1、,Guidelines for Coronary Intervention in ACS,Michael KY LeeQueen Elizabeth Hospital李耿渊 香港伊丽莎白医院 SCC 2008,Division of CardiologyDepartment of Medicine,ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/NonST-Elevation Myocardial Infarction,Hospitalizations in the U.S. Due to
2、ACS,Acute Coronary Syndromes*,1.57 Million Hospital Admissions - ACS,UA/NSTEMI,STEMI,1.24 million Admissions per year,0.33 million Admissions per year,*Primary and secondary diagnoses. About 0.57 million NSTEMI and 0.67 million UA.Heart Disease and Stroke Statistics 2007 Update. Circulation 2007; 11
3、5:69171.,Primary PCI for STEMI,STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 min of first medical contact as a systems goal. STEMI patients presenting to a hospital without PCI capability, and who cannot be transferred to a PCI center and un
4、dergo PCI within 90 min of first medical contact, should be treated with fibrinolytic therapy within 30 min of hospital presentation as a systems goal, unless fibrinolytic therapy is contraindicated.,A strategy of coronary angiography with intent toperform PCI (or emergency CABG) isrecommended in pa
5、tients who have receivedfibrinolytic therapy and have:Cardiogenic shock in patients 0.01 ng/mL, ST-segment deviation, TIMI risk score 3) No high-risk features, outcomes Death/MI 6 mo for older adults with early inv strategy Benefit of early inv strategy for high-risk women ( TnT); low-risk women ten
6、ded to have worse outcomes, incl risk of major bleeding,Cannon CP, et al. N Engl J Med 2001;344:187987.,Third RandomizedIntervention Treatment of Angina (RITA-3),1,810 moderate-risk ACS patientsEarly inv or conserv (ischemia-driven) strategyExclusions: CK-MB 2X ULN randomization, new Q-waves, MI w/i
7、n 1 mo, PCI w/in 1 y, any prior CABG Death, MI, & refractory angina for inv strategy Benefit driven primarily by in refractory angina Death/MI 5 y for early inv armNo benefit of early inv strategy in women,Fox KA, et al. Lancet 2002;360:74351. Fox KA, et al. Lancet 2005;366:91420 (5-y results).,RITA
8、-3 - 5 Year Follow-up,Fox KA, et al. Lancet 2005;366:91420. Reprinted with permission from Elsevier.,DeathOR 0.76 (0.58-1.00) P = 0.054,Death,15.1%,12.1%,IntracoronaryStenting with Antithrombotic Regimen Cooling-off Study (ISAR-COOL),410 patients within 24 h intermediate-high risk UA/NSTEMIVery earl
9、y angio (cath median time 2.4 h) + revasc or delayed inv/“cooling off” (cath median time 86 h) strategyMeds: ASA, heparin, clopidogrel (600-mg LD) and tirofiban Death/MI 30 d for early angio group Diff in outcome attributed to events that occurred before cath in the “cooling off” group, which suppor
10、ts rationale for intensive medical rx & very early angio,Neumann FJ, et al. JAMA 2003;290:15939. LD = loading dose.,Global Registry of Acute Coronary Events (GRACE),24,165 ACS patients in 102 hospitals in 14 countries stratified by age 2/3 men, but proportion with age Hx angina, TIA/stroke, MI, CHF,
11、 CABG, hypertension or AF in elderly (65y) Delay in seeking medical attention and NSTEMI significantly in elderly Use in elderly ASA, -blockers, lytic therapy, statins and GP IIb/IIIa inhibitors; calcium antagonists and ACE inhibitorsUFH young patients; LMWHs across all age groupsAngio and PCI rates
12、 significantly with ageElderly patients a high-risk population for whom physicians andhealthcare systems should provide evidence-based ACS therapies,such as aggressive, early invasive strategy and key pharmacotherapies (e.g.anticoagulants, -blockers, clopidogrel and GP IIb/IIIa inhibitors),Avezum A,
13、 et al. Am Heart J 2005;149:6773.,Initial Conservative Versus Initial Invasive Strategies,In initially stabilized patients, an initially conservative (i.e., a selectively invasive) strategy may be considered as a treatment strategy for UA/ NSTEMI patients (without serious comorbidities or contraindi
14、cations to such procedures) who have an elevated risk for clinical events including those who are troponin positive. The decision to implement an initial conservative (vs. initial invasive) strategy in these patients may be made by considering physician and patient preference. An invasive strategy m
15、ay be reasonable in patients with chronic renal insufficiency.,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,Invasive versus Conservative Treatment in Unstable coronary Syndromes (ICTU
16、S),1,200 high-risk ACS patients Routine inv vs selective inv strategyMeds: ASA, clopidogrel, LMWH, and lipid-lowering rx; abciximab for revasc patientsNo death, MI, and ischemic rehosp 1 y and longer-term follow-up by routine inv strategyRelatively high (47%) rate revasc actually performed in select
17、ive inv arm and lower-risk pop than in other studiesRecommendation: Initially conserv (i.e., selectively inv) strategy may be considered in initially stabilized patients who have risk for events, incl troponin + (Class IIb, LOE:B),de Winter RJ, et al. N Engl J Med 2005;353:1095104. Hirsch A, et al.
18、Lancet 2007;369:82735 (follow-up study). LOE = level of evidence.,Initial Conservative Versus Initial Invasive Strategies,An early invasive strategy* is indicated in UA/NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindicat
19、ions to such procedures).An early invasive strategy* is indicated in initially stabilized UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events.,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,
20、III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,*Diagnostic angiography with intent to perform revascularization.,Initial Conservative Versus Initial Invasive Strategies,An early invasive strategy* is not recommended in patients with extensive comorbidities
21、(e.g., liver or pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization. An early invasive strategy* is not recommended in patients with acute chest pain and a low likelihood of ACS. An early invasive strateg
22、y* should not be performed in patients who will not consent to revascularization regardless of the findings.,*Diagnostic angiography with intent to perform revascularization.,Selection of Initial Treatment Strategy: Initial Invasive Versus Conservative Strategy,Bavry AA, et al. J Am Coll Cardiol 200
23、6;48:13191325. Reprinted with permission from Elsevier. CI = confidence interval; RR = relative risk.,Relative Risk of All-Cause Mortality for Early Invasive Therapy Compared With Conservative Therapy at a Mean Follow-Up of 2 y,Bavry AA, et al. J Am Coll Cardiol 2006; 48:13191325. CI = confidence in
24、terval; RR = relative risk. Reprinted with permission from Elsevier.,Relative Risk of Recurrent Nonfatal MI for Early Invasive Therapy Compared With Conservative Therapy at a Mean Follow-Up of 2 y,Relative Risk of Recurrent UA Resulting in Rehosp for Early Invasive Therapy Compared With Conservative
25、 Therapy at a Mean Follow-Up of 13 Months,Bavry AA, et al. J Am Coll Cardiol 2006; 48:13191325. Reprinted with permission from Elsevier. CI = confidence interval; RR = relative risk; UA = unstable angina.,Initial Invasive Strategy,Efficacy and Safety ofSubcutaneous Enoxaparin in Non-Q-Wave Coronary
26、Events (ESSENCE) trial,3,171 patients within 24 h UA/NSTEMI Enoxaparin vs UFHOther meds: ASA Death, MI or recurrent angina for enox 14 d, 30d and 1 y minor bleeding major bleeding ,Cohen M, et al. N Engl J Med 1997;337:44752. Cohen M, et al. Am J Cardiol 1998;82:19L24L (bleeding). Goodman SG, et al.
27、 J Am Coll Cardiol 2000;36:69348 (1-y results).,Thrombolysis In Myocardial Ischemia trial, phase 11B (TIMI 11B),3,910 patients within 24 h UA/NSTEMIEnoxaparin vs UFHOther meds: ASA Death, MI or urgent revasc for enox 48 h, 8 d, 14 d, & 43 d major & minor bleeding (inhosp) with enox,Antman EM, et al.
28、 Circulation 1999;100:1593601.,Superior Yield of the New strategy ofEnoxaparin, Revascularization and GlYcoprotein IIb/IIIa Inhibitors (SYNERGY),Ferguson JJ, et al. JAMA 2004;292:4554. Mahaffey KW, et al. Am Heart J 2005;149:S81S90 (6 mo & 1-y results).,9,978 patients within 24 h high-risk UA/NSTEMI
29、Enoxaparin vs UFH early inv strategyOther meds: ASA, GP IIb/IIIa physician discretionEnox noninferior for death/MI 30 d, 6 mo 1 y Major bleeding with enox ? due to crossover to UFH time of PCI,SYNERGY Primary Outcomes,Absolute Risk Reduction0.5Hazard Ratio0.9695% CI0.861.06p0.40,Freedom from Death/M
30、I,0.8,0.85,0.9,0.95,1.0,0,5,10,15,20,25,30,Days from Randomization,Kaplan Meier Curve,UFH,Enoxaparin,Reprinted with permission from Ferguson JJ, et al. JAMA 2004;292:4554.,Antithrombotic CombinationUsing Tirofiban and Enoxaparin (ACUTE II),525 patients within 24 h UA/NSTEMI Enoxaparin vs UFH Other m
31、eds: ASA, tirofiban LD 0.4 mcg/kg over 30 min 0.1 mcg/kg/minNo death/MI during first 30 d Trend to lower event rates with enoxNo major/minor bleeding,Cohen M, et al. Am Heart J 2002;144:4707. LD = loading dose.,INTegrilin and Enoxaparin Randomized Assessment of Acute Coronary syndrome Treatment (INT
32、ERACT),746 patients within 24 h high-risk UA/NSTEMIEnoxaparin vs UFHOther meds: ASA, eptifibatide 180 mcg/kg IV bolus 2.0 mcg/kg/min infusion for 48 hours Death/MI for enox 30 d Minor bleeding - for enox 96 h, no diff by 30 dMajor bleeding - for enox 96 h (1o safety endpoint),Goodman SG, et al. Circ
33、ulation 2003;107:23844.,Aggrastat to Zocor (A to Z),3,987 patients within 24 h UA/NSTEMI on ASA & tirofibanEnoxaparin vs UFH Coronary angio in 60% of ptsNo all-cause mortality, MI or refractory ischemia w/in 7 d by enox Nonsig trend to ischemic events with enox Major bleeding with enox,Blazing MA, e
34、t al. JAMA 2004;292:5564.,Acute Catheterization and Urgent InterventionTriage strategY (ACUITY),Within 24 h UA/NSTEMI heparin (enox/UFH) upstream GP IIb/IIIa (n=4603) vs bivalirudin (bival) upstream GP IIb/IIIa (n=4604) vs bival alone + provisional GP IIb/IIIa (n=4612)Compared to heparin + GP IIb/II
35、a: Bival + GP IIb/IIIa noninferior for composite ischemia, major bleeding net clinical outcomes 30 dCaution using bival alone, esp with delay to angio and high-risk features, or if early ischemic discomfort occurs after initial antithrombotic strategy implementedRecommend: Concomitant use of GP IIb/IIIa or thienopyridine before angio whether bival-based or heparin-based strategy used,
