ACS治疗原则专题知识

TheManagementofAcuteMyocardialInfarction北京协和医院急诊科朱华栋EarlyRepolarizationBrugadaSyndromeAnteriorAMIPrinzmetalAnginaPericarditisAcuteInf.AMISTSegmentElevation(Transmuralischemia)Non-infarctSTElevationSTSegmentDepression(Non-transmuralischemia)STDepressionNSTEMITwaveinversionNSTEMINSTEACS:KeyThemesNSTEACS:ahighriskpopulationpatientriskbenefitfromtreatmentwithmedications,aninvasivestrategyInteractionbetweeninvasivestrategyandpharmacologictxAntithromboticscornerstoneoftreatmentAnticoagulants:heparin,LMWH,directthrombininhibitorsAntiplateletagents:aspirin,IIb/IIIa,ADPinhibitorsAntmanEMetalNEnglJMed1996;335:1342-9Invasivevs.ConservativeStrategyforACS

Deathor(re)-MI

TrialNPCIConsRITA318107.68.3VINO1316.322.4TACTICS22207.39.5TRUCS1487.616.7FRISCII245110.414.1MATE2019.96.7VANQUISH92024.012.2Overall7876Fox,Lancet360:743‘03Death/(re)Infarction

RR=0.88,p=0.05Interventionbetter

0.10.20.30.50.71.01.52.0Death/(re)-MICP971744-45

%ConsInvTACTICS–TIMI18TnTcutpoint=0.01ng/mL(54%ofptTnT+)TroponinT:Death,MI,RehospACS,6MonthsOR=0.52*P<0.001InteractionP<0.001P=NS*n=414n=396n=463n=495BenefitsofanInvasiveStrategyinNon-STElevationACS

OnlyshowntoreducedeathandMIin highriskptsReducesre-hospitalization,anginain manyothersShortenshospitalization,maybecost effectiveWhatabouttheoptimaltimingofan invasivestrategy?MedicalTxfor72-170hrThen,cathlabn=207Cathlab6hrn=203ISAR-COOLCP1107655-4NeumannFJetalJAMA2023

67%hadtroponin,65%hadSTdepression

Aspirin 500mg,100mgbid

Clopidogrel 600mg,75mgbid

Tirofiban 10mg/kgbolus,0.10mg/kg/mininfusion

Heparin (PTT60-85seconds)Non-STAcuteCoronarySyndrometroponinorSTdepressionn=410ISAR-COOL

PrimaryEndpointCP1107655-230-dayeventrate(%)

Death&MI

DeathNeumannFJetalJAMA2023P=0.04P=0.23P=0.12P=0.56

AnynonfatalMINonfatalQ-waveMIRR1.96(1.01-3.82)

Coolingoff(n=207)

Earlyintervention(n=203)TimingofanInvasiveStrategyinNon-STElevationACS

ISAR-REACTwasasmall,single centerstudy.Clinicaltrialsarestillgoing on.Otheranalysesalsoindicatethatcath within24hoursisbetterthanlatercathOughttouseintensiveantiplatelet therapywithaveryearlyinvasivestrategyWhatmedicaltherapyoughttobeusedinACS?AntithromboticTrialists’Collaboration.BMJ.2023;324:71–86.

OR*0.51.01.52.0500–1500mg 34 19160–325mg 19 2675–150mg 12 32<75mg 3 13Anyaspirin 65 23AntiplateletBetterAntiplateletWorse

AspirinDose No.ofTrials (%)OddsRatio0AspirinDoseandEventsinHigh-RiskPts

FrequencyofCVDeath,MI,StrokeP=0.0001CURECP999547-2YusufSetalNEJM2023;16:494-502Non-STelevationACS12,562patientsASA75to325mgpoqdplacebon=6,3033-12monthfollow-up(average9mo)ASA+clopidogrel(300mgload,75mgqd)n=6,259CURE

CVDeath/MI/Stroke,1YearCP999731-3CVdeath,MI,stroke(%)Clopidogrel(n=6,303)Placebo(n=6,259)P=0.00003DaysafterenrollmentCUREEvent

rate

(%)RR0.80P=0.00005CP995058-6CVdeath,

MI,strokeClopidogrel(n=6,259)Placebo(n=6,303)AspirinandCV

deathMIStrokeNon-CV

deathRR0.92P=NSRR0.77P<0.001RR0.85P=NSRR0.96P=NSCURE

Major/Life-ThreateningBleedsinthe7DaysAfterCABGPlaceboClopRRpStopped<5dayspriortoCABG:N=476N=436PtswithMajororLifeThreateningBleeding6.3%9.6%1.530.06MajorBleeds:

Significantlydisabling,intraocular,ortransfusion2unitsLifeThreatening:Hgb>5g/dl,hypotension(inotropes),surgerytostopbleeding,symptomaticICHortransfusion4unitsACC/AHAACSGuidelineUpdateClassIAspirin75to325mg/day(levelofevidence:A)ASAandclopidogrelfor9monthsafterNSTEACS(levelofevidence:B)Class3Donotadministerclopidogrelinthe5daysbeforeCABG BraunwaldE,etal.Heparin(UForLMW)inACSWithoutST

DeathorMI

UFHorLMWH

Control

OR 95%CIGurfinkel 4/70(5.7%) 7/73(9.6%) 0.58 0.17-1.98

(UFH)Gurfinkel 0/68 7/73(9.6%) 0.13 0.03-0.60

(LMWH)UFHvs 55/698(7.9%) 68/655(10.4%) 0.67 0.45-0.99

placebo/controlLMWHvs 13/809(1.6%) 43/830(5.2%) 0.34 0.20-0.58

placeboTotal

OnlyRCTs,placebooruntreatedcontrols

EikelboomJWetal:Lancet55:1936-42,2023CP951342-10.1Heparinbetter1.010.0ControlbetterTrial: FRIC(dalteparin;n=1482)FRAXIS(nadroparin;n=2357)ESSENCE(enoxaparin;n=3171)

TIMIIIB(enoxaparin;n=3910)

.75 1.0 1.5(P=0.032)(P=0.029)BraunwaldEetal.Circulation2023;102:1193-1209LMWHBetterUFHBetterLMWHversusUFHinUA/NSTEMIManagedNon-invasively:

EffectonDeath,MI,RecurrentIschemiaCLASSIa（Ia级推荐）一旦出现UA/NSTEMI，需尽快在抗血小板治疗旳基础上予以患者抗凝药物。a.介入方案：证据级别A-涉及依诺肝素和普通肝素；证据级别B-涉及比伐卢定和戊聚糖钠b.保守方案：药物选择能够是依诺肝素、普通肝素（证据级别A）或者戊聚糖钠（证据级别B），有效性已经确立。c.对于选择保守治疗旳病人，假如有较高旳出血风险，倾向于选择戊聚糖钠（证据级别B）CLASSIIa（IIa级推荐）对于最初选择保守治疗策略旳UA/NSTEMI病人，作为抗凝治疗，依诺肝素或者戊聚糖钠要优于普通肝素，除非计划在二十四小时内进行冠脉搭桥手术。（证据级别B）2023年ACC/AHAUA/NSTEMI旳指南抗凝治疗推荐ACC/AHA2023更新旳抗凝治疗指南高危或确诊ACS实施导管或PCI疑似/确诊ACS可能ACS阿司匹林+IVUFH/LMWH*GPIIb/IIIa拮抗剂阿司匹林+皮下LMWH*或IVUFH氯吡格雷氯吡格雷阿司匹林*证据等级Ia：依诺肝素优于IVUFHACC/AHA治疗提议2023“不稳定型心绞痛/非ST段抬高心梗患者，除非计划在二十四小时内行冠脉搭桥手术，相对于普通肝素，依诺肝素（Enoxaparin）作为抗凝剂应优先选用。(证据级别A)”2023updateACC/AHAguidelineACCP7指南对LMWH旳治疗提议急性期LMWH优于UFH（1B级）；LMWH治疗时不需常规监测（1C级）；已使用LMWH旳患者如需进行PCI，应继续使用LMWH（2C级）；应用GPIIb/IIIa受体拮抗剂者，

LMWH安全性优于UFH（2B级）。NSTEACS患者中LMWH旳疗程评价是：NSTEACS患者应早期介入治疗，假如冠脉干预延迟，可考虑延长LMWH治疗作为血运重建旳“桥梁”。Restpain>5minandSTΔ>0.1mVorDocumentedCADorCK-MBN=132Heparin70U/kgbolus+15U/kg/hrinfusion

Bivalirudin0.1mg/kgbolus+0.25mg/kginfusionTIMI-8:Bivalirudinvs.PlaceboinACSTIMI-8:Bivalirudinvs.PlaceboinACS4-6wks7days4-6wks7daysp=0.008p=0.024p=NSp=NSBetaBlockersReduceCVdeath,MI,strokeby25-30%inhighriskptsNotwellstudiedinnon-STEACSReduceheartrate,bloodpressure,ischemia,chestdiscomfortClass1indication;qualityindicatorUseineveryonewithoutcontraindications15.75.617.911.712.814.23.812.910.311.805101520PrimaryEndpoint%PlaceboGPIIb/IIIaPURSUIT

30daysPRISM

48hrsPRISM

PLUS

7daysP=0.04P=0.01P=0.004PARAGONA

30daysP=0.48PARAGONB

30daysP=0.33PlateletGPIIb/IIIaInhibitionforNon-STACS

PrimaryEndpointResultsfromthe5MajorRCTs1.02.00.25AllPCItrials 17,393 0.66 8.5 5.6AllACStrials 24,311 0.89 12.8 11.4ACStroponin(+) 1,368 0.42 16.3 6.9ACSPCI 2,311 0.66 14.4 9.6ACSnoPCI 12,685 0.93 14.3 13.3ACStroponin(–) 2,901 1.05 6.2 6.5IIb/IIIaMeta-Analysis

30-DayDeath,MIat30DaysCP944328-1

Relative

risk Placebo IIb/IIIa

No. ratio (%) (%)ChewDPetal:JACC2023;36:2028–35IIb/IIIabetterPlacebobetterIIb/IIIaInhibitorsinACSPatientsGreatestbenefitisduringPCIIfpursuinganon-invasivestrategy,recommendtreatingptswithelevatedtroponins,highTIMIscores,etc;probablythosewithdiabetes,markedSTsegmentshiftsDonotrecommendtheirroutineadministrationtoallACSptsinwhomanon-invasivestrategyisplannedConclusionsMuchremainstobelearnedabouttheoptimalmedicaltherapyforACSptsThedatafavoraninvasivestrategy,andsuggestdifferentmedicationsanddosesoughtbeadministeredifpursuinganinvasivevs.non-invasivestrategy,andinhighvs.lowriskptsUA/NSTEMI:

PharmacologicalandMechanicalInterventionBraunwaldEetal.JAmCollCardiol2023;36:970-1062BraunwaldEetal.Circulation2023;106:1893-1900危险分层(TIMI危险评分)高危

TIMI评分5-7低危

TIMI评分0-2中危

TIMI评分3-4ASA+LMWH(一般肝素)+氯吡格雷依替巴肽/替罗非班ASA+LMWHor一般肝素+氯吡格雷ASA+LMWH(一般肝素)+氯吡格雷依替巴肽/替罗非班Cath/PCI/CABG进行监测/危险评估缺血二级预防无缺血

AlgorithmforPatientswithUA/NSTEMIManagedbyanInitialInvasiveStrategyProceedtoDiagnosticAngiographyASA(ClassI,LOE:A)ClopidogrelifASAintolerant(ClassI,LOE:A)DiagnosisofUA/NSTEMIisLikelyorDefiniteInvasiveStrategyInitiateA/CRx(ClassI,LOE:A)Acceptableoptions:enoxaparin

orUFH(ClassI,LOE:A)bivalirudinorfondaparinux(ClassI,LOE:B)SelectManagementStrategyProceedwithanInitialConservativeStrategyAndersonJL.JAmCollCardiol.2023,Inpress.Figure7ABB1B2PriortoAngiographyInitiateatleastone(ClassI,LOE:A)orboth(ClassIIa,LOE:B)ofthefollowing:ClopidogrelIVGPIIb/IIIainhibitorFactorsfavoringadminofbothclopidogrelandGPIIb/IIIainhibitorinclude:DelaytoAngiographyHighRiskFeaturesEarlyrecurrentischemicdiscomfortInitiateclopidogrel(ClassI,LOE:A)ConsideraddingIVeptifibatideortirofiban(ClassIIb,LOE:B)ConservativeStrategyInitiateA/CRx(ClassI,LOE:A):

Acceptableoptions:enoxaparinorUFH(ClassI,LOE:A)orfondaparinux(ClassI,LOE:B),butenoxaparinorfondaparinuxarepreferable(ClassIIA,LOE:B)SelectManagementStrategyASA(ClassI,LOE:A)ClopidogrelifASAintolerant(ClassI,LOE:A)DiagnosisofUA/NSTEMIisLikelyorDefiniteAlgorithmforPatientswithUA/NSTEMIManagedbyanInitialConservativeStrategyProceedwithInvasiveStrategy(Continued)AndersonJL.JAmCollCardiol.2023.Inpress.Figure8

C2

C1

A

EvidenceforPrimaryPCIasTreatmentofChoiceforSTEMIACS

Summaryof23RandomizedTrials(n=7739)p=0.0003p<0.0001p=0.0004p<0.0001OR=0.57Keeley&GrinesLancet2023PCILyticRiskReductionDeath 28%Death/MI/CVA 43% PrimaryPCI:

ThePreferredReperfusionStrategyPrimary,Transfer,Facilitated&RescuePCIforSTEMI

PrimaryPCI

(PPCI) DirecttoCVLforPCIreperfusiontherapyTransferPCI PtstransferredfromhospitalswithoutPCIfacilities(no

lysis)toaPCIcentreFacilitatedPCI Patientsreceivingthrombolysis*followedbyintentionalPCIRescuePCI PCIafterfailedthrombolysis(at90mins)*ThrombolysismaybePre-hospitalDoor-To-Balloon(DTB)Time

&ChoiceofReperfusionTherapyinSTEMI

Sxonset<3hr: FibrinolysisonlyifestimatedDTB>60minSxonset>3hrs<12hr: PrimaryPCIwithDTBof90min;otherwiseFibrinolysisisacceptablealternativeSxonset>12hr: NolysisbutPCImaystillbebeneficialEvidenceforPre-HospitalThrombolysis forEarly(<2H