非ST段抬高性急性冠脉综合介入治疗

非ST断抬高性急性冠脉综合的介入治疗RITA-3-results intervention conservative RR(95%CI) p n=895 n=9154-MonthD/MI/Angina 86(9.6%) 133(14.5%) 0.66(0.51-0.85) 0.0011-yearD/MI 68(7.6%) 76(8.3%) 0.91(0.67-1.25) 0.58Symptomsofanginawereimprovedanduseofantianginalmedicationsreducedwiththeinterventionalstrategy(p<0.0001)FRISC-II2yearsfollow-upJACC2002.40:1902-14

invasiveconservative RR(95%CI) PMortality(%) 3.7 5.4 0.68(0.47-0.98) 0.038MI(%) 9.2 12.7 0.72(0.57-0.91) 0.005D/MI(%) 12.1 16.3 0.74(0.61-0.09) 0.003Afterthefirstyear,therewasnodifferenceinmortalitybetweenthetwogroups,fewerMIsininvasivegroup.NumberofD/MIswithin1yearCombinedriskratio0.88(95%CI0.78-0.99)0.10.51.02.010.0早期侵入治疗优于早期保守治疗这些试验比较些什么?早期介入治疗与早期保守治疗？早期介入策略与早期保守策略？非ST断抬高性

急性冠脉综合的介入治疗

是早期介入策略获益！非ST断抬高性

急性冠脉综合的介入策略是早期介入策略获益！早期介入策略如何获益？UA&NSTEMIEarlyinvasivevs.earlyconservativestrategiesEarlyinvasive:EarlycoronaryarteriographyfollowedbyrevascularizationasindicatedbyarteriographicfindingsEarlyconservative:Catheterization,andifindicated,revascularization,onlyintheeventoffailureofmedicaltherapy6-monthMortalityforAcute

CoronarySyndromesT-waveinversion

ACSST

ACSGrangerCBetal.JAmCollCardiol.1998;31:79A.%Cumulativemortality

at6monthsST

MIwith

fibrinolytics2457patientswithACS(follow-up6months)EarlyInvasive

Strategies-FRISCⅡLancet1999,Vol35404’/05’:我们的策略是否有所改变？ICTUS研究对我们的启示ClassI:一、无严重合并症,合并以下高危因素,早期介入治疗:1抗缺血治疗中,反复休息时或轻微活动时胸痛/缺血2TnT或TnI升高3新出现ST段压低4反复胸痛/缺血,伴CHF症状,S3奔马律,肺水肿,MR5非创伤性负荷试验高危发现非ST段抬高性ACS早期介入干预时机-AHA/ACC指南（2002）ClassI:6LV收缩功能降低(EF<0.4)7血流动力学不稳定8持续性室速96个月内PCI10CABG史二、无上述情况下，无再血管化禁忌症的住院病人，可选用早期介入或早期保守治疗（B）非ST段抬高性ACS早期介入干预时机-AHA/ACC指南（2002）ClinicalsuspicionofACSPhysicalexamination,EchocardiogramECGmonitoring,BloodsamplesNopersistentSegment

elevationGp2b/3aCor.AngiographyLowriskHighriskPositiveTwicenegativeStresstest

Cor.angiogrpahyASA,Clopidogrel,Heparin(s)Betablockers,NitratesSecondtroponinmeasurementESCGuidelines2002监护(心律和心肌缺血)

阻滞剂硝酸脂类药物肝素/LMWH、ASA、氯吡格雷GPIIb/IIIa拮抗剂(?)12-48小时冠脉造影病情稳定立即冠脉造影评价左室功能EF>.40负荷试验非低危低危药物治疗反复缺血症状心衰严重心律失常EF<.40早期介入策略早期保守策略ACS:院内治疗UA/NSTEMI:血运重建术策略心导管术药物治疗、PCI或CABG1支或2支病变PCI或CABG否CABG心衰或糖尿病CABG是查胸痛原因无3支或2支(伴LAD近端)病变冠心病有左主干病变是无小结早期介入策略优于早期保守策略早期介入策略的意义在于通过冠脉造影深化危险分层早期介入策略使中危和高危病人获益THANKYOU!Earlyinvasivevs.earlyconservativestrategiesEarlyinvasive:

earlycoronaryarteriographyfollowedbyrevascularizationasindicatedbyarteriographicfindingsEarlyconservative:catheterization,andifindicated,revascularization,onlyintheeventoffailureofmedicaltherapyUA&NSTEMIBenefitofIntervention7.68.39.614.505