非 st 段抬高急性冠脉综合征介入治疗 - 策略与选择阜外心血管病医院 ...

非 ST 段抬高急性冠脉综合征介入治疗- 策略与选择

阜外心血管病医院乔树宾

ACS 住院患者（ NSTE-ACS vs STEMI ）

National Center for Health Statistics. 2001.

ACS

2.3 million hospital admissions ACS ( 230 万 / 年 ACS 住院患者）

UA / NSTEMIUA / NSTEMI

1.43 million admissions per year

（ 143 万 / 年患者占 63% ）

STEMISTEMI

829,000 admissions per year

（ 82.9 万 / 年患者占 36% ）

ACS 主要发病机理

• 动脉粥样硬化斑块 -- 不稳定或破裂• 血栓形成

炎症炎症细胞细胞

少量平滑肌少量平滑肌细胞细胞

激活的巨噬细胞激活的巨噬细胞

血栓

ACS 的病理生理基础

CK- MB or Troponin Troponin elevated or not

Adapted from Michael Davies Adapted from Michael Davies

ACS 无持续 ST 段抬高 ACS 伴持续 ST 段抬高

ACS 的临床分型

ACS

ST 段持续抬高的 ACS 无 ST 段抬高的 ACS

cTnT ( cTnI ) ≥0.1μg/L

或 CK-MB≥ 正常上限的 2 倍cTnT ( cTnI ) ＜ 0.1μg/L

或 CK-MB< 正常上限的 2 倍

STEMI NSTEMI UA

非 ST 段抬高 ACS 的治疗

抗血小板治疗抗凝治疗抗缺血治疗调脂治疗介入治疗冠脉搭桥

抗栓—不溶栓抗血小板、抗凝

PCI ？！

诊断• 常规血生化，特别包括 Tn T 或 I• 监测心电 ST 段的变化• 超声心动图检查如需排除主动脉夹层，做 MRI ；排除肺栓塞行 CT 或核素检查• 观察对抗缺血治疗的效果• 评定危险记分• 评价出血的危险性

NSTE-ACS 危险分层

• 临床因素– 年龄– 原有基础的左室功能– 冠脉解剖– 糖尿病及肾肺功能异常等其它合并病

• 心绞痛的病史特点

• 心电图或动态心电图心肌缺血的表现 ST段和 T 波改变

• 肌钙蛋白• Ｃ反应蛋白• 纤维蛋白肽Ａ• BNP 或 NTproBNP

NSTE-ACS危险分层方法 ---- 早期 CAG的价值早期冠脉造影目的：病变范围和分布、狭窄程度和部位、适合何种血管重建术等。

早期冠脉造影 ------ 提高预后分层的可靠性 ------ 确定治疗方案的有效方法： ① 没有病变可迅速出院 ② 罪犯病变适合 PCI 者可立即介入治疗加快出院 ③ 左主干病变、复杂病变伴左室功能不全者迅速 CABG ------ 发现高危病人，使患者从早期血管重建术中获益

ACC/AHA ：治疗的选择（一）

• 有创治疗：1. 尽管充分药物治疗仍发生静息或低水平活动心绞痛；2.TnT 或 TnI 升高；3. 新出现的 ST 压低；4.HF 体征和症状或新出现或加重的二尖瓣返流；5. 无创检查有高危的证据；6. 持续性室速；7. 六个月内曾 PCI ；8. 先前 CABG ；9. 危险积分属高危（ TIMI ， GRACE ）；10. 左心室功能降低（ LVEF<40% ）

ACC/AHA ：治疗的选择（二）

• 保守治疗：计分属低危险（ TIMI ， GRACE ）无高危特征的患者或医生选择

2007-ESC 介入治疗紧急（ Urgent ）

1. 患者出现持续性或反复胸痛，伴有或不伴有 ST 改变（≥ 2mm ）或深的倒置 T波，抗缺血治疗效果不好

2. 出现心衰临床症状或血流动力学不稳定3. 致命性心律失常（ VF 、 VT ）

早期 <72 小时1.Tn T 或 I↑ 2. 动态 ST 或 T 改变（有症状或无症状）3. 糖尿病 4. 肾功能异常（ GFR<60ml/min/1.73m2 ）5. 左心室功能降低（ LVEF<40% ）6. 梗塞后心绞痛7. 有 MI 病史8.6 个月内行 PCI , 有 CABG 史9. 中高 GRACE 危险记分

不做或择期做• 无再发胸痛• 无心衰的体征• 无新的 ECG 改变（就诊 6-12 小时）• TnT 或 I 正常（就诊 6-12 小时）

0.2 0.5 1 2 5

Favors Invasive Favors Conservative

Odds Ratio Death or MI

OR 0.82, P=0.001

Trial

TIMI 3B

VANQWISH

MATE

FRISC II

TACTICS

RITA 3

TOTAL

Mehta SR et al. JAMA 2005;293:2908-17

5.1% 8.1%

27.2% 28.0%

12.0% 8.9%

4.3% 11.4%

4.0% 5.3%

7.4% 10.9%

VINO 4.8% 14.8%

Inv Cons

7.4% 11.0%

Invasive Management of UA/NSTEMI Meta-analysis: Death/MI at 17 mo. F/U

Overall 12.2 14.4

Trials < 1999* 19.3 19.6Trials > 1999† 9.4 12.4

Troponin +ve 10.0 14.0Troponin –ve 6.7 7.4

Any Marker +ve 14.7 17.4Any Marker -ve 7.7 8.5

Favors Invasive Favors Conservative

0.5 1 2

Trial Inv(%)

Cons(%)

Odds Ratio P value

0.0010.82

0.400.900.0120.82

0.420.890.0010.69

0.00010.730.920.99

*TIMI 3B, VANQWISH and MATE† FRISC II, TACTICS, VINO, RITA 3Data by troponin status available only in FRISC II, TACTICS, RITA 3

Invasive Management of UA/NSTEMI Meta-analysis: Subgroups


Death or MI at Followup

36018090300

Pro

bab

ility

of

Pro

bab

ility

of

DDe

ath

eat

h

.04

.03

.02

.01

0

Non-Invasive (n = 1235)Non-Invasive (n = 1235)

Invasive (n = 1222)Invasive (n = 1222)

InvasiveInvasive Noninvasive Noninvasive RR (95 % CI) RR (95 % CI) 2.2 %2.2 % 4.0 %4.0 % 0.56 (0.35 - 0.89) p = 0.018 0.56 (0.35 - 0.89) p = 0.018

Wallentin, Lancet 2000Wallentin, Lancet 2000Wallentin, Lancet 2000Wallentin, Lancet 2000

FRISC-II Mortality at One-Year

Invasive Vs. Conservative Management Strategies

FRISC II: 5 Year Outcomes

End point

Invasivestrategy (%)

Noninvasive strategy (%)

Relative risk (95% CI)

Death or MI

19.9 24.50.81

(0.69–0.95)

All-cause

mortality9.7 10.1

0.95 (0.75–1.21)

MI 12.9 17.70.73

(0.60–0.89)

Lagerqvist B. World Congress of Cardiology 2006; September 4, 2006, Barcelona, Spain.Lagerqvist B. World Congress of Cardiology 2006; September 4, 2006, Barcelona, Spain.

FRISC II: 5 Year OutcomesDeath or MI at 5 years in high-, medium-, and low-risk patientsDeath or MI at 5 years in high-, medium-, and low-risk patients

End pointInvasive

strategy (%)Noninvasive strategy (%)

Relative risk (95% CI)

Death or MI in high-risk patients

(FRISC 4–7)32.7 41.6

0.79 (0.64–0.97)

Death or MI in

medium-risk

patients

(FRISC 2–3)

14.6 20.40.72 (0.55–1.1

3)

Death or MI in low-riskpatients (FRISC 0–1) 10.3 8.2

1.26 (0.66–2.40)

Lagerqvist B. World Congress of Cardiology 2006; September 4, 2006, Barcelona, Spain.Lagerqvist B. World Congress of Cardiology 2006; September 4, 2006, Barcelona, Spain.

Routine vs Selective InvasiveStrategies in ACS

Adapted from Mehta S, et al. Adapted from Mehta S, et al. JAMA. JAMA. 2005;293;2908-2917.2005;293;2908-2917.

Odds Ratio (95% CI)0.1 1.0

OR - 0.82OR - 0.8295% CI, 0.72-0.9395% CI, 0.72-0.93

P < 0.001P < 0.001

OR - 0.82OR - 0.8295% CI, 0.72-0.9395% CI, 0.72-0.93

P < 0.001P < 0.001

Total Total 561/4608 (12.2) 561/4608 (12.2) 663/4604 (14.4)663/4604 (14.4)

Composite of Death or Myocardial InfarctionNo./Total (%)

FavorsRoutineInvasive

FavorsSelectiveInvasive

SourceSource RoutineRoutineInvasiveInvasive

SelectiveSelectiveInvasiveInvasive

TIMI IIIB TIMI IIIB 86/740 (11.6) 101/733 (13.8) 86/740 (11.6) 101/733 (13.8)

VANQWISH 152/462 (32.9) 139/458 (30.3)VANQWISH 152/462 (32.9) 139/458 (30.3)

MATE 16/111 (14.4) 11/90 (12.2)MATE 16/111 (14.4) 11/90 (12.2)

FRISC II 127/1222 (10.4) 174/1235 (14.1)FRISC II 127/1222 (10.4) 174/1235 (14.1)

TACTICS 81/1114 (7.3) 105/1106 (9.5)TACTICS 81/1114 (7.3) 105/1106 (9.5)

VINO 4/64 (6.3) 15/67 (22.4)VINO 4/64 (6.3) 15/67 (22.4)

RITA 3 95/895 (10.6) 118/915 (12.9)RITA 3 95/895 (10.6) 118/915 (12.9)

10

StudyMortality during hospitalization

Mortality after discharge

Cons (%)Inv (%) Odds Ratio, 95% CI

TIMI 3B 3.32.8

0.1 0.2 0.5 1 2 5 10Favors Routine Favors Selective

VANQWISH 11.713.4MATE 6.910.0FRISC II 3.01.2TACTICS 2.81.9VINO 9.41.6RITA 3 7.35.2

Subtotal 1.11.8

TIMI 3B 1.92.2VANQWISH 1.34.5MATE 3.30.9FRISC II 0.91.1TACTICS 0.71.4VINO 4.51.6RITA 3 0.71.6

Subtotal 3.8 4.9


OR 1.60, P=0.007

OR 0.76, P=0.01

Invasive Rx in ACS: Early and Late Mortality

CRUSADE: Invasive Cardiac Procedures in the US

Procedures Performed (non-transfer)

Diagnostic Cath 64 % —Within 48 hours 41 % —Within 24 hours 27 %

Percutaneous Intervention 35 % —Within 48 hours 25 %

Coronary Bypass Grafting 11 %

An International Randomized Trial ofEarly Versus Delayed Invasive Strategies

in Patients with Non-ST Segment Elevation Acute Coronary Syndromes

FUNDED BY THE CANADIAN INSTITUTES OF HEALTH RESEARCH

Grant # 150904

TIMACS Timing of Intervention

in patients with Acute Coronary Syndromes

TIMACSTIMACSTIMACSTIMACS Study ObjectiveStudy Objective

To determine whether early intervention is superior to delayed

intervention in patients with high risk non-ST segment elevation acute

coronary syndrome

TIMACSTIMACSTIMACSTIMACS

Design, Eligibility Criteria and Design, Eligibility Criteria and ProtocolProtocol

UA or NSTEMI2 of 3 Criteria: Age > 60, ischemic EKG Δ or ↑ biomarker

AND suitable for revascularization

RANDOMIZE*

Early Invasive

Coronary angiography as soon as possible (no later than 24 hours)

followed by PCI or CABG

Delayed Invasive

Coronary angiography any time >36 hrs followed by PCI or CABG

ASA, clopidogrel, GP IIb/IIIa antagonist as per routine practice

*Center chose randomization ratio 1:1, 1:2 or 2:1 Early: Delayed

ExcludedContraindication for LMWH or high risk of bleeding or not a suitable candidate

for revascularization

Follow-up at 30 days and 6 months

TIMACSTIMACSTIMACSTIMACS OutcomesOutcomes

Primary Primary

Composite of Death, new MI or Stroke at 6 mo.Composite of Death, new MI or Stroke at 6 mo.

SecondarySecondary

Composite of: Composite of:

1.1. Death, new MI or refractory ischemiaDeath, new MI or refractory ischemia

2.2. Death, new MI, stroke, refractory ischemia or Death, new MI, stroke, refractory ischemia or repeat revascularizationrepeat revascularization

3.3. StrokeStroke

TIMACSTIMACSTIMACSTIMACS Study Flow ChartStudy Flow Chart

TIMACS Stand Alone

N=1,398

TIMACSTotal

N=3,031

TIMACS OASIS 5N=1,633

+

30 Day and 6 month Follow-up 3,029Lost to Follow-up: 4


Recommended Medical Recommended Medical TreatmentTreatment

ASA, clopidogrel

GP IIb/IIIa inhibitor at discretion of attending physician (especially if pt is not on a thienopyridine)

Antithrombin:

OASIS 5: Either fondaparinux or enoxaparin

TIMACS stand alone: UFH or LMWH or fondaparinux or bivalirudin (investigator discretion)

Beta blocker

Statin


Participating Participating CountriesCountries

North America 650

South America 442

Europe 1065

Asia 846

Australia 28


TIMACS Steering TIMACS Steering CommitteeCommittee

A. Avezum – A. Avezum – BrazilBrazil C. Morillo --C. Morillo -- Columbia Columbia

J-P. Bassand – J-P. Bassand – FranceFrance L. Piegas – L. Piegas – BrazilBrazil

W. Boden – W. Boden – USAUSA J. Probstfield – J. Probstfield – USAUSA

J. Col – J. Col – BelgiumBelgium S. Qiao -- S. Qiao -- ChinaChina

R. Diaz – R. Diaz – ArgentinaArgentina H-J Rupprecht – H-J Rupprecht – GermanyGermany

D. Faxon – D. Faxon – USAUSA P. G. Steg – P. G. Steg – FranceFrance

C. Granger – C. Granger – USAUSA J-F. Tanguay--J-F. Tanguay--CanadaCanada

C. Joyner --C. Joyner -- Canada Canada P. Widimsky – P. Widimsky – Czech RepCzech Rep

M. Kenda – M. Kenda – SloveniaSlovenia J. Varigos – J. Varigos – AustraliaAustralia

S. Mehta --S. Mehta -- Canada Canada S. Yusuf -- S. Yusuf -- CanadaCanada

T. Moccetti – T. Moccetti – SwitzerlandSwitzerland J. Zhu – J. Zhu – ChinaChina

TIMACSTIMACSTIMACSTIMACS Study OrganizationStudy Organization

Coordinating Center: PHRI, McMaster University S. Mehta, S. Yusuf, S. Jolly, C. Horsman, S. Chrolavicius, B. Meeks

DSMB: P. Sleight (chair), J. Anderson, D. DeMets, D. Johnstone, D. Holmes

Adjudication Committee Chair: C. Joyner

Coordinator: M. Lawrence


Criteria for Crossover from Criteria for Crossover from Delayed Group to Early GroupDelayed Group to Early Group

Refractory ischemiaRefractory ischemia

New MINew MI

Hemodynamic instabilityHemodynamic instability

Crossover from Early to DelayedCrossover from Early to Delayed: 11.9%: 11.9%

Crossover from Delayed to EarlyCrossover from Delayed to Early: 25% : 25%


Interventions and Interventions and TimingTiming

EarlyEarlyN=1,593N=1,593

DelayedDelayedN=1,438N=1,438

Coronary Angiography (%)Coronary Angiography (%) 97.697.6 95.595.5

Median time (h Median time (h ± iqr± iqr)) 14 (3-21)14 (3-21) 50 (41-81)50 (41-81)

PCI (%)PCI (%) 59.659.6 55.055.0

Median time (h Median time (h ± iqr± iqr)) 16 (3-23)16 (3-23) 52 (41-101)52 (41-101)

CABG (%)CABG (%) 14.714.7 13.613.6

Median time (d Median time (d ± iqr± iqr)) 7.7 (4.7-17.4)7.7 (4.7-17.4) 10.8 (6.7-19.8)10.8 (6.7-19.8)

Iqr=interquartile range

TIMACSTIMACSTIMACSTIMACS Baseline CharacteristicsBaseline Characteristics



AgeAge 65.165.1 65.865.8

% Female% Female 34.834.8 34.734.7

DiabetesDiabetes 26.526.5 27.327.3

Prior MIPrior MI 19.719.7 20.920.9

Prior PCIPrior PCI 13.813.8 14.114.1

Prior CABGPrior CABG 7.07.0 7.37.3

Prior StrokePrior Stroke 7.27.2 7.57.5

Ischemic ECG Ischemic ECG ΔΔ 80.580.5 79.979.9

Elevated BiomarkerElevated Biomarker 77.277.2 76.976.9

TIMACSTIMACSTIMACSTIMACS In-Hospital MedicationsIn-Hospital MedicationsEarlyEarly

N=1,593N=1,593DelayedDelayedN=1,438N=1,438

ASAASA 98.098.0 98.198.1

ThieonopyridineThieonopyridine 87.287.2 86.786.7

Thienopyridine or GP Thienopyridine or GP IIb/IIIa inhibitorIIb/IIIa inhibitor

88.288.2 88.488.4

GP IIb/IIIa InhibitorGP IIb/IIIa Inhibitor 23.223.2 22.522.5

AnticoagulantAnticoagulant

UFHUFH 24.624.6 24.624.6

LMWHLMWH 64.064.0 64.664.6

FondaparinuxFondaparinux 41.941.9 41.341.3

BivalirudinBivalirudin 0.50.5 0.40.4

Beta BlockerBeta Blocker 86.886.8 86.986.9

StatinStatin 85.085.0 84.384.3


Primary and Secondary Primary and Secondary OutcomesOutcomes



HR HR 95% CI95% CI PP

Death, MI, Stroke 9.79.7 11.411.4 0.850.85 0.68-1.060.68-1.06 0.150.15

Death, MI, refractory ischemia

9.69.6 13.113.1 0.720.72 0.58-0.890.58-0.89 0.0020.002

Death, MI, Stroke, refractory ischemia + repeat intervention

16.716.7 19.719.7 0.840.84 0.71-0.990.71-0.99 0.0390.039

Death 4.94.9 6.06.0 0.810.81 0.60-1.110.60-1.11 0.190.19

MI 4.84.8 5.85.8 0.830.83 0.61-1.140.61-1.14 0.250.25

Stroke 1.31.3 1.41.4 0.900.90 0.48-1.680.48-1.68 0.740.74

Ref. Ischemia 1.01.0 3.33.3 0.300.30 0.17-0.530.17-0.53 <0.00001<0.00001

Rep. Intervention* 8.88.8 8.68.6 1.041.04 0.82-1.340.82-1.34 0.730.73

*At 30 days: 5.9 vs 4.2%, HR 1.39, 95% CI 1.00-1.95, P=0.047


Primary OutcomePrimary OutcomeDeath, MI, or StrokeDeath, MI, or Stroke

Days

Cum

ula

tive

Haz

ard

0.0

0.02

0.06

0.10

0 30 60 90 120 150 180

Death/MI/Stroke at 180 days

Early

No. at Risk

Delayed

Early

1438 1328 1269 1254 1234 1229 1211

1593 1484 1413 1398 1391 1382 1363

Delayed

HR 0.8595% CI 0.68-1.06

P= 0.15


Secondary OutcomeSecondary OutcomeDeath, MI, or refractory ischemiaDeath, MI, or refractory ischemia

Days

Cum

ulat

ive

Haz

ard

0.0

0.04

0.08

0.12

0 30 60 90 120 150 180

Death/MI/RI at 180 days

Delayed

Early

No. at Risk

Delayed

Early

1438 1303 1243 1230 1209 1205 1187

1593 1485 1417 1402 1394 1386 1366

HR 0.7295% CI 0.58-0.79

P=0.002


Secondary OutcomeSecondary OutcomeDeath, MI, stroke, RFI or Rep Death, MI, stroke, RFI or Rep InterventionIntervention

Death/MI/RI/Stroke/Rep Int at 180 days

Days

Cu

mu

lativ

e H

aza

rd

0.0

0.05

0.10

0.15

0.20

0 30 60 90 120 150 180

Delayed

Early

No. at RiskDelayed

Early

1438 1250 1166 1150 1128 1118 1097

1593 1400 1321 1304 1287 1276 1256

HR 0.8495% CI 0.71-0.99

P=0.039

TIMACSTIMACSTIMACSTIMACS Safety OutcomesSafety Outcomes



HR HR CICI PP

Major Bleed during initial hospitalization

3.1 3.5 0.88 0.60-1.31 0.53

ICH 0 0.1

Surg Intervention 0.4 0.8

Retroperitoneal 0.1 0.2

↓ Hb >= 3 g/dL 2.3 2.6

Transfusion ≥ 2 U 2.2 2.9

TIMACSTIMACSTIMACSTIMACS Pre-specified SubgroupsPre-specified Subgroups

Overall

Age < 65>=65

FemaleMale

No ST deviationST deviation

No elevated marker

Elevated Marker

GRACE 0-140GRACE >=141

3031

12931736

10521976

15231508

668

2363

2070961

9.7

6.512.3

9.79.8

7.611.7

10.5

9.5

7.714.1

0.463

0.540

0.722

0.423

0.0097

0.85 ( 0.68 - 1.06 )

0.98 ( 0.64 - 1.52 )0.83 ( 0.64 - 1.07 )

0.77 ( 0.54 - 1.12 )0.89 ( 0.68 - 1.18 )

0.88 ( 0.62 - 1.26 )0.81 ( 0.61 - 1.07 )

1.00 ( 0.62 - 1.60 )

0.81 ( 0.63 - 1.04 )

1.14 ( 0.82 - 1.58 )

0.65 ( 0.48 - 0.88 )

NCharacteristic HR (95% CI) Interaction p-Value

0.33 0.5 0.7 1.00 1.5 2.0 3.0Early better Delayed better

Hazard Ratio (95% CI)

Early%

11.4

6.514.8

12.310.9

8.714.3

10.5

11.7

6.721.6

Delayed%


GRACE Risk Score: Primary GRACE Risk Score: Primary OutcomeOutcome

6.7

21.6

7.7

14.1

0

5

10

15

20

25

Death

/MI/

Str

oke a

t 6 m

o.

(%)

Delayed

Early

HR 1.1495% CI 0.82-1.58

P=0.43

HR 0.6595% CI 0.48-0.88

P=0.005

Interaction P=0.0097

Low/Int RiskGRACE Score < 140

N=2070

High RiskGRACE Score >= 140

N=961

Death, MI or Stroke at 6 mo.

TIMACSTIMACSTIMACSTIMACS ConclusionsConclusions

Overall, we found no significant difference between an early and a delayed invasive strategy for prevention of death, MI or stroke (primary outcome).

However, in the subgroup at highest risk (GRACE score > 140), an early invasive strategy was superior to a delayed invasive strategy for prevention of death, MI or stroke

The early invasive strategy also had a large impact on reducing the rate of refractory ischemia by 70%.

There were no significant differences in major bleeding or other safety concerns between the two strategies

TIMACSTIMACSTIMACSTIMACS ImplicationsImplications

1. Most patients with ACS can be managed safely with either an early or a delayed invasive strategy

2. In a subset of patients at highest risk (GRACE score>140), early intervention is superior and these patients should be taken to the cath lab as early as possible

3. In all other patients, the decision regarding timing of intervention can depend on other factors, such as cath lab availability and economic considerations.

TIMACSAn International Randomized Trial of Early Versus Delayed Invasive Strategies in Patients with Non-ST Segment Elevation Acute Coronary Syndromes

对比非 ST段抬高的急性冠状动脉综合征患者早期与延迟干预治疗的

国际随机研究—中国亚组


共有815名患者入选本研究早期介入组 446名，随访率98.4%

延迟介入组 369名，随访率98.8%

临床基线、合并用药及冠造结果两组无统计学差异

冠造的平均时间早期介入组18.4小时延迟介入组72.6小时


180天随访主要终点事件（死亡、心梗、卒中）早期介入组 9.0% 延迟介入组 14.6% （P=0.01） - 死亡早期介入组 3.6% 延迟介入组 3.3% （P=0.79） - 心梗早期介入组 5.2% 延迟介入组 10.8% （P=0.002） - 卒中早期介入组 0.2% 延迟介入组 0.5% （P=0.87）


180天随访次要终点事件死亡、心梗、难治性心肌缺血早期介入组 14.6% 延迟介入组 22.0% （ P=0.01）死亡、心梗、卒中、难治性心肌缺血、再次血运重建早期介入组 26.7% 延迟介入组 30.4% （ P=0.25）


0

2

4

6

8

10

12

14

180天

终点

事件

发生

率

早期介入组延迟介入组

**

*P≤0.05


30天随访主要终点事件（死亡、心梗、卒中）早期介入组 8.1% 延迟介入组 12.5% （P=0.04） - 死亡早期介入组 2.9% 延迟介入组 2.2% （P=0.503） - 心梗早期介入组 5.2% 延迟介入组 10.0% （P=0.01） - 卒中早期介入组 0% 延迟介入组 0.3% （P=0.45）


30天随访次要终点事件死亡、心梗、难治性心肌缺血早期介入组 13.0% 延迟介入组 19.0% （ P=0.02）死亡、心梗、卒中、难治性心肌缺血、再次血运重建早期介入组 23.5% 延迟介入组 26.6% （ P=0.32）


0

2

4

6

8

10

12

30

%天

终点

事件

发生

率（

）

早期介入组延迟介入组

*

*P≤0.05


180天随访安全性终点- 大出血早期介入组 0.7% 延迟介入组 0.5% （ P=1.00）

30天随访安全性终点- 大出血

早期介入组 0.7% 延迟介入组 0.3% （ P=0.75）

ESC 指南（一）• 对于伴有 ST 段动态改变顽固性或反复发作的

心绞痛，心衰，恶性心律失常或血流动力学不稳定者应做紧急冠状动脉造影（ I-C ）

• 对于具有中高危险特征的患者应做早期冠状动脉造影（ <72 小时），进行血运重建（ PCI 或CABG ）（ I-A ）

• 不推荐常规对没有中高危险特征的患者进行有创评价（ III-C ），建议进行能够诱发心肌缺血的无创检查（ I-C ）

ESC 血运重建指南（二）• 不推荐对非显著病变进行 PCI （ III-C ）

• 选择 BMS 或 DES 时，应仔细认真评估风险 - 效益比，合并病和是否近期非心脏手术停用双重抗血小板药物的可能性（ I-C ）

ESC 血运重建（三）• 造影没有显著病变—药物治疗• 造影有显著病变：单支病变处理罪犯病变；

多支： PCI 或 CABG 的选择应个体化有些仅处理罪犯病变以后再择期外科• 提倡介入术前应用 GPIIb/IIIa 拮抗剂• 如计划搭桥，波立维应停用 5 天

NSTE-ACS不完全或完全”罪犯”血管

再血管化治疗 ?

Anibal A Damonte,Argenitina.Am J Cardiol.2007,TCT

出院及出院后的治疗

特别强调• 各种危险因素的控制• 生活方式的改善• 规律服药

NSTE － ACS 介入治疗选择

NSTE － ACS 患者的自然转归差别很大，危险分层有助于判断预后和指导治疗策略。

介入治疗是 ACS 现代治疗整体的一部分。目前更倾向于早期介入干预治疗高危患者。

辅助治疗中可以用很多药物替代，但对于高危患者尽快行心导管检查比选择哪个药物合适更重要。

非 st 段抬高急性冠脉综合征介入治疗 - 策略与选择 阜外心血管病医院 ...

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非 st 段抬高急性冠脉综合征介入治疗 - 策略与选择阜外心血管病医院 ...