHS, PhD; Yuliya Lokhnygina, PhD; Lisa G. Berdan, PA

10、-C, MHS; Steven R. Steinhubl, MD; Dietrich C. Gulba, MD; Harvey D. White, MD; Neal S. Kleiman, MD; Philip E. Aylward, MD; Anatoly Langer, MD; Robert M. Califf, MD; James J. Ferguson, MD; Elliott M. Antman, MD; L. Kristin Newby, MD, MHS; Robert A. Harrington, MD; Shaun G. Goodman, MD; Kenneth W. Maha

11、ffey, MD Division of Cardiology, Duke Clinical Research Institute, Durham, NC 第48页/共60页Background 2007 ACC/AHA Guidelines for NSTE ACS recommend the use of an early invasive strategy for high-risk patients Randomized clinical trials on early vs. conservative strategy used different timing of cardiac

12、 catheterization Optimal timing of cardiac catheterization in NSTE ACS not yet established (expedited vs. deferred) Expedited catheterization increasingly adopted in the US第49页/共60页Study Objective To evaluate the association between time from hospital admission to cardiac catheterization and adverse

13、 outcomes among high-risk patients with NSTE ACS treated with an early invasive strategy (cardiac catheterization 48h of hospital admission)第50页/共60页Study Population Patients randomized in the SYNERGY trial Ischemic symptoms 60 years ST-segment depression or transient elevation Positive troponin and

14、/or CK-MB Use of coronary angiography in SYNERGY 10,027 pts randomized in the SYNERGY trial 9,188 pts underwent cardiac catheterization 6,352 pts underwent cardiac catheterization 48h第51页/共60页Adjusted Estimates of 30-day Death/MI Rates (with 95% CI).0.0第52页/共60页Landmark Analysis: Adjusted OR of 30-d

15、ay Death/MI (with 95% CI)第53页/共60页Adjusted Estimates of In-hospital Transfusion Rates (with 95% CI)第54页/共60页Study Limitations Non-randomized observational analysis Propensity-based models used to deal with lack of randomization Time to cath is a post-baseline and “dynamic” variable Statistical metho

16、dologies attempted to address these issues Events from hospital admission to randomization not available Events unlikely prior to randomization Myocardial infarction in the first hours following the hospitalization is more difficult to adjudicate第55页/共60页Conclusions from Synergy- 1 Observational ana

17、lysis among high-risk NSTE ACS patients enrolled in the SYNERGY trial treated with an early invasive strategy Reduced time to cardiac catheterization was associated with decreased probability of 30-day death/MI and no changes in bleeding No signals suggesting benefits of delaying the cardiac cathete

18、rization were observed第56页/共60页Conclusions from Synergy- 2 Randomized clinical trials to establish optimal timing of catheterization in NSTE ACS are needed but challenging Delaying cath is problematic for hospital adopting expedited cath strategy Lag from hospitalization to randomization may confound actual time to catheterization intervals Early re-MI adjudication complex Well-