急性冠脉综合征(ACS)及其治疗进展培训课件

1、急性冠脉综合征（ACS）及其治疗进展急性冠脉综合征（ACS）及其治疗进展 急性冠状动脉综合征的定义和分类 定义：急性冠状动脉综合征(acute coronary syndomes , ACS) 是从不稳定性心绞痛到Q波心肌梗死的一组临床综合征 ，通常(但并非总是)由于CAD所致，在病理生理上有很多相似之处。急性冠状动脉综合征的分类 ： ST段不抬高的急性冠状动脉综合征 非Q波心肌梗死NSTEMI（CK-MB大于正常上限的2倍） 不稳定性心绞痛UAP（CK-MB小于正常上限的2倍） ST段抬高的急性冠状动脉综合征 急性Q波心肌梗死STEMI 5/982急性冠脉综合征（ACS）及其治疗进展 急性冠

2、状动脉综合征的定义和分类 定义：急性冠状动脉综合征(国际现状每年: 4 million patients are admitted with unstable angina and acute MI 900,000 patients undergo PTCA with or without stent5/983急性冠脉综合征（ACS）及其治疗进展国际现状每年:5/983急性冠脉综合征（ACS）及其治疗进展Ischemic Heart DiseaseevaluationBased on the patientshistory / physical examelectrocardiogramPat

3、ients are categorized into 3 groupsnon-cardiac chest painunstable anginamyocardial infarction5/984急性冠脉综合征（ACS）及其治疗进展Ischemic Heart Diseaseevaluat急性冠脉综合征（ACS）ACS非 ST-segment抬高 ST-segment抬高不稳定 非-Q波Q-Wave心绞痛 AMI AMIECGAcuteReperfusionHistoryPhysical Exam5/985急性冠脉综合征（ACS）及其治疗进展急性冠脉综合征（ACS）ACS非 ST-segmen

4、t抬Acute Coronary SyndromeThe spectrum of clinical conditions ranging from:unstable anginanon-Q wave MIQ-wave MIcharacterized by the common pathophysiology of a disrupted atheroslerotic plaque5/986急性冠脉综合征（ACS）及其治疗进展Acute Coronary SyndromeThe spe5/987急性冠脉综合征（ACS）及其治疗进展5/987急性冠脉综合征（ACS）及其治疗进展STEMI和UA/N

5、STEMI病理5/988急性冠脉综合征（ACS）及其治疗进展STEMI和UA/NSTEMI病理5/988急性冠脉综合征（不稳定心绞痛 定义angina at rest ( 20 minutes)new-onset ( 2 months) exertional angina (at least CCSC III in severity)recent ( 2Non-Q-Wave MIclues to diagnosisProlonged chest painAssociated symptoms from the autonomic nervous systemnausea, vomiting,

6、diaphoresisPersistent ST-segment depression after resolution of chest pain 5/9810急性冠脉综合征（ACS）及其治疗进展Non-Q-Wave MIclues to diagnos5/9811急性冠脉综合征（ACS）及其治疗进展5/9811急性冠脉综合征（ACS）及其治疗进展NSTEACS诱发因素Inappropriate tachycardiaanemia, fever, hypoxia, tachyarrhythmias, thyrotoxicosisHigh afterloadaortic valve steno

7、sis, LVHHigh preloadhigh cardiac output, chamber dilatationInotropic statesympathomimetic drugs, cocaine intoxication5/9812急性冠脉综合征（ACS）及其治疗进展NSTEACS诱发因素Inappropriate tachNSTEACS预后预测因素 Presence of ST-T-wave changes with painHemodynamic deteriorationpulmonary edema, new mitral regurgitation,3rd heart

8、sound, hypotensionOther predictorsleft ventricular dysfunction, extensive CAD, age, comorbid conditions (diabetes mellitus, obstructive pulmonary disease, renal failure, malignancy) 5/9813急性冠脉综合征（ACS）及其治疗进展NSTEACS预后预测因素 Presence of ST非ST段抬高ACS（NSTEACS）Plaque disruption斑块破裂Acute thrombosis急性血栓Vasocon

9、striction血管收缩5/9814急性冠脉综合征（ACS）及其治疗进展非ST段抬高ACS（NSTEACS）5/9814急性冠脉综合NSTEACSpathogenesis斑块破裂Passive plaque disruptionsoft plaque with high concentration of cholesteryl esters and a thin fibrous capActive plaque disruptionmacrophage-rich area with enzymes that may degrade and weaken the fibrous cap; pr

10、edisposing it to rupture 5/9815急性冠脉综合征（ACS）及其治疗进展NSTEACSpathogenesis斑块破裂5/9815NSTEACS pathogenesis急性血栓Vulnerable plaquedisrupted plaque with ulcerationoccurring in 2/3 of unstable patientsthe exposed lipid-rich core abundant in cholesteryl ester is highly thrombogenic Systemic Hypercoagulable Stated

11、isrupted plaque with erosionoccurring in 1/3 of unstable patients5/9816急性冠脉综合征（ACS）及其治疗进展NSTEACS pathogenesis急性血栓5/981NSTEACS pathogenesis血管收缩the culprit lesion in response to deep arterial damage or plaque disruptionarea of dysfunctional endothelium near the culprit lesionplatelet-dependent and thr

12、ombin-dependent vasoconstriction, mediated by serotonin and thromboxane A25/9817急性冠脉综合征（ACS）及其治疗进展NSTEACS pathogenesis血管收缩5/981Risk Stratification by ECGThe risk of death or MI at 30 days is strongly related to the ECG at the time of chest pain.ST depression 10%T-wave inversion 5%No ECG changes1-2%5

13、/9818急性冠脉综合征（ACS）及其治疗进展Risk Stratification by ECGThe有以下表现者为高危险性：(1) 危险性随病变血管支数、病变弥漫程度、小血管病变、闭 塞血管病变数而增高。(2) 左主干病变(3) 含血栓性病变(见图1) (4) 病变形态复杂,行介入治疗难以或无法植入支架。(见图2) 图1 图2冠脉造影5/9819急性冠脉综合征（ACS）及其治疗进展有以下表现者为高危险性：(1) 危险性随病变血管支数、NSTEACS治疗目标Therapeutic Goals减少心肌缺血 控制症状 预防心肌梗死和猝死Medical Management抗缺血 therapy抗

14、血栓 therapy5/9820急性冠脉综合征（ACS）及其治疗进展NSTEACS治疗目标Therapeutic Goals5药物治疗抗缺血 therapynitrates, beta blockers, calcium antagonists抗血栓 therapy抗血小板 therapyaspirin, ticlopidine, clopidogrel, GP IIb/IIIa inhibitors抗凝 therapy heparin, low molecular weight heparin (LMWH), warfarin, hirudin, hirulog5/9821急性冠脉综合征（A

15、CS）及其治疗进展药物治疗抗缺血 therapy5/9821急性冠脉综合征（5/9822急性冠脉综合征（ACS）及其治疗进展5/9822急性冠脉综合征（ACS）及其治疗进展NSTEACSAnti-thrombotic Therapy不适宜溶栓“lytic agents may stimulate the thrombogenic process and result in paradoxical aggravation of ischemia and myocardial infarction”TIMI IIIB InvestigatorsCirculation 1994; 89:1545-1

16、5565/9823急性冠脉综合征（ACS）及其治疗进展NSTEACSAnti-thrombotic Therap5/9824急性冠脉综合征（ACS）及其治疗进展5/9824急性冠脉综合征（ACS）及其治疗进展Unstable AnginaAnti-platelet Therapy阿司匹林是“金标准”irreversible inhibition of the cyclooxygenase pathway in platelets, blocking formation of thromboxane A2, and platelet aggregationin AMI, ASA reduced

17、the risk of death by 20-25%in UA, ASA reduced the risk of fatal or nonfatal MI by 71% during the acute phase, 60% at 3 months, and 52% at 2 yearsbolus dose of 160-325 mg, followed by maintenance dose of 80-160 mg/d5/9825急性冠脉综合征（ACS）及其治疗进展Unstable AnginaAnti-platelet 缺血事件发生率无阿司匹林(early 1980s)阿司匹林Aspi

18、rin + Heparin16%12%9%Incidence of death and MI5/9826急性冠脉综合征（ACS）及其治疗进展缺血事件发生率无阿司匹林(early 1980s)阿司匹林Unstable AnginaAnti-platelet TherapyClopidogrel氯比格雷CAPRIE (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events)19,000 patients randomly assigned to clopidogrel (75 mg/d) or to aspirin (32

19、5 mg/d)there was an 8.7% reduction in the combined incidence of stroke, MI, or death (P=.043)patients with MI did better with aspirinpatients with PVD or stroke did better with clopidogrelLancet 1996;348:1329-1339Circulation 1998;97:11075/9827急性冠脉综合征（ACS）及其治疗进展Unstable AnginaAnti-platelet GP IIb/III

20、a Receptor血小板聚集的最终通路Platelet activation and aggregation are early events in the development of coronary thrombosisGP IIb/IIIa receptors on activated platelets undergo a conformational change allowing recognition and binding of fibrinogenFibrinogen “acts like glue”, bridging GP IIb/IIIa receptors on

21、adjacent platelets, leading to platelet aggregation5/9828急性冠脉综合征（ACS）及其治疗进展GP IIb/IIIa Receptor血小板聚集的最终通Unstable AnginaAnti-platelet TherapyTirofiban (Aggrastat; Merk & Co.)PRISM (Platelet Receptor Inhibition for Ischemic Syndrome Management)3,200 patients with unstable angina were treated with eith

22、er heparin or tirofibanAt 48 hours, there was significant risk reduction (5.9% to 3.6%) in the rate of death, MI, or refractory ischemia. The benefit was lost at 30 days.N Engl J Med 1998;338:1498-5055/9829急性冠脉综合征（ACS）及其治疗进展Unstable AnginaAnti-platelet 5/9830急性冠脉综合征（ACS）及其治疗进展5/9830急性冠脉综合征（ACS）及其治疗进

23、展调脂治疗他汀类药物5/9831急性冠脉综合征（ACS）及其治疗进展调脂治疗5/9831急性冠脉综合征（ACS）及其治疗进展急性冠脉综合征(ACS)及其治疗进展培训课件ACS 的治疗策略进展冠脉综合征治疗策略进展主要表现在以下三个方面：(1) 抗血小板制剂：包括阿斯匹林,ADP受体拮抗剂(抵克力得Ticlopidine、氯吡格雷Clopidogrel )和GPb / a 受体拮抗剂(Rrepro)(2) 抗凝制剂：包括肝素、低分子肝素(LMWH)、凝血酶抑制剂(水蛭素 Hirudin )和戊聚糖钠(3) 介入治疗5/9833急性冠脉综合征（ACS）及其治疗进展ACS 的治疗策略进展冠脉综合征治

24、疗策略进展主要表现在以下三Unstable Angina 介入治疗TIMI 3B early intervention vs conservative strategy(coronary angiography within 24-48 hrs, followed by angioplasty or bypass surgery)1473 patients with UA or non-Q-wave MI were randomized, there were no difference between the groups in the rates of death or MI at 1 y

25、earCirculation 1994;89:1545-15565/9834急性冠脉综合征（ACS）及其治疗进展Unstable Angina 介入治疗TIMI 3B C非ST段抬高ACS的PCI 复发静息心绞痛 动态ST段改变：ST压低0.1mv或一过性抬 高 0.1mv TnT、TnIC或CK-MB升高血流动力学不稳定室速、室颤AMI后不稳定心绞痛糖尿病 高危患者可能迅速发生血栓事件，进展为严重AMI或死亡，专家建议常规置入支架5/9835急性冠脉综合征（ACS）及其治疗进展非ST段抬高ACS的PCI 复发静息心绞痛5/9835急性冠AMI的再灌注治疗 溶栓治疗 介入治疗 5/9836急性

26、冠脉综合征（ACS）及其治疗进展AMI的再灌注治疗 溶栓治疗 再灌注策略危险和获益 时间 静脉溶栓5/9837急性冠脉综合征（ACS）及其治疗进展再灌注策略危险和获益 时间 再灌注开始的时间与获益5/9838急性冠脉综合征（ACS）及其治疗进展再灌注开始的时间与获益5/9838急性冠脉综合征（ACS）及ST段抬高ACS的再灌注-溶栓优先溶栓治疗： AMI患者来院3小时 不能行PCI PCI慢（D-TO-B90分钟）5/9839急性冠脉综合征（ACS）及其治疗进展ST段抬高ACS的再灌注-溶栓优先溶栓治疗：5/9介入治疗的优点 梗塞相关血管（IRA）开通率 开通率 95% TIMI-3级率 90% 死亡率低 30天3% 脑卒中率低 再闭塞率低 适应症范围广5/9840急性冠脉综合征（ACS）及其治疗进展介入治疗的优点 5/9840急性冠脉综合征（AST段抬高ACS的再灌注-PCI优先PCI治疗： AMI患者来院3小时 PCI条件好（D-TO-B90分钟） 高危STEMI患者: 心源性休克或合并心衰 溶栓禁忌者 疑诊AMI5/9841急性冠脉综合征（ACS）及其治疗进展ST段抬高ACS的再灌注-PCI优先PCI治疗：5ACCAHA有关