穩(wěn)定性冠心病的治療策略

穩(wěn)定性冠心病的治療策略2012-3現(xiàn)在是1頁(yè)\一共有59頁(yè)\編輯于星期三2現(xiàn)在是2頁(yè)\一共有59頁(yè)\編輯于星期三內(nèi)容在穩(wěn)定性冠心病治療中標(biāo)準(zhǔn)藥物治療的價(jià)值血管重建在那些患者可能獲益？如何選擇CABG或是PCI

單支、雙支病變

三支、左主干病變多支病變功能性完全血管重建選擇藥物洗脫支架還是裸金屬支架？3現(xiàn)在是3頁(yè)\一共有59頁(yè)\編輯于星期三COURAGE:StudydesignBodenWEetal.AmHeartJ.2006;151:1173-9.BodenWEetal.NEnglJMed.2007;356:1503-16.Optimalmedicaltherapy*+PCI(n=1149)Optimalmedicaltherapy

(n=1138)AHA/ACCClassI/IIindicationsforPCI,suitablecoronaryarteryanatomy+

≥70%stenosisin≥1proximalepicardialvessel+objectiveevidenceofischemia

(or≥80%stenosis+CCSclassIIIanginawithoutprovocationtesting)Primaryoutcomes:All-causemortality,nonfatalMIFollow-up:Median4.6yearsRandomized*Intensivepharmacologictherapy+lifestyleintervention

CCS=CanadianCardiovascularSocietySecondaryoutcomes:Death,MI,stroke;ACShospitalization現(xiàn)在是4頁(yè)\一共有59頁(yè)\編輯于星期三COURAGE:TreatmenteffectonprimaryoutcomeHR1.05(0.87-1.27)P=0.62*BodenWEetal.NEnglJMed.2007;356:1503-16.All-causedeath,MI(timetofirstevent)*UnadjustedNo.atriskMedicaltherapy 1138 1017 959 834 638 408 192 30PCI 1149 1013 952 833 637 417 200 35MedicaltherapyPCI+medicaltherapySurvivalfreeofprimaryoutcome024700.50.60.70.81.00.9Years6531現(xiàn)在是5頁(yè)\一共有59頁(yè)\編輯于星期三6現(xiàn)在是6頁(yè)\一共有59頁(yè)\編輯于星期三現(xiàn)在是7頁(yè)\一共有59頁(yè)\編輯于星期三現(xiàn)在是8頁(yè)\一共有59頁(yè)\編輯于星期三PharmacologictherapyAntiplateletAspirinClopidogrelinaccordancewithestablishedpracticestandardsDyslipidemiaSimvastatin±ezetimibe

orERniacinACEIorARBLisinoprilorlosartan-blockerERmetoprololsuccinateCalciumchannelblockerAmlodipineNitrateIsosorbide5-mononitrateBodenWEetal.AmHeartJ.2006;151:1173-9.BodenWEetal.NEnglJMed.2007;356:1503-16.現(xiàn)在是9頁(yè)\一共有59頁(yè)\編輯于星期三內(nèi)容在穩(wěn)定性冠心病治療中標(biāo)準(zhǔn)藥物治療的價(jià)值血管重建在那些患者可能獲益？如何選擇CABG或是PCI

單支、雙支病變

三支、左主干病變多支病變功能性完全血管重建選擇藥物洗脫支架還是裸金屬支架？10現(xiàn)在是10頁(yè)\一共有59頁(yè)\編輯于星期三11現(xiàn)在是11頁(yè)\一共有59頁(yè)\編輯于星期三現(xiàn)在是12頁(yè)\一共有59頁(yè)\編輯于星期三現(xiàn)在是13頁(yè)\一共有59頁(yè)\編輯于星期三14現(xiàn)在是14頁(yè)\一共有59頁(yè)\編輯于星期三內(nèi)容在穩(wěn)定性冠心病治療中標(biāo)準(zhǔn)藥物治療的價(jià)值血管重建在那些患者可能獲益？如何選擇CABG或是PCI

單支、雙支病變

三支、左主干病變多支病變功能性完全血管重建選擇藥物洗脫支架還是裸金屬支架？15現(xiàn)在是15頁(yè)\一共有59頁(yè)\編輯于星期三ProximalLADdisease,medicine,PTCAorCABG

（MASStrial）1724301.41.42.82.81.49.7420328298P=0.0002P=0.006NSNSP=0.019P<0.01P<0.01Eventrateatf-up(%)Huebetal.JAmCollCardiol1995;26:1600-1605SingleCenter,randomizedtrialStableangina,proximalLADsignificantlesion<12mminlength,nopriorMI,nototalocclusion,nopriorCABGorangioplasty.n=214:Medicaln=72;BAn=72;LIMAn=70現(xiàn)在是16頁(yè)\一共有59頁(yè)\編輯于星期三穩(wěn)定性冠心病血運(yùn)重建策略SilberS,TCT2010現(xiàn)在是17頁(yè)\一共有59頁(yè)\編輯于星期三內(nèi)容在穩(wěn)定性冠心病治療中標(biāo)準(zhǔn)藥物治療的價(jià)值血管重建在那些患者可能獲益？如何選擇CABG或是PCI

單支、雙支病變

三支、左主干病變

多支病變功能性完全血管重建選擇藥物洗脫支架還是裸金屬支架？18現(xiàn)在是18頁(yè)\一共有59頁(yè)\編輯于星期三71%enrolled

(N=3,075)AllPtswithdenovo3VDand/orLMdisease(N=4,337)Treatmentpreference(9.4%)ReferringMDorpts.refused

informedconsent(7.0%)Inclusion/exclusion(4.7%)Withdrewbeforeconsent(4.3%)Other(1.8%)Medicaltreatment(1.2%)TAXUSn=903PCIn=198CABGn=1077CABGn=897nof/un=4285yrf/un=649PCIallcapturedw/followupCABG2500750w/f/uvsTotalenrollmentN=3075Stratification:

LMandDiabetesTwoRegistryArmsRandomizedArmsn=1800TwoRegistryArmsN=1275RandomizedArmsN=1800HeartTeam(surgeon&interventionalist)PCIN=198CABGN=1077AmenableforonlyonetreatmentapproachTAXUS*N=903

CABGN=897vsAmenableforbothtreatmentoptionsStratification:

LMandDiabetesLM33.7%3VD66.3%LM34.6%3VD65.4%DM28.5%NonDM71.5%NonDM71.8%DM28.2%23USSites62EUSites+SYNTAXTrialDesign現(xiàn)在是19頁(yè)\一共有59頁(yè)\編輯于星期三PatientProfiling

LocalHeartteam(surgeon&interventionalcardiologist)assessedeachpatientinregardsto:Patient’soperativerisk(EuroSCORE&Parsonnetscore)Coronarylesioncomplexity(newlydevelopedSYNTAXscore)ThegoaloftheSYNTAXscoreistoprovideatooltoassistphysiciansintheirrevascularizationstrategiesforpatientswithhighrisklesionsSianosetal,EuroIntervention2005;1:219-227Valgimiglietal,AmJCardiol2007;99:1072-1081Serruysetal,EuroIntervention2007;3:450-459CoronarytreesegmentsbasedontheclassificationproposedbytheAHAandmodifiedfortheARTSstudyCirculation1975;51:31-3&SeminIntervCardiol1999;4:209-19Leamanscore,Circ1981;63:285-299LesionsclassificationACC/AHA,Circ2001;103:3019-3041Bifurcationclassification,CCI2000;49:274-283CTOclassification,JAmCollCardiol1997;30:649-656TortuosityThrombusBifurcationTotalOcclusion3VesselLeftMainDominanceCalcificationNumber&locationoflesionsSYNTAXscore現(xiàn)在是20頁(yè)\一共有59頁(yè)\編輯于星期三MACCEto12MonthsP=0.0015*061210200MonthsSinceAllocationCumulativeEventRate(%)ITTpopulation12.1%

17.8%EventRate±1.5SE.*Fisher’sExactTestTAXUS*

(N=903)CABG

(N=897).SerruysPW,atTCT2008現(xiàn)在是21頁(yè)\一共有59頁(yè)\編輯于星期三SYNTAXTrial

AdverseEventsto12Months

ITTpopulationEventRate±1.5SE,*FisherexacttestAllDeathRevascularizationCVA(Stroke)MyocardialInfarctionTAXUS*(N=903)CABG(N=897).SerruysPW,atTCT2008現(xiàn)在是22頁(yè)\一共有59頁(yè)\編輯于星期三現(xiàn)在是23頁(yè)\一共有59頁(yè)\編輯于星期三SabikJF,TCT2010現(xiàn)在是24頁(yè)\一共有59頁(yè)\編輯于星期三Patient1Patient1Patient2Patient2SYNTAXSCORE21SYNTAXSCORE52LCx70-90%LAD70-90%RCA270-90%RCA370-90%LM99%LCx100%LAD99%RCA100%Thereis‘3-vesseldisease’and‘3-vesseldisease’現(xiàn)在是25頁(yè)\一共有59頁(yè)\編輯于星期三SYNTAXTrial,MACCEto12Months

LeftMainSubsetP=0.44*061220400MonthsSinceAllocationCumulativeEventRate(%)13.6%

15.8%

TAXUS

(N=357)CABG

(N=348)Eventrate±1.5SE,*FisherexacttestITTpopulation現(xiàn)在是26頁(yè)\一共有59頁(yè)\編輯于星期三P=0.2026.8%22.3%0CumulativeEventRate(%)2040Before1year*13.7%vs15.8%P=0.441-2years*7.5%vs10.3%P=0.222-3years*5.2%vs5.7%P=0.780123624MonthsSinceAllocationTAXUS

(N=357)CABG

(N=348)MACCEto3Years

LMSubsetCumulativeKMEventRate±1.5SE;log-rankPvalue;*BinaryratesSerruysP,TCT2010現(xiàn)在是27頁(yè)\一共有59頁(yè)\編輯于星期三CABGPCIPvalueDeath6.0%2.6%0.21CVA4.1%0.9%0.12MI2.0%4.3%0.36Death,CVAorMI11.0%6.9%0.26Revasc.13.4%15.4%0.69MonthsSinceAllocationCumulativeEventRate(%)P=0.33LeftMainTAXUS

(N=118)CABG

(N=104)MACCEto3YearsbySYNTAXScoreTercileLowScores(0-22)18.0%23.0%MonthsSinceAllocationCumulativeEventRate(%)0122440020301036Site-reportedData;ITTpopulationCumulativeKMEventRate±1.5SE;log-rankPvalue>>><<現(xiàn)在是28頁(yè)\一共有59頁(yè)\編輯于星期三CABGPCIPvalueDeath12.4%4.9%0.06CVA2.3%1.0%0.46MI3.3%5.0%0.63Death,CVAorMI15.6%10.8%0.29Revasc.14.0%15.9%0.75P=0.90LeftMainTAXUS

(N=103)CABG

(N=92)MACCEto3YearsbySYNTAXScoreTercile

IntermediateScores(23-32)23.4%23.4%MonthsSinceAllocationCumulativeEventRate(%)0122440020301036Site-reportedData;ITTpopulationCumulativeKMEventRate±1.5SE;log-rankPvalue>>><<現(xiàn)在是29頁(yè)\一共有59頁(yè)\編輯于星期三P=0.003LeftMainTAXUS

(N=135)CABG

(N=149)MACCEto3YearsbySYNTAXScoreTercile

LeftMainSYNTAXScore3337.3%21.2%LeftMainMonthsSinceAllocationCumulativeEventRate(%)0122440020301036CABGPCIPvalueDeath7.6%13.4%0.10CVA4.9%1.6%0.13MI6.1%10.9%0.18Death,CVAorMI15.7%20.1%0.34Revasc.9.2%27.7%<0.001Site-reportedData;ITTpopulationCumulativeKMEventRate±1.5SE;log-rankPvalue><<<<現(xiàn)在是30頁(yè)\一共有59頁(yè)\編輯于星期三ESC穩(wěn)定性冠心病血運(yùn)重建策略(2010)SilberS,TCT2010現(xiàn)在是31頁(yè)\一共有59頁(yè)\編輯于星期三

血運(yùn)重建策略的制定應(yīng)由多學(xué)科完成32現(xiàn)在是32頁(yè)\一共有59頁(yè)\編輯于星期三一站式雜交手術(shù)（MIDCAB+PCI）對(duì)部分三支或左主干病變可能是一選擇ThefirstHybridOperatingRoominAsiawasbuiltatFuwaiHospitalin2007.33新技術(shù)、新理念呼喚新的治療策略現(xiàn)在是33頁(yè)\一共有59頁(yè)\編輯于星期三內(nèi)容在穩(wěn)定性冠心病治療中標(biāo)準(zhǔn)藥物治療的價(jià)值血管重建在那些患者可能獲益？如何選擇CABG或是PCI

單支、雙支病變

三支、左主干病變

多支病變功能性完全血管重建選擇藥物洗脫支架還是裸金屬支架？現(xiàn)在是34頁(yè)\一共有59頁(yè)\編輯于星期三Angiography-guidedPCIFFR-guidedPCIMeasureFFRinallindicatedstenosesStentallindicatedstenosesStentonlythosestenoseswithFFR≤0.80RandomizationIndicateallstenoses≥50%consideredforstentingPatientwithstenoses≥50%inatleast2ofthe3majorepicardialvessels1-yearfollow-upFLOWCHART現(xiàn)在是35頁(yè)\一共有59頁(yè)\編輯于星期三

FAMEstudy:ProceduralResultsANGIO-groupN=496FFR-groupN=509P-valueProceduretime(min)70±4471±430.51Contrastagentused(ml)302±127272±133<0.001Materialsusedatprocedure(US$)60075332<0.001Lengthofhospitalstay(days)3.7±3.5

3.4±3.30.05stentsperpatient2.7±1.21.9±1.3<0.001現(xiàn)在是36頁(yè)\一共有59頁(yè)\編輯于星期三FFR-guided30days2.9%90days3.8%180days4.9%360days5.3%Angio-guidedabsolutedifferenceinMACE-freesurvivalFAMEstudy:Event-freeSurvival現(xiàn)在是37頁(yè)\一共有59頁(yè)\編輯于星期三

ANGIO-groupN=496FFR-groupN=509P-valueEventsat1year,No(%)Death,MI,CABG,orrepeat-PCI91(18.4)67(13.2)0.02Death15(3.0)9(1.8)0.19Deathormyocardialinfarction55(11.1)37(7.3)0.04CABGorrepeatPCI47(9.5)33(6.5)0.08Totalno.ofMACE113760.02AdverseEventsat1year現(xiàn)在是38頁(yè)\一共有59頁(yè)\編輯于星期三

PCI應(yīng)用的適當(dāng)性（美國(guó)注冊(cè)資料），全美1091所醫(yī)院PCI500154例急癥PCI占71.1%STEMI20.6%，NSTEMI21.1%，高危UA29.3%非急癥PCI占28.9%適當(dāng)性急癥PCI：適當(dāng)98.6%非急癥PCI：適當(dāng)50.4%，不肯定38.0%

不適當(dāng)11.6%

無(wú)心絞痛53.8%

無(wú)創(chuàng)檢查屬低危71.6%

藥物治療不適當(dāng)（≤1種藥物）95.8%

ChanP.JAMA2011；306:53現(xiàn)在是39頁(yè)\一共有59頁(yè)\編輯于星期三

PCIsinChina現(xiàn)在是40頁(yè)\一共有59頁(yè)\編輯于星