ACC2005公布的临床试验的启示

Heartbeat–Mar2005ACC2005ACC2005:MessagefromthetrialsValentinFusterMDDirector,CardiovascularInstituteMountSinaiMedicalCenterNewYork,NYChristopherCannonMDStaffcardiologistBrighamandWomen'sHospitalBoston,MAJamesFergusonMDAssociateDirector,CardiologyStLuke'sEpiscopalHospitalandTexasHeartInstituteHouston,TXHeartbeat–Mar2005ACC2005Women'sHealthStudyUseofaspirinforprimarypreventionCOMMITandCLARITYUseofclopidogrelinacute-MIpatientsTNTHigh-doseatorvastatininstableCHDpatientsASCOT-BPLACalciumchannelblockerplusACEinhibitorreducedall-causemortalityandothercardiovascularendpointsTopicsHeartbeat–Mar2005ACC2005Women'sHealthStudyUseofaspirinforprimarypreventionHeartbeat–Mar2005ACC2005Women'sHealthStudy:DesignUseofaspirinforprimarypreventioninwomen(NEnglJMed2005:publishedMarch7th)•39876initiallyhealthywomen45yearsofageorolder•Randomizedto100mgofaspirinonalternatedaysorplacebo•MonitoredforfirstmajorCVevent(nonfatalMI,nonfatalstroke,ordeathfromCVcauses)•10-yearfollow-upHeartbeat–Mar2005ACC2005WHS:CardiovascularendpointsEndpointEvents(n),aspirin(n=19934)Events(n),placebo(n=19942)RelativeriskpMajorCVevent4775220.910.13StrokeMI2211982661930.831.020.040.83DeathfromCVcauses1201260.950.68Heartbeat–Mar2005ACC2005WHS:StrokeendpointsEndpointEvents(n),aspirin(n=19934)Events(n),placebo(n=19942)RelativeriskpStroke2212660.830.04•Ischemic1702210.760.009•Hemorrhagic51411.240.31•Fatal23221.040.90•Nonfatal1982440.810.02Heartbeat–Mar2005ACC2005WHS:AmbitioustrialGlasshalf-fullvshalf-empty•Reducesstrokeinaprimary-preventionpopulation•Butdoesnotreducemortality,whichmayhavebeenanambitiousendpoint,inretrospectFergusonHeartbeat–Mar2005ACC2005WHS:SurprisingresultsBenefitinstrokeandmyocardialinfarctionreductioninwomenolderthan65yearsYoudohavetobeatrisktogetbenefitfromaspirin.CannonHeartbeat–Mar2005ACC2005GenderdifferencesSignificantdifferencesinstrokereductionintheWomen'sHealthStudyandthePhysician'sHealthStudy•Doesstrokeoccurearlierinwomenthanitdoesinmen?Heartbeat–Mar2005ACC2005GenderdifferencesMeanagesroughlythesame,butdifferentfollow-up•Physician'sHealthStudy:5-yearfollow-up•Women'sHealthStudy:10-yearfollow-upThesearenotapplesandappleswe'recomparing.-FergusonHeartbeat–Mar2005ACC2005WHS:AspirindoseWedon'tknowwhattherightdoseofaspirinisrightnow.-Ferguson•Physician'sHealthStudyused325-mgdose•AntithromboticTrialistCollaborationsuggestsdoseslessthan75mg/daynotaseffectiveHeartbeat–Mar2005ACC2005WHS:TheguidelinesChangingguidelines?Noneed...•Aspirinusedinprimarypreventiononlywhenpatient'srisk-factorprofileisintermediatebasedonFraminghamriskscore•ButmayneedtorevisitthestrokereductionbenefitFusterHeartbeat–Mar2005ACC2005WHS:Whogetsaspirin?Howlowdowntheriskspectrumdowego?•Nobenefitinyoungerpatients•NeedtocategorizewomenathighriskforstroketodirectaspirintherapytothemCannonHeartbeat–Mar2005ACC2005WHS:NotchangepracticeIt'stellinguswhatwesortofknewalready.Noteverybodyneedstobetakingaspirin.•Benefitstiedtothedegreeofrisk•Stroke-preventiondataneedtobeteasedoutfurtherFergusonHeartbeat–Mar2005ACC2005COMMITClopidogrelandMetoprololinMyocardialInfarctionTrialCLARITYClopidogrelasAdjunctiveReperfusionTherapy-ThrombolysisinMyocardialInfarction(TIMI)28Heartbeat–Mar2005ACC2005NewdataaboutclopidogrelCLARITY(NEnglJMed2005:publishedMarch9,2005)•3500patients•Clopidogrelimprovedinfarct-relatedarterypatencyinMIpatientsreceivingthrombolysis-Reducedoccludedarteriesby36%-Reduceddeath,MI,orrecurrentischemiarequiringrevascularizationat30daysby20%Heartbeat–Mar2005ACC2005NewdataaboutclopidogrelCOMMIT•46000patients•AdditionofclopidogrelinpatientswithST-segment-elevationMIwithorwithoutthrombolysis-Death/MI/strokereducedby9%-Deathreducedby7%Heartbeat–Mar2005ACC2005CLARITYandCOMMITThisaddsthefinalpieceofthepuzzlethatclopidogrelisbeneficialinST-segment-elevationMI-CannonHeartbeat–Mar2005ACC2005CLARITYandCOMMITSubstantialclinicalbenefitinkeepingvesselsopen•COMMITcounterintuitive:mostofthebenefitinpatientspresentingwithinfirst12hours•TrendtowardbenefitinpatientsalsotreatedwithfibrinolyticsFergusonHeartbeat–Mar2005ACC2005MechanismsSamemechanismasaspirin?•After180minutes,thearteriesopenmoreandstayopenbecauseofthecombination•PreventionofreocclusionislikelytheoperativemechanismTwoagentsarebetterthanone.CannonHeartbeat–Mar2005ACC2005CLARITYandCOMMITIfyouhaverisk,moreantiplatelettherapyprovidesincrementalbenefit•OpportunitytosignificantlyimproveaspirinFergusonHeartbeat–Mar2005ACC2005TNTTreatingtoNewTargetsHigh-doseatorvastatininstableCHDpatientsHeartbeat–Mar2005ACC2005TNT:DesignLoweringLDLcholesterollevelsinstableCHDpatientssubstantiallybelowcurrentguidelines(NEnglJMed2005:publishedMarch8,2005)•Parallel-groupstudyrandomizing10001patientstoatorvastatin10mgor80mg•Patientsincludedweremenandwomenaged35yearsto75yearswithclinicallyevidentCHD•PrimaryendpointwasfirstmajorCVevent(deathfromCHD,nonfatalMI,nonfatalandfatalstroke,orresuscitationaftercardiacarrest)•5-yearfollow-upHeartbeat–Mar2005ACC2005TNT:LDLcholesterollevelsLDLcholesterollevelAtorvastatin10mg(n=5006)Atorvastatin80mg(n=4995)MeanbaselineLDLcholest