ACS是否應該早期介入治療課件

IsearlyinvasivetheanswerforACSDr.BenHeMD/PhD/FSCAI/FAPSICDirectorofCardiologyDepartmentRenjiHospitalAffiliatedtoShanghaiJiaotonguniversity編輯課件PathophysiologyofAcuteCoronarySyndrome編輯課件ACSisanImportantManifestationofAtherothrombosis11.CannonCP.JThrombThrombolysis1995;2:205–218.AntithrombotictherapyStableanginaUANon-

Q-waveMIThrombolysisprimaryPCIQ-waveMIMinutes–

hoursDays–weeksSTEMIUA/NSTEMIAtherothrombosisNewtermOldtermPlaque

rupture編輯課件編輯課件RelationofTIMIriskscoreandMACErate編輯課件HottopicinACSIsearlyinvasivesuperiortoconservativestrategyinACS?Shouldinvasivebedeferredforcoolingoff?

Whatistheoptimaltimeforinvasive?編輯課件編輯課件OptimalStrategyforUA/NSTEMITIMIIIIB2005ConservativeInvasiveVANQWISHFRISCIITACTICS-

TIMI18RITA-3編輯課件FRICS-II:highriskgetmore編輯課件TIMI-18:highriskgetmore編輯課件RITA-3:1&3yrsoutcome編輯課件RITA-3:5yrsoutcome編輯課件編輯課件編輯課件編輯課件In2005,ItseemswefoundanswerInACS,earlyinvasivesuperiortoearlyconservativeThisisparticulartrueinhighriskpatients編輯課件ESCGuideline2005編輯課件編輯課件Istheproblemsettled?編輯課件ICTUSDesigned編輯課件編輯課件編輯課件編輯課件編輯課件編輯課件編輯課件4yrsICTUSLancet2007;369:827-835However,mostofselectiveptswereperformedPCISo,thelong-termf/uresultsdonotinflectInv/Consstrategy編輯課件4yrsICTUSLancet2007;369:827-835編輯課件ICTUS’scriticism

LibertydefinitionofMI(only1*ULN)causingtheearlyMIincreaseinearlyinvasivegroup3yrsrevascularizationratewasequalin2group(81%PCI)1yearmortalityrateinACSinbotharmareverylow(2.5%),Isitarealhighrisk?編輯課件EvenputICTUSintopool,Inv>Cons編輯課件InvvsCons/AllcausedeathHighrisk?編輯課件編輯課件編輯課件2007ESCGuidelineUrgentCoronaryangiographyisrecommendedinPtswithrefractoryorrecurrentanginaassociatedwithdynamicSTdeviation,heartfailure,lifethreateningarrhythmias,orhaemodynamicinstability(I-C)Early(<72h)angiographyfollowedbyrevascularization(PCIorCABG)inpatientswithintermediatetohighriskfeaturesisrecommended(I-A)編輯課件MonocyteLDL-CAdhesion

moleculeMacrophageFoamcellOxidized

LDL-CPlaqueruptureSmoothmuscle

cellsCRP2編輯課件ISAR-COOLTrial編輯課件ISAR-COOLAntithromboticRegimen編輯課件編輯課件ISAR-COOL編輯課件編輯課件編輯課件編輯課件WhatistheoptimaltimeforPCI?編輯課件編輯課件MethodsforOptimaltrial編輯課件ResultsofOptimaltrial編輯課件ConclusionfromOptimaltrial編輯課件What’sthedifferencebetweenISAR-Cool&Optimal?2.5vs84+0.5vs25-編輯課件TimetoCoronaryAngiographyandOutcomesAmongPatientsWithHigh-RiskNon–ST-Segment–ElevationAcuteCoronarySyndromes:ResultsFromtheSYNERGYTrial

PierluigiTricoci,MD,MHS,PhD;YuliyaLokhnygina,PhD;LisaG.Berdan,PA-C,MHS;StevenR.Steinhubl,MD;DietrichC.Gulba,MD;HarveyD.White,MD;NealS.Kleiman,MD;PhilipE.Aylward,MD;AnatolyLanger,MD;RobertM.Califf,MD;JamesJ.Ferguson,MD;ElliottM.Antman,MD;L.KristinNewby,MD,MHS;RobertA.Harrington,MD;ShaunG.Goodman,MD;KennethW.Mahaffey,MDDivisionofCardiology,DukeClinicalResearchInstitute,Durham,NC編輯課件Background2007ACC/AHAGuidelinesforNSTEACSrecommendtheuseofanearlyinvasivestrategyforhigh-riskpatientsRandomizedclinicaltrialsonearlyvs.conservativestrategyuseddifferenttimingofcardiaccatheterizationOptimaltimingofcardiaccatheterizationinNSTEACSnotyetestablished(expeditedvs.deferred)ExpeditedcatheterizationincreasinglyadoptedintheUS編輯課件StudyObjectiveToevaluatetheassociationbetweentimefromhospitaladmissiontocardiaccatheterizationandadverseoutcomesamonghigh-riskpatientswithNSTEACStreatedwithanearlyinvasivestrategy(cardiaccatheterization<48hofhospitaladmission)編輯課件StudyPopulationPatientsrandomizedintheSYNERGYtrial

Ischemicsymptoms<24handatleast2of3high-riskfeatures

Age>60yearsST-segmentdepressionortransientelevationPositivetroponinand/orCK-MBUseofcoronaryangiographyinSYNERGY10,027ptsrandomizedintheSYNERGYtrial9,188ptsunderwentcardiaccatheterization6,352ptsunderwentcardiaccatheterization<48h編輯課件AdjustedEstimatesof30-dayDeath/MIRates(with95%CI).0.0編輯課件LandmarkAnalysis:AdjustedORof30-dayDeath/MI(with95%CI)編輯課件AdjustedEstimatesofIn-hospitalTransfusionRates

(with95%CI)編輯課件StudyLimitationsNon-randomizedobservationalanalysisPropensity-basedmodelsusedtodealwithlackofrandomizationTimetocathisapost-baselineand“dynamic”variableStatisticalmethodologiesattemptedtoaddresstheseissues

EventsfromhospitaladmissiontorandomizationnotavailableEventsunlikelypriortorandomizationMyocardialinfarctioninthefirsthoursfollowingthehospitalizationismoredifficulttoadjudicate編輯課件ConclusionsfromSynergy-1Observationalanalysisamonghigh-riskNSTEACSpatientsenrolledintheSYNERGYtrialtreatedwithanearlyinvasivestrategyReducedtimetocardiaccatheterizationwasassociatedwithdecreasedprobabilityof30-daydeath/MIandnochangesinbleedingNosignalssuggestingbenefitsofdelayingthecardiaccatheterizationwereobserved編輯課件ConclusionsfromSynergy-2RandomizedclinicaltrialstoestablishoptimaltimingofcatheterizationinNSTEACSareneededbutchallengingDelayingcathisproblematicforhospitaladoptingexpeditedcathstrategyLagfromhospitalizationtorandomizationmayconfoundactualtimetocatheterizationinter