1、冠心病不同治疗方法的选择,中国医学科学院 阜外心血管病医院冠心病诊断治疗中心陈纪林教授,冠心病的治疗方法,药物治疗（抗凝 、抗血小板、降脂治疗）手术治疗（心肌保护、Offpump、MIDCAB）介入治疗（1977年，PTCA PCI）,LAD近端单支病变药物治疗、 PTCA or CABG （ MASS trial）,17,24,3,0,1.4,1.4,2.8,2.8,1.4,9.7,42,0,32,82,98,P=0.0002,P=0.006,NS,NS,P=0.019,P0.01,P0.01,Event rate at f-up (%),Hueb et al. J Am Coll Card
2、iol 1995;26:1600-1605,Single Center, randomized trialStable angina, proximal LAD significant lesion 75%（单中心）,110 Stenting110 微创搭桥,心脏死亡、MI两组间无显著差别MACE在支架组（31%）高于CABG组（15%），（P=0.02）结论:对LAD单支孤立性病变, 支架与CABG均安全有效; 支架近期效果好,围术期不良反应少； 但外科组6个月无心绞痛及重复血管重建少。 Diegeler A, N Engl Med 2002,347:561,OCTOSTENT Trial,
3、267例LAD近段病变患者随机分成MIDCAB组（n=136）和支架组（n=131），比较12个月死亡率、脑血管事件、AMI、TVR以及生活质量和费用效益比在两组患者中主要研究终点没有显著性差异，有趋势表明搭桥术再血管化率低，无心绞痛和减少药物干预的可能性高两组中无脑血管事件、AMI和TVR生存分别为91.5%和85.5%（P=0.11）支架患者恢复更快，费用更低（P0.01），两组患者生活质量没有显著性差异如果使用了药物释放支架，TVR方面两组患者结果可能相似,Peter M de Jaegere el., ACC2003,PCI在急性冠状动脉综合征(ACS)中的价值ST抬高AMI可降低病死
4、率，优于溶栓治疗非ST抬高ACS可减少死亡和AMI发生率,AMI直接PTCA与溶栓治疗的荟萃分析,CADILLAC: 30-Day MACE,CADILLAC: 12 Month MACE,CADILLAC: Angiographic Restenosis,FRISC II,2,433 patients with ACSrandomization: invasive vs. non-invasive rxinvasive strategy: cath + revasc within 7 dnon-invasive strategy: cath (14% 6d) for +ETT, refrac
5、tory / severe ischemia, MIall pts received ASA, b-blocker, dalteparininvasive conserv.cath98% 48%PCI44% 18%CABG34% 19%,Fast Revascularization During Instabilityin Coronary Artery DiseaseWallentin L, 1999 ACC Scientific Sessions; JACC 34:1-4, 1999,FRISC II 6 Month Death / MI,Wallentin L, 1999 ACC Sci
6、entific Sessions; JACC 34:1-4, 1999,p=0.045,TACTICS - TIMI 18,2,200 patients with ACSrandomization: invasive vs. non-invasive rxinvasive strategy: cath + revasc within 4-48 hrnon-invasive strategy: cath for +ETT, refractory / severe ischemia, MIall pts received ASA, b-blocker, Aggrastat,Cannon C, 20
7、00 AHA Scientific Sessions; Late Breaking Clinical Trials,TACTICS TIMI 18 6 Month Outcomes,Cannon C, 2000 AHA Scientific Sessions; Late Breaking Clinical Trials,p=0.05,p=0.05,CABG术后心肌缺血复发,LIMA10年通畅率90%以上，SVG最初几年每年10%病变发生率，10年通常率40-50%自身血管新病变处理：再次CABG可能性小，死亡率高，介入 治疗成为最佳选择,Stenting for degenerated SVG
8、 stenosis with distal protection device,Medtronic GuardWireTM plus,Male, 68yrs, CABG Oct. 1994, 心绞痛复发 Jul. 2002,Stenting for distal anastomosis stenosis of LIMA-LAD 2w post-MIDCAB,Male, 56yrs, MIDCAB（LIMA-LAD）Mar.11th 2003, 2周后AP复发,Stenting for distal anastomosis stenosis of LIMA-LAD 2w post-MIDCAB,
9、LAO,RAO,Stenting for distal anastomosis stenosis of LIMA-LAD 2w post-MIDCAB,球囊扩张后,支架植入后,Intervention 2001,From ,全国逐年PTCA例数增长情况,阜外心血管病医院冠心病介入治疗,Predicted Angiographic Restenosis Rates,Post-Procedure Lesion Length In-Stent MLD 10 mm15 mm20 mm25 mmDiabetics 2.5 mm 35%39%43%46% 3.0 mm 23%26%30%33% 3.5 m
10、m 15%17%19%22% 4.0 mm 9%10%12%14% Non-Diabetics 2.5 mm27%30%33%37% 3.0 mm17%19%22%25% 3.5 mm10%12%14%16% 4.0 mm 6% 7% 8%10%,Kuntz/Popma CDAC Stent Database,CypherTM Sirolimus-Eluting Stent,Basecoat = polymer + Sirolimus+Topcoat = diffusion barrier,Topcoat (TC),Stent,Basecoat,ACC 2003: The Evidence C
11、ontinues,RESEARCH注册研究，Thorax Center，Rotterdam全球超过50000例患者已植入Cypher支架,RAVEL Update to 24m,SIRIUS Update to 12m,E-SIRIUS Result,C-SIRIUS Result,TAXUS I up to 12m,ControlPTxRef Diameter(mm)2.942.97Late Loss(mm)0.700.35Binary Restenosis10%0%MI (Q & non-Q-wave)0%0%TVR (non-target lesion)0%3.2%TLR10%0%CAB
12、G3.3%0%Death0%0%Stent Thrombosis0%0%,6-mo. Restenosis Rates,2.3% (3/128),1.6% (2/127),3.1% (8/262),Distal Edge,2.3% (3/128),1.6% (2/127),3.4 % (9/261),Proximal Edge,22.0% (58/264),18.6% (49/263),19.0% (50/263),Combined Control(n=270),8.6% (11/128),0.8% ( 1/128),4.7% (6/128),TAXUSNIRx MR(n=135 ),5.5%
13、 (7/128),Total Analysis Segment,1.5% (2/128),If confounders excluded,2.3% ( 3/128),Stented Segment,TAXUSNIRx SR(n=131),TAXUS II,QCA Analysis Stented Segment,TAXUS II,0.3716,0.7279,0.0003,0.0262,0.3552,1.0000,1.0000,0.0023,P-valueoverall,1.5 (2),1.5 (2),3.8 (5),6.9 (9),2.3 (3),1.5 (2),0.0,9.9 (13),TA
14、XUSNIRx MR(n=135)Rate %/ (n),0.2244,1.0000,0.0035,0.0704,0.2354,1.0000,1.0000,0.0082,P-value SR vs. Control,0.5069,3.1 (4),3.0 (8),TVR Remote,1.0000,3.1 (4),1.1 (3),CABG,0.0010,4.7 (6),14.4 (38),TLR,0.0048,10.9 (14),21.7 (57),6-Month MACE,0.0034,0.4026,P-value MR vs. Control,10.1 (13),1.6 (2),0.8 (1
15、),0.0,TAXUSNIRx SR(n=131)Rate % / (n),17.5 (46),TVR - Overall,4.2 (11),Non Q-Wave MI,1.1 (3),Q-Wave MI,0.8 (2),Death,Combined Control(n=270)Rate % / (n),1.0000,1.0000,12-Mo. Major Adverse Cardiac Events,TAXUS II,From ACC 2003, by Dr.Colombo,药物涂层支架不仅给介入心脏病学带来突破性进展，而且可能影响整个心脏病学的发展。,对药物涂层支架的思考,更复杂病变的结果
16、不一定有现在的报告好晚期血栓,支架错位(mal apposition)晚期再狭窄(“Catch-up”现象)其它尚不明的病理生物学反应价格目前应用在再狭窄高危患者,小结（1）,优先药物治疗者：无症状或轻度（CCS I、II级）患者，无大面积心肌缺血证据者二级分支病变非前降支开口部或近端病变而不能进行血管重建者病变70%者,小结（2）,优先CABG者：左主干伴多支血管病变多支血管病变伴左心功能不全（EF70%，有AP或心肌缺血证据，左心功能良好3支病变，有AP或心肌缺血证据，病变类型为A型或B型，左心功能良好AMI恢复期的PCI（AMI一周后）：IRA100%闭塞，有较多存活心肌或远端已有侧枝循
17、环CABG术后1-3年出现桥病变或自体血管新病变，同时伴心肌缺血证据紧急情况下的左冠状动脉主干病变不能行CABG的严重左冠脉主干病变单纯左冠脉主干口部和体部病变，左心功能良好,血管重建后的药物治疗,抗动脉粥样硬化治疗抗血栓治疗,在PTCA/CABG的基础上， 阿托伐他汀仍能提供显著临床益处,* 随机化前患者均进行了PTCA/CABG术；阿斯匹林和-受体阻滞剂使用率分别为83和63 P0.05 Flaker et al. J Am Coll Cardiol. 1999;34:106112,下降百分数,0,10,20,30,40,CHD死亡,PCI-CURE 总体长期结果从随机分组至随访结束时 ，心血管死亡或心肌梗死的联合终点,0.15,0.10,0.05,0.0,10,0,40,100,200,300,400,累积事件率,31% RRRp=0.002n=2658,随访天数,a,b,a = 从随机分组至PCI的时间中位数 (10 天)b = PCI时间中位数后 30 天,标准治疗 氯吡格雷 + 标准治疗,The CURE Investigators. Lancet August 2001,至 12 个月 包括阿司匹林,12.6%,8.8%,Thanks,
