1、单击此处编辑母版标题样式 单击此处编辑母版副标题样式 * 1 Is early invasive the answer for ACS Dr. Ben He MD/PhD/FSCAI/FAPSIC Director of Cardiology Department Renji Hospital Affiliated to Shanghai Jiaotong university Pathophysiology of Acute Coronary Syndrome ACS is an Important Manifestation of Atherothrombosis1 1. Cannon C
2、P. J Thromb Thrombolysis 2019; 2: 205218. Antithrombotic therapy Stable angina UA Non- Q-wave MI Thrombolysis primary PCI Q-wave MI Minutes hours Days weeks STEMIUA/NSTEMIAtherothrombosisNew term Old term Plaque rupture Relation of TIMI risk score and MACE rate Hot topic in ACS 1. Is early invasive
3、superior to conservative strategy in ACS? 2. Should invasive be deferred for cooling off? 3. What is the optimal time for invasive? Optimal Strategy for UA/NSTEMI TIMI IIIB 2019Conservative Invasive VANQWISH FRISC II TACTICS- TIMI 18 RITA-3 FRICS-II: high risk get more TIMI-18: high risk get more RI
4、TA-3: 1369:827-835 However, most of selective pts were performed PCI So, the long-term f/u results do not inflect Inv/Cons strategy 4 yrs ICTUS Lancet 2019;369:827-835 ICTUSs criticism Liberty definition of MI (only 1*ULN) causing the early MI increase in early invasive group 3yrs revascularization
5、rate was equal in 2 group(81%PCI) 1year mortality rate in ACS in both arm are very low(2.5%),Is it a real high risk? Even put ICTUS into pool, Inv Cons Inv vs Cons/All cause death High risk? 2019 ESC Guideline Urgent Coronary angiography is recommended in Pts with refractory or recurrent angina asso
6、ciated with dynamic ST deviation, heart failure, life threatening arrhythmias, or haemodynamic instability (I-C) Early(72h) angiography followed by revascularization (PCI or CABG) in patients with intermediate to high risk features is recommended (I-A) Monocyte LDL-C Adhesion molecule Macrophage Foa
7、m cell Oxidized LDL-C Plaque rupture Smooth muscle cells CRP 2 ISAR-COOL Trial ISAR-COOL Antithrombotic Regimen ISAR-COOL What is the optimal time for PCI? Methods for Optimal trial Results of Optimal trial Conclusion from Optimal trial Whats the difference between ISAR- Cool Yuliya Lokhnygina, PhD;
8、 Lisa G. Berdan, PA-C, MHS; Steven R. Steinhubl, MD; Dietrich C. Gulba, MD; Harvey D. White, MD; Neal S. Kleiman, MD; Philip E. Aylward, MD; Anatoly Langer, MD; Robert M. Califf, MD; James J. Ferguson, MD; Elliott M. Antman, MD; L. Kristin Newby, MD, MHS; Robert A. Harrington, MD; Shaun G. Goodman,
9、MD; Kenneth W. Mahaffey, MD Division of Cardiology, Duke Clinical Research Institute, Durham, NC Background 2019 ACC/AHA Guidelines for NSTE ACS recommend the use of an early invasive strategy for high-risk patients Randomized clinical trials on early vs. conservative strategy used different timing
10、of cardiac catheterization Optimal timing of cardiac catheterization in NSTE ACS not yet established (expedited vs. deferred) Expedited catheterization increasingly adopted in the US Study Objective To evaluate the association between time from hospital admission to cardiac catheterization and adver
11、se outcomes among high-risk patients with NSTE ACS treated with an early invasive strategy (cardiac catheterization 48h of hospital admission) Study Population Patients randomized in the SYNERGY trial Ischemic symptoms 60 years ST-segment depression or transient elevation Positive troponin and/or CK
12、-MB Use of coronary angiography in SYNERGY 10,027 pts randomized in the SYNERGY trial 9,188 pts underwent cardiac catheterization 6,352 pts underwent cardiac catheterization 48h Adjusted Estimates of 30-day Death/MI Rates (with 95% CI) .0 .0 Landmark Analysis: Adjusted OR of 30- day Death/MI (with 9
13、5% CI) Adjusted Estimates of In-hospital Transfusion Rates (with 95% CI) Study Limitations Non-randomized observational analysis Propensity-based models used to deal with lack of randomization Time to cath is a post-baseline and “dynamic” variable Statistical methodologies attempted to address these
14、 issues Events from hospital admission to randomization not available Events unlikely prior to randomization Myocardial infarction in the first hours following the hospitalization is more difficult to adjudicate Conclusions from Synergy- 1 Observational analysis among high-risk NSTE ACS patients enr
15、olled in the SYNERGY trial treated with an early invasive strategy Reduced time to cardiac catheterization was associated with decreased probability of 30-day death/MI and no changes in bleeding No signals suggesting benefits of delaying the cardiac catheterization were observed Conclusions from Syn
16、ergy- 2 Randomized clinical trials to establish optimal timing of catheterization in NSTE ACS are needed but challenging Delaying cath is problematic for hospital adopting expedited cath strategy Lag from hospitalization to randomization may confound actual time to catheterization intervals Early re
17、-MI adjudication complex Well-designed observational studies may be of value in the debate on optimal timing of cardiac catheterization among NSTE ACS patients Conclusion & Prospective ACS, early invasive is superior to early conservative in most Pts especially high risk Immediate invasive strategy
18、is recommended in very high risk (instability of hemodynamic or electricity) In high risk pts, short-term(24hrs) cooling-off may be benefited (but no more than 48hs ) In low risk ,esp in women, early conservative can be chosen New antiplatelet drug may change practice Thank you for your attention Thank you 拯 畏 怖 汾 关 炉 烹 霉 躲 渠 早 膘 岸 缅 兰 辆 坐 蔬 光 膊 列 板 哮 瞥 疹 傻 俘 源 拯 割 宜 跟 三 叉 神 经 痛 - 治 疗 三 叉 神 经 痛 - 治 疗
