稳定性冠心病的治疗策略

稳定性冠心病的治疗策略2012-3当前第1页\共有59页\编于星期四\20点2当前第2页\共有59页\编于星期四\20点内容在稳定性冠心病治疗中标准药物治疗的价值血管重建在那些患者可能获益？如何选择CABG或是PCI

单支、双支病变

三支、左主干病变多支病变功能性完全血管重建选择药物洗脱支架还是裸金属支架？3当前第3页\共有59页\编于星期四\20点COURAGE:StudydesignBodenWEetal.AmHeartJ.2006;151:1173-9.BodenWEetal.NEnglJMed.2007;356:1503-16.Optimalmedicaltherapy*+PCI(n=1149)Optimalmedicaltherapy

(n=1138)AHA/ACCClassI/IIindicationsforPCI,suitablecoronaryarteryanatomy+

≥70%stenosisin≥1proximalepicardialvessel+objectiveevidenceofischemia

(or≥80%stenosis+CCSclassIIIanginawithoutprovocationtesting)Primaryoutcomes:All-causemortality,nonfatalMIFollow-up:Median4.6yearsRandomized*Intensivepharmacologictherapy+lifestyleintervention

CCS=CanadianCardiovascularSocietySecondaryoutcomes:Death,MI,stroke;ACShospitalization当前第4页\共有59页\编于星期四\20点COURAGE:TreatmenteffectonprimaryoutcomeHR1.05(0.87-1.27)P=0.62*BodenWEetal.NEnglJMed.2007;356:1503-16.All-causedeath,MI(timetofirstevent)*UnadjustedNo.atriskMedicaltherapy 1138 1017 959 834 638 408 192 30PCI 1149 1013 952 833 637 417 200 35MedicaltherapyPCI+medicaltherapySurvivalfreeofprimaryoutcome024700.50.60.70.81.00.9Years6531当前第5页\共有59页\编于星期四\20点6当前第6页\共有59页\编于星期四\20点当前第7页\共有59页\编于星期四\20点当前第8页\共有59页\编于星期四\20点PharmacologictherapyAntiplateletAspirinClopidogrelinaccordancewithestablishedpracticestandardsDyslipidemiaSimvastatin±ezetimibe

orERniacinACEIorARBLisinoprilorlosartan-blockerERmetoprololsuccinateCalciumchannelblockerAmlodipineNitrateIsosorbide5-mononitrateBodenWEetal.AmHeartJ.2006;151:1173-9.BodenWEetal.NEnglJMed.2007;356:1503-16.当前第9页\共有59页\编于星期四\20点内容在稳定性冠心病治疗中标准药物治疗的价值血管重建在那些患者可能获益？如何选择CABG或是PCI

单支、双支病变

三支、左主干病变多支病变功能性完全血管重建选择药物洗脱支架还是裸金属支架？10当前第10页\共有59页\编于星期四\20点11当前第11页\共有59页\编于星期四\20点当前第12页\共有59页\编于星期四\20点当前第13页\共有59页\编于星期四\20点14当前第14页\共有59页\编于星期四\20点内容在稳定性冠心病治疗中标准药物治疗的价值血管重建在那些患者可能获益？如何选择CABG或是PCI

单支、双支病变

三支、左主干病变多支病变功能性完全血管重建选择药物洗脱支架还是裸金属支架？15当前第15页\共有59页\编于星期四\20点ProximalLADdisease,medicine,PTCAorCABG

（MASStrial）1724301.41.42.82.81.49.7420328298P=0.0002P=0.006NSNSP=0.019P<0.01P<0.01Eventrateatf-up(%)Huebetal.JAmCollCardiol1995;26:1600-1605SingleCenter,randomizedtrialStableangina,proximalLADsignificantlesion<12mminlength,nopriorMI,nototalocclusion,nopriorCABGorangioplasty.n=214:Medicaln=72;BAn=72;LIMAn=70当前第16页\共有59页\编于星期四\20点稳定性冠心病血运重建策略SilberS,TCT2010当前第17页\共有59页\编于星期四\20点内容在稳定性冠心病治疗中标准药物治疗的价值血管重建在那些患者可能获益？如何选择CABG或是PCI

单支、双支病变

三支、左主干病变

多支病变功能性完全血管重建选择药物洗脱支架还是裸金属支架？18当前第18页\共有59页\编于星期四\20点71%enrolled

(N=3,075)AllPtswithdenovo3VDand/orLMdisease(N=4,337)Treatmentpreference(9.4%)ReferringMDorpts.refused

informedconsent(7.0%)Inclusion/exclusion(4.7%)Withdrewbeforeconsent(4.3%)Other(1.8%)Medicaltreatment(1.2%)TAXUSn=903PCIn=198CABGn=1077CABGn=897nof/un=4285yrf/un=649PCIallcapturedw/followupCABG2500750w/f/uvsTotalenrollmentN=3075Stratification:

LMandDiabetesTwoRegistryArmsRandomizedArmsn=1800TwoRegistryArmsN=1275RandomizedArmsN=1800HeartTeam(surgeon&interventionalist)PCIN=198CABGN=1077AmenableforonlyonetreatmentapproachTAXUS*N=903

CABGN=897vsAmenableforbothtreatmentoptionsStratification:

LMandDiabetesLM33.7%3VD66.3%LM34.6%3VD65.4%DM28.5%NonDM71.5%NonDM71.8%DM28.2%23USSites62EUSites+SYNTAXTrialDesign当前第19页\共有59页\编于星期四\20点PatientProfiling

LocalHeartteam(surgeon&interventionalcardiologist)assessedeachpatientinregardsto:Patient’soperativerisk(EuroSCORE&Parsonnetscore)Coronarylesioncomplexity(newlydevelopedSYNTAXscore)ThegoaloftheSYNTAXscoreistoprovideatooltoassistphysiciansintheirrevascularizationstrategiesforpatientswithhighrisklesionsSianosetal,EuroIntervention2005;1:219-227Valgimiglietal,AmJCardiol2007;99:1072-1081Serruysetal,EuroIntervention2007;3:450-459CoronarytreesegmentsbasedontheclassificationproposedbytheAHAandmodifiedfortheARTSstudyCirculation1975;51:31-3&SeminIntervCardiol1999;4:209-19Leamanscore,Circ1981;63:285-299LesionsclassificationACC/AHA,Circ2001;103:3019-3041Bifurcationclassification,CCI2000;49:274-283CTOclassification,JAmCollCardiol1997;30:649-656TortuosityThrombusBifurcationTotalOcclusion3VesselLeftMainDominanceCalcificationNumber&locationoflesionsSYNTAXscore当前第20页\共有59页\编于星期四\20点MACCEto12MonthsP=0.0015*061210200MonthsSinceAllocationCumulativeEventRate(%)ITTpopulation12.1%

17.8%EventRate±1.5SE.*Fisher’sExactTestTAXUS*

(N=903)CABG

(N=897).SerruysPW,atTCT2008当前第21页\共有59页\编于星期四\20点SYNTAXTrial

AdverseEventsto12Months

ITTpopulationEventRate±1.5SE,*FisherexacttestAllDeathRevascularizationCVA(Stroke)MyocardialInfarctionTAXUS*(N=903)CABG(N=897).SerruysPW,atTCT2008当前第22页\共有59页\编于星期四\20点当前第23页\共有59页\编于星期四\20点SabikJF,TCT2010当前第24页\共有59页\编于星期四\20点Patient1Patient1Patient2Patient2SYNTAXSCORE21SYNTAXSCORE52LCx70-90%LAD70-90%RCA270-90%RCA370-90%LM99%LCx100%LAD99%RCA100%Thereis‘3-vesseldisease’and‘3-vesseldisease’当前第25页\共有59页\编于星期四\20点SYNTAXTrial,MACCEto12Months

LeftMainSubsetP=0.44*061220400MonthsSinceAllocationCumulativeEventRate(%)13.6%

15.8%

TAXUS

(N=357)CABG

(N=348)Eventrate±1.5SE,*FisherexacttestITTpopulation当前第26页\共有59页\编于星期四\20点P=0.2026.8%22.3%0CumulativeEventRate(%)2040Before1year*13.7%vs15.8%P=0.441-2years*7.5%vs10.3%P=0.222-3years*5.2%vs5.7%P=0.780123624MonthsSinceAllocationTAXUS

(N=357)CABG

(N=348)MACCEto3Years

LMSubsetCumulativeKMEventRate±1.5SE;log-rankPvalue;*BinaryratesSerruysP,TCT2010当前第27页\共有59页\编于星期四\20点CABGPCIPvalueDeath6.0%2.6%0.21CVA4.1%0.9%0.12MI2.0%4.3%0.36Death,CVAorMI11.0%6.9%0.26Revasc.13.4%15.4%0.69MonthsSinceAllocationCumulativeEventRate(%)P=0.33LeftMainTAXUS

(N=118)CABG

(N=104)MACCEto3YearsbySYNTAXScoreTercileLowScores(0-22)18.0%23.0%MonthsSinceAllocationCumulativeEventRate(%)0122440020301036Site-reportedData;ITTpopulationCumulativeKMEventRate±1.5SE;log-rankPvalue>>><<当前第28页\共有59页\编于星期四\20点CABGPCIPvalueDeath12.4%4.9%0.06CVA2.3%1.0%0.46MI3.3%5.0%0.63Death,CVAorMI15.6%10.8%0.29Revasc.14.0%15.9%0.75P=0.90LeftMainTAXUS

(N=103)CABG

(N=92)MACCEto3YearsbySYNTAXScoreTercile

IntermediateScores(23-32)23.4%23.4%MonthsSinceAllocationCumulativeEventRate(%)0122440020301036Site-reportedData;ITTpopulationCumulativeKMEventRate±1.5SE;log-rankPvalue>>><<当前第29页\共有59页\编于星期四\20点P=0.003LeftMainTAXUS

(N=135)CABG

(N=149)MACCEto3YearsbySYNTAXScoreTercile

LeftMainSYNTAXScore3337.3%21.2%LeftMainMonthsSinceAllocationCumulativeEventRate(%)0122440020301036CABGPCIPvalueDeath7.6%13.4%0.10CVA4.9%1.6%0.13MI6.1%10.9%0.18Death,CVAorMI15.7%20.1%0.34Revasc.9.2%27.7%<0.001Site-reportedData;ITTpopulationCumulativeKMEventRate±1.5SE;log-rankPvalue><<<<当前第30页\共有59页\编于星期四\20点ESC稳定性冠心病血运重建策略(2010)SilberS,TCT2010当前第31页\共有59页\编于星期四\20点

血运重建策略的制定应由多学科完成32当前第32页\共有59页\编于星期四\20点一站式杂交手术（MIDCAB+PCI）对部分三支或左主干病变可能是一选择ThefirstHybridOperatingRoominAsiawasbuiltatFuwaiHospitalin2007.33新技术、新理念呼唤新的治疗策略当前第33页\共有59页\编于星期四\20点内容在稳定性冠心病治疗中标准药物治疗的价值血管重建在那些患者可能获益？如何选择CABG或是PCI

单支、双支病变

三支、左主干病变

多支病变功能性完全血管重建选择药物洗脱支架还是裸金属支架？当前第34页\共有59页\编于星期四\20点Angiography-guidedPCIFFR-guidedPCIMeasureFFRinallindicatedstenosesStentallindicatedstenosesStentonlythosestenoseswithFFR≤0.80RandomizationIndicateallstenoses≥50%consideredforstentingPatientwithstenoses≥50%inatleast2ofthe3majorepicardialvessels1-yearfollow-upFLOWCHART当前第35页\共有59页\编于星期四\20点

FAMEstudy:ProceduralResultsANGIO-groupN=496FFR-groupN=509P-valueProceduretime(min)70±4471±430.51Contrastagentused(ml)302±127272±133<0.001Materialsusedatprocedure(US$)60075332<0.001Lengthofhospitalstay(days)3.7±3.5

3.4±3.30.05stentsperpatient2.7±1.21.9±1.3<0.001当前第36页\共有59页\编于星期四\20点FFR-guided30days2.9%90days3.8%180days4.9%360days5.3%Angio-guidedabsolutedifferenceinMACE-freesurvivalFAMEstudy:Event-freeSurvival当前第37页\共有59页\编于星期四\20点

ANGIO-groupN=496FFR-groupN=509P-valueEventsat1year,No(%)Death,MI,CABG,orrepeat-PCI91(18.4)67(13.2)0.02Death15(3.0)9(1.8)0.19Deathormyocardialinfarction55(11.1)37(7.3)0.04CABGorrepeatPCI47(9.5)33(6.5)0.08Totalno.ofMACE113760.02AdverseEventsat1year当前第38页\共有59页\编于星期四\20点

PCI应用的适当性（美国注册资料），全美1091所医院PCI500154例急症PCI占71.1%STEMI20.6%，NSTEMI21.1%，高危UA29.3%非急症PCI占28.9%适当性急症PCI：适当98.6%非急症PCI：适当50.4%，不肯定38.0%

不适当11.6%

无心绞痛53.8%

无创检查属低危71.6%

药物治疗不适当（≤1种药物）95.8%

ChanP.JAMA2011；306:53当前第39页\共有59页\编于星期四\20点

PCIsinChina当前第40页\共有59页\编于星期四\20点内容在稳定性冠心病治疗中标准药物治疗的价值血