ACS是否应该早期介入治疗课件

IsearlyinvasivetheanswerforACSDr.BenHeMD/PhD/FSCAI/FAPSICDirectorofCardiologyDepartmentRenjiHospitalAffiliatedtoShanghaiJiaotonguniversity编辑课件Isearlyinvasivetheanswerf1PathophysiologyofAcuteCoronarySyndrome编辑课件PathophysiologyofAcuteCoron2ACSisanImportantManifestationofAtherothrombosis11.CannonCP.JThrombThrombolysis1995;2:205–218.AntithrombotictherapyStableanginaUANon-

Q-waveMIThrombolysisprimaryPCIQ-waveMIMinutes–

hoursDays–weeksSTEMIUA/NSTEMIAtherothrombosisNewtermOldtermPlaque

rupture编辑课件ACSisanImportantManifestat3编辑课件编辑课件4RelationofTIMIriskscoreandMACErate编辑课件RelationofTIMIriskscorean5HottopicinACSIsearlyinvasivesuperiortoconservativestrategyinACS?Shouldinvasivebedeferredforcoolingoff?

Whatistheoptimaltimeforinvasive?编辑课件HottopicinACS编辑课件6编辑课件编辑课件7OptimalStrategyforUA/NSTEMITIMIIIIB2005ConservativeInvasiveVANQWISHFRISCIITACTICS-

TIMI18RITA-3编辑课件OptimalStrategyforUA/NSTEMI8FRICS-II:highriskgetmore编辑课件FRICS-II:highriskgetmore编辑9TIMI-18:highriskgetmore编辑课件TIMI-18:highriskgetmore编辑课10RITA-3:1&3yrsoutcome编辑课件RITA-3:1&3yrsoutcome编辑课件11RITA-3:5yrsoutcome编辑课件RITA-3:5yrsoutcome编辑课件12编辑课件编辑课件13编辑课件编辑课件14编辑课件编辑课件15In2005,ItseemswefoundanswerInACS,earlyinvasivesuperiortoearlyconservativeThisisparticulartrueinhighriskpatients编辑课件In2005,Itseemswefoundansw16ESCGuideline2005编辑课件ESCGuideline2005编辑课件17编辑课件编辑课件18Istheproblemsettled?编辑课件Istheproblemsettled?编辑课件19ICTUSDesigned编辑课件ICTUSDesigned编辑课件20编辑课件编辑课件21编辑课件编辑课件22编辑课件编辑课件23编辑课件编辑课件24编辑课件编辑课件25编辑课件编辑课件264yrsICTUSLancet2007;369:827-835However,mostofselectiveptswereperformedPCISo,thelong-termf/uresultsdonotinflectInv/Consstrategy编辑课件4yrsICTUSLancet2007;369:274yrsICTUSLancet2007;369:827-835编辑课件4yrsICTUSLancet2007;369:28ICTUS’scriticism

LibertydefinitionofMI(only1*ULN)causingtheearlyMIincreaseinearlyinvasivegroup3yrsrevascularizationratewasequalin2group(81%PCI)1yearmortalityrateinACSinbotharmareverylow(2.5%),Isitarealhighrisk?编辑课件ICTUS’scriticismLibertydefi29EvenputICTUSintopool,Inv>Cons编辑课件EvenputICTUSintopool,Inv30InvvsCons/AllcausedeathHighrisk?编辑课件InvvsCons/AllcausedeathHi31编辑课件编辑课件32编辑课件编辑课件332007ESCGuidelineUrgentCoronaryangiographyisrecommendedinPtswithrefractoryorrecurrentanginaassociatedwithdynamicSTdeviation,heartfailure,lifethreateningarrhythmias,orhaemodynamicinstability(I-C)Early(<72h)angiographyfollowedbyrevascularization(PCIorCABG)inpatientswithintermediatetohighriskfeaturesisrecommended(I-A)编辑课件2007ESCGuidelineUrgentCoron34MonocyteLDL-CAdhesion

moleculeMacrophageFoamcellOxidized

LDL-CPlaqueruptureSmoothmuscle

cellsCRP2编辑课件MonocyteLDL-CAdhesion

molecul35ISAR-COOLTrial编辑课件ISAR-COOLTrial编辑课件36ISAR-COOLAntithromboticRegimen编辑课件ISAR-COOLAntithromboticRegim37编辑课件编辑课件38ISAR-COOL编辑课件ISAR-COOL编辑课件39编辑课件编辑课件40编辑课件编辑课件41编辑课件编辑课件42WhatistheoptimaltimeforPCI?编辑课件WhatistheoptimaltimeforP43编辑课件编辑课件44MethodsforOptimaltrial编辑课件MethodsforOptimaltrial编辑课件45ResultsofOptimaltrial编辑课件ResultsofOptimaltrial编辑课件46ConclusionfromOptimaltrial编辑课件ConclusionfromOptimaltrial编47What’sthedifferencebetweenISAR-Cool&Optimal?2.5vs84+0.5vs25-编辑课件What’sthedifferencebetween48TimetoCoronaryAngiographyandOutcomesAmongPatientsWithHigh-RiskNon–ST-Segment–ElevationAcuteCoronarySyndromes:ResultsFromtheSYNERGYTrial

PierluigiTricoci,MD,MHS,PhD;YuliyaLokhnygina,PhD;LisaG.Berdan,PA-C,MHS;StevenR.Steinhubl,MD;DietrichC.Gulba,MD;HarveyD.White,MD;NealS.Kleiman,MD;PhilipE.Aylward,MD;AnatolyLanger,MD;RobertM.Califf,MD;JamesJ.Ferguson,MD;ElliottM.Antman,MD;L.KristinNewby,MD,MHS;RobertA.Harrington,MD;ShaunG.Goodman,MD;KennethW.Mahaffey,MDDivisionofCardiology,DukeClinicalResearchInstitute,Durham,NC编辑课件TimetoCoronaryAngiographya49Background2007ACC/AHAGuidelinesforNSTEACSrecommendtheuseofanearlyinvasivestrategyforhigh-riskpatientsRandomizedclinicaltrialsonearlyvs.conservativestrategyuseddifferenttimingofcardiaccatheterizationOptimaltimingofcardiaccatheterizationinNSTEACSnotyetestablished(expeditedvs.deferred)ExpeditedcatheterizationincreasinglyadoptedintheUS编辑课件Background2007ACC/AHAGuideli50StudyObjectiveToevaluatetheassociationbetweentimefromhospitaladmissiontocardiaccatheterizationandadverseoutcomesamonghigh-riskpatientswithNSTEACStreatedwithanearlyinvasivestrategy(cardiaccatheterization<48hofhospitaladmission)编辑课件StudyObjectiveToevaluatethe51StudyPopulationPatientsrandomizedintheSYNERGYtrial

Ischemicsymptoms<24handatleast2of3high-riskfeatures

Age>60yearsST-segmentdepressionortransientelevationPositivetroponinand/orCK-MBUseofcoronaryangiographyinSYNERGY10,027ptsrandomizedintheSYNERGYtrial9,188ptsunderwentcardiaccatheterization6,352ptsunderwentcardiaccatheterization<48h编辑课件StudyPopulationPatientsrando52AdjustedEstimatesof30-dayDeath/MIRates(with95%CI).0.0编辑课件AdjustedEstimatesof30-dayD53LandmarkAnalysis:AdjustedORof30-dayDeath/MI(with95%CI)编辑课件LandmarkAnalysis:AdjustedOR54AdjustedEstimatesofIn-hospitalTransfusionRates

(with95%CI)编辑课件AdjustedEstimatesofIn-hospi55StudyLimitationsNon-randomizedobservationalanalysisPropensity-basedmodelsusedtodealwithlackofrandomizationTimetocathisapost-baselineand“dynamic”variableStatisticalmethodologiesattemptedtoaddresstheseissues

EventsfromhospitaladmissiontorandomizationnotavailableEventsunlikelypriortorandomizationMyocardialinfarctioninthefirsthoursfollowingthehospitalizationismoredifficulttoadjudicate编辑课件StudyLimitationsNon-randomize56ConclusionsfromSynergy-1Observationalanalysisamonghigh-riskNSTEACSpatientsenrolledintheSYNERGYtrialtreatedwithanearlyinvasivestrategyReducedtimetocardiaccatheterizationwasassociatedwithdecreasedprobabilityof30-daydeath/MIandnochangesinbleedingNosignalssuggestingbenefitsofdelayingthecardiaccatheterizationwereobserved编辑课件ConclusionsfromSynergy-1Obs57ConclusionsfromSynergy-2RandomizedclinicaltrialstoestablishoptimaltimingofcatheterizationinNSTEACSareneededbutchallengingDelayingcathisproblematicforhospitaladoptingexpeditedcathstrategyLagfromhospitalizationtorandomizationmayconfoundactualtimetocatheterizationintervalsEarlyre-MIadjudicationcomplexWell-designedobservationalstudiesmaybeofvalueinthedebateonoptimaltimingofcardiaccatheterizationamongNSTEACSpatients编辑课件ConclusionsfromSynergy-2Ran58Conclusion&ProspectiveACS,earlyinvasiveissuperiortoearlyconservativeinmostPtsespeciallyhighriskImmediateinvasivestrategyisrecommendedinveryhighrisk(instabilityofhemodynamicorelectricity)Inhighriskpts,short-term(24hrs)cooling-offmaybebenefited(butnomorethan48hs)Inlowrisk,espinwomen,earlyconservativecanbechosenNewantiplateletdrugmaychangepractice编辑课件Conclusion&ProspectiveACS,e59Thankyouforyourattention编辑课件Thankyouforyourattention编辑60IsearlyinvasivetheanswerforACSDr.BenHeMD/PhD/FSCAI/FAPSICDirectorofCardiologyDepartmentRenjiHospitalAffiliatedtoShanghaiJiaotonguniversity编辑课件Isearlyinvasivetheanswerf61PathophysiologyofAcuteCoronarySyndrome编辑课件PathophysiologyofAcuteCoron62ACSisanImportantManifestationofAtherothrombosis11.CannonCP.JThrombThrombolysis1995;2:205–218.AntithrombotictherapyStableanginaUANon-

Q-waveMIThrombolysisprimaryPCIQ-waveMIMinutes–

hoursDays–weeksSTEMIUA/NSTEMIAtherothrombosisNewtermOldtermPlaque

rupture编辑课件ACSisanImportantManifestat63编辑课件编辑课件64RelationofTIMIriskscoreandMACErate编辑课件RelationofTIMIriskscorean65HottopicinACSIsearlyinvasivesuperiortoconservativestrategyinACS?Shouldinvasivebedeferredforcoolingoff?

Whatistheoptimaltimeforinvasive?编辑课件HottopicinACS编辑课件66编辑课件编辑课件67OptimalStrategyforUA/NSTEMITIMIIIIB2005ConservativeInvasiveVANQWISHFRISCIITACTICS-

TIMI18RITA-3编辑课件OptimalStrategyforUA/NSTEMI68FRICS-II:highriskgetmore编辑课件FRICS-II:highriskgetmore编辑69TIMI-18:highriskgetmore编辑课件TIMI-18:highriskgetmore编辑课70RITA-3:1&3yrsoutcome编辑课件RITA-3:1&3yrsoutcome编辑课件71RITA-3:5yrsoutcome编辑课件RITA-3:5yrsoutcome编辑课件72编辑课件编辑课件73编辑课件编辑课件74编辑课件编辑课件75In2005,ItseemswefoundanswerInACS,earlyinvasivesuperiortoearlyconservativeThisisparticulartrueinhighriskpatients编辑课件In2005,Itseemswefoundansw76ESCGuideline2005编辑课件ESCGuideline2005编辑课件77编辑课件编辑课件78Istheproblemsettled?编辑课件Istheproblemsettled?编辑课件79ICTUSDesigned编辑课件ICTUSDesigned编辑课件80编辑课件编辑课件81编辑课件编辑课件82编辑课件编辑课件83编辑课件编辑课件84编辑课件编辑课件85编辑课件编辑课件864yrsICTUSLancet2007;369:827-835However,mostofselectiveptswereperformedPCISo,thelong-termf/uresultsdonotinflectInv/Consstrategy编辑课件4yrsICTUSLancet2007;369:874yrsICTUSLancet2007;369:827-835编辑课件4yrsICTUSLancet2007;369:88ICTUS’scriticism

LibertydefinitionofMI(only1*ULN)causingtheearlyMIincreaseinearlyinvasivegroup3yrsrevascularizationratewasequalin2group(81%PCI)1yearmortalityrateinACSinbotharmareverylow(2.5%),Isitarealhighrisk?编辑课件ICTUS’scriticismLibertydefi89EvenputICTUSintopool,Inv>Cons编辑课件EvenputICTUSintopool,Inv90InvvsCons/AllcausedeathHighrisk?编辑课件InvvsCons/AllcausedeathHi91编辑课件编辑课件92编辑课件编辑课件932007ESCGuidelineUrgentCoronaryangiographyisrecommendedinPtswithrefractoryorrecurrentanginaassociatedwithdynamicSTdeviation,heartfailure,lifethreateningarrhythmias,orhaemodynamicinstability(I-C)Early(<72h)angiographyfollowedbyrevascularization(PCIorCABG)inpatientswithintermediatetohighriskfeaturesisrecommended(I-A)编辑课件2007ESCGuidelineUrgentCoron94MonocyteLDL-CAdhesion

moleculeMacrophageFoamcellOxidized

LDL-CPlaqueruptureSmoothmuscle

cellsCRP2编辑课件MonocyteLDL-CAdhesion

molecul95ISAR-COOLTrial编辑课件ISAR-COOLTrial编辑课件96ISAR-COOLAntithromboticRegimen编辑课件ISAR-COOLAntithromboticRegim97编辑课件编辑课件98ISAR-COOL编辑课件ISAR-COOL编辑课件99编辑课件编辑课件100编辑课件编辑课件101编辑课件编辑课件102WhatistheoptimaltimeforPCI?编辑课件WhatistheoptimaltimeforP103编辑课件编辑课件104MethodsforOptimaltrial编辑课件MethodsforOptimaltrial编辑课件105ResultsofOptimaltrial编辑课件ResultsofOptimaltrial编辑课件106ConclusionfromOptimaltrial编辑课件ConclusionfromOptimaltrial编107What’sthedifferencebetweenISAR-Cool&Optimal?2.5vs84+0.5vs25-编辑课件What’sthedifferencebetween108TimetoCoronaryAngiographyandOutcomesAmongPatientsWithHigh-RiskNon–ST-Segment–ElevationAcuteCoronarySyndromes:ResultsFromtheSYNERGYTrial

PierluigiTricoci,MD,MHS,PhD;YuliyaLokhnygina,PhD;LisaG.Berdan,PA-C,MHS;StevenR.Steinhubl,MD;DietrichC.Gulba,MD;HarveyD.White,MD;NealS.Kleiman,MD;PhilipE.Aylward,MD;AnatolyLanger,MD;RobertM.Califf,MD;JamesJ.Ferguson,MD;ElliottM.Antman,MD;L.KristinNewby,MD,MHS;RobertA.Harrington,MD;ShaunG.Goodman,MD;KennethW.Mahaffey,MDDivisionofCardiology,DukeClinicalResearchInstitute,Durham,NC编辑课件TimetoCoronaryAngiographya109Background2007ACC/AHAGuidelinesforNSTEACSrecommendtheuseofanearlyinvasivestrategyforhigh-riskpatientsRandomizedclinicaltrialsonearlyvs.conservativestrategyuseddifferenttimingofcardiaccatheterizationOptimaltimingofcardiaccatheterizationinNSTEACSnotyetestablished(expeditedvs.deferred)ExpeditedcatheterizationincreasinglyadoptedintheUS编辑课件Background2007ACC/AHAGuideli110StudyObjectiveToevaluatetheassociationbetweentimefromhospitaladmissiontocardiaccatheterizationandadverseoutcomesamonghigh-riskpatientswithNSTEACStreatedwithanearlyinvasivestrategy(cardiaccatheterization<48hofhospitaladmission)编辑课件StudyObjectiveToevaluatethe111StudyPopulationPatientsrandomizedintheSYNERGYtrial

Ischemicsymptoms<24handatleast2of3high-riskfeatures

Age>60yearsST-segmentdepressionortransientelevationPositivetroponinand/orCK-MBUseofcoronaryangiographyinSYNERGY10,027ptsrandomizedintheSYNERGYtrial9,188ptsunderwentcardiaccatheterization6,352ptsunderwentcardiaccatheterization<48h编辑课件StudyPopulationPatientsrando112AdjustedEstimatesof30-dayDeath/MIRates(with95%CI).0.0编辑课件AdjustedEstimatesof30-dayD113LandmarkAnalysis:AdjustedORof30-dayDeath/MI(with95%CI)编辑课件LandmarkAnalysis:AdjustedOR114AdjustedEstimatesofIn-hospitalTransfusionRates

(with95%CI)编辑课件AdjustedEstimatesofIn-hospi115StudyLimitationsNon-randomizedobservationalanalysisPropensity-basedmodelsusedtodealwithlackofrandomizationTimetocathisapost-baselineand“dynamic”variableStatisticalmethodologiesattemptedtoaddresstheseissues

EventsfromhospitaladmissiontorandomizationnotavailableEventsunlikelypriortorandomizationMyocardialinfarctioninthefirsthours