急性冠脉综合征评估及危险分层.ppt

1、Acute Coronary SyndromesEvaluation and Risk Stratification,New Terminology in ACS,ACS, acute coronary syndrome; MI, myocardial infarction; UA, unstable angina; NSTEMI, nonST-segment elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction; PCI, percutaneous coronary interve

2、ntion.Cannon CP. J Thromb Thrombolysis. 1995;2:205-218.,Troponin I (TnI), C-Reactive Protein (CRP), and B-type Natriuretic Peptide (BNP) as Determinants of 30-Day Mortality Risks in Acute Coronary Ischemia: A Multimarker Approach,P=.014,P50%) Aspirin in last 7 days2 anginal events in 24 hoursST devi

3、ation Elevated cardiac markers (CK-MB or troponin),TIMI Risk Score For UA/NSTEMI,Antman EM, et al. JAMA. 2000;284:835-442. (with permission),Age 65 years3CAD Risk FactorsPrior Stenosis 50 % ST deviation2 Anginal events 24 hoursASA in last 7 daysElev Cardiac Markers (CK-MB or troponin),4.7,8.3,13.2,1

4、9.9,26.2,40.9,0,10,20,30,40,50,0/1,2,3,4,5,6/7,D/MI/Urg Revasc (%),Number of Risk Factors,Population (%):,4.3,17.3,32.0,29.3,13.0,3.4,C Statistic=0.65c2 trend P.001,P.001,P=.004,P.001,P.001,Scirica BM, et al. Am J Cardiol. 2002;90:303-305. (with permission),TIMI Risk Score vs Prognosis in Unselected

5、 Patients (TIMI 3 Registry),0%,10%,20%,30%,40%,50%,Death,MI,Death/MI,Death/MI/RI,Event Rate at 1 year (%),Prognostic Value of Troponin T or I in ACS: A Meta-analysis,%,RR 3.9(2.9-5.3),RR 3.8(2.6-5.5),No. Studies:136,NegPos (Trop I + T),3634,1849,737,322,Heidenreich PA, J Am Coll Cardiol. 2001;38:478

6、-485.,TIMI IIIB: Troponin I Levels Predict Mortality In UA/NSTEMI,1.0,1.7,3.4,3.7,6.0,7.5,0,2,4,6,8,0 to 0.4,0.4 to 1.0,1.0 to 2.0,2.0 to 5.0,5.0 to 9.0,831,174,148,134,67,50,Risk Cardiac Troponin I (ng/ml)Ratio1.0 1.83.5 3.96.27.8,Mortality at 42 Days (% of Patients),Antman EA, et al. N Engl J Med.

7、 1996;335:1342-1349. (with permission),Lindahl B, et al. N Engl J Med. 2000;343:1139-1147. (with permission),Predictive Value of Troponin T and hs-CRP for Mortality from ACS in FRISC Substudy,20,10,0,0,6,12,18,24,30,36,42,48,Cumulative Probability of Death (%),Months,Troponin T 0.60 g/l (n=377),Trop

8、onin T 0.60-0.59 g/l (n=367),Troponin T 10mg/l (n=309),CRP 2mg/l (n=314),P=.001,P=.29,CRPTroponin,Months,Risk Stratification With CRP and Troponin T,Morrow DA, et al. J Am Coll Cardiol. 1998;31:1460-1465.,WBC Count (x103),30-Day Mortality,0,5,10,15,20,0,5%,10%,15%,20%,White Blood Cell Count vs Morta

9、lity,Cannon CP, et al. Am J Cardiol. 2001;87:636-639. (with permission),B-type Natriuretic Peptide (BNP) and Mortality in ACS Patients,de Lemos JA, et al. N Engl J Med. 2001;345:1014-1021. (with permission),ST MINon-ST MIUnstable Angina,8255651133,P=.02P.0001P=.001,de Lemos JA, et al. N Engl J Med.

10、2001;345:1014-1021. (with permission),BNP and Risk of Death in ACS,Multimarker Approach: Troponin I, CRP, and BNP to Predict 30-Day Mortality in ACS,Sabatine M, et al. Circulation. 2002;105:1760-1763. (with permission),P=.014,P=.001,67,150,155,78,504,717,324,90,30 Day Mortality (%),30-Day Mortality

11、Rel Risk,Inflammation, ACS, and CD-40L,Andre P, et al. Circulation. 2002;106:896-899. (with permission)Varo N, et al. Circulation. 2003;108:1049-1052. (with permission),Clinical Investigation Reports,Soluble CD40LRisk Prediction After Acute Coronary Syndromes,3.5,3,2.5,2,1.5,1,0.5,0,Death,MI,DIMI,CH

12、F,DIMI CHF,Hazard Ratios (HR),*,*,*,*P.01 compared to first quartile P.03 compared to first quartile,Soluble CD-40L in ACS,Heeschen C, et al. N Engl J Med. 2003;348:1104-1111. (with permission),Association between soluble CD40 ligand levels and the rate of cardiac events (death or nonfatal myocardia

13、l infarction) at 24 hours, 72 hours, 30 days, and 6 months among 544 patients receiving placebo.,Time,Death or Nonfatal Myocardial Infarction (%),24 hours,72 hours,30 hours,6 months,P=.13,P=.003,P=.004,P=.001,1st quartile2nd quartile3rd quartile4th quartile5th quartile,Clopidogrel, but not ASA, Redu

14、ces ADP-Induced Expression of CD40L,Hermann A, et al. Platelets. 2001;12:74-82. (with permission),Effect of Treatment with Abciximab According to the Levels of Troponin T and Soluble CD40 Ligand,Heeschen C, et al. N Eng J Med. 2003;348:1104-1111. (with permission),Vascular Damage,Inflammation,Myocyte Necrosis,Accelerated Atherosclerosis,Hemodynamic Stress,HbA1cBlood glucose,CrClMicroalbuminuria,Troponin,BNP, NT-proBNP,hs-CRP, CD40L,Morrow DA, et al. Circulation. 2003;108:250-252.,Multimarker Strategy in ACS,