非ST段抬高急性ACS的诊断治疗NSTEACS临床指南解读

北京朝阳医院BeijingChaoyangHospital非ST段抬高急性ACS的诊断治疗------NSTEACS临床指南解读首都医科大学附属北京朝阳医院心脏中心杨新春北京朝阳医院BeijingChaoyangHospital概况急性冠脉综合征图谱STElevationMINonSTElevationACSECG–STCK-MBTroponinCRP,IL-6,TNFa,PAI1,NF-KB,CD40,COX-2ECG-STStableAnginaUnstableAnginaNon-QwaveMIQwaveMI北京朝阳医院BeijingChaoyangHospital急性冠脉综合征Presumedprognosis:veryhighriskofin-hospitaldeathTreatmentgoal:preventdeathbyrestoringcoronarybloodflowFibrinolytictherapyDirectPCIPresumedprognosis:lowriskofin-hospitaldeath,unlessMIdevelopsTreatmentgoal:stabilizewithaspirinheparin&monitorforMIdevelopment+Cardiacenzymes–CardiacEnzymesScheduledPCIManagemedicallyLow-riskfeaturesHigh-riskfeaturesACS患者6个月死亡率0%2%4%6%8%10%0306090120150180DaysfromrandomizationT-waveinversionST-segmentdepressionST-segmentelevationT-waveinversionACSSTACSGrangerCBetal.JAmCollCardiol.1998;31:79A.%Cumulativemortalityat6monthsSTMIwithfibrinolyticsSTEMI&NSTEMI冠状动脉病变支数的比较No.diseasedvesselsST(n=1864)ST(n=2170)010%11%145%26%227%28%318%36%SavonittoS,etal.JAmMedAsoc.1999;281:707-713.北京朝阳医院BeijingChaoyangHospital病因及病理北京朝阳医院BeijingChaoyangHospital急性冠脉综合征的病理机制易损斑块因破裂、侵蚀、钙化结节等因素引起血栓形成血栓形成可以形成阻塞性(15%)或非阻塞性(85%)的血栓阻塞状态取决于血栓形成的速度与体内自溶的平衡北京朝阳医院BeijingChaoyangHospital血小板聚集形成血栓血小板的粘附和激活血流中的正常血小板血小板粘附于损伤的内皮表面并被激活血小板内皮细胞内皮下腔血小板粘附到内皮下腔血小板血栓北京朝阳医院BeijingChaoyangHospital非ST段抬高的ACSResultsfromcross-linkingofplateletsbyfibrinogenatplateletreceptorsGPIIb-IIIaatsiteofplaqueruptureplateletfibrinogenRupturedplaqueGPIIb-IIIa冠脉被富含血小板的血栓部分堵塞UnobstructedlumenthrombusArterywall北京朝阳医院BeijingChaoyangHospitalST段抬高AMIResultsfromstabilizationofaplateletaggregateatsiteofplaquerupturebyfibrinmeshplateletRBCfibrinmeshGPIIb-IIIa冠脉被血栓完全堵塞北京朝阳医院BeijingChaoyangHospital危险分层北京朝阳医院BeijingChaoyangHospital肌钙蛋白T对预后的影响:荟萃分析1.96.76.420.80510152025DeathDeath/MI%RR3.9(2.9-5.3)RR3.8(2.6-5.5)No.Studies:136NegPos(TropI+T)36341849737322HeidenreichPA,JAmCollCardiol.2001;38:478-485.北京朝阳医院BeijingChaoyangHospitalWBCCount(x103)30-DayMortality0510152005%10%15%20%白细胞计数和死亡率的关系CannonCP,etal.AmJCardiol.2001;87:636-639.(withpermission)北京朝阳医院BeijingChaoyangHospital肌钙蛋白I(TnI),C反应蛋白(CRP),以及脑钠肽(BNP)水平与30天死亡率的关系OPUS-TIMI1611.83.5601234560123No.ofElevatedBiomarkers30-DayMortalityRelativeRiskTACTICS-TIMI1812.15.713024681012140123No.ofElevatedBiomarkersP=.014P.001671501557850471732490SabatineM,etal.Circulation.2002;105:1760-1763.(withpermission)北京朝阳医院BeijingChaoyangHospitalGUSTOIIb:ACS患者基础ECG改变与6个月死亡率的关系CumulativeMortality(%)02468100306090120150180DaysFromRandomizationT-waveinversionSTACSSTEMIwithfibrinolyticsGUSTO,GlobalUseofStrategiesToOpenOccludedArteriesinAcuteCoronarySyndromes;ECG,electrocardiogram;ACS,acutecoronarysyndrome;STEMI,ST-segmentelevationmyocardialinfarction.SavonittoS,etal.JAMA.1999;281:707-713.(withpermission)北京朝阳医院BeijingChaoyangHospital北京朝阳医院BeijingChaoyangHospital北京朝阳医院BeijingChaoyangHospitalTIMI,thrombosisinmyocardialinfarction;UA,unstableangina;NSTEMI,non–ST-segmentelevationmyocardialinfarction;CAD,coronaryarterydisease.AntmanEM,etal.JAMA.2000;284:835-842.非ST段抬高ACS的TIMI积分评价年龄≥65years≥3冠心病危险因素继往冠心病史(狭窄50%)7天内已服用阿斯匹林史≤24小时内心绞痛发作2次ST改变心肌标志物升高(CK-MBor肌钙蛋白)TIMI积分5-7，为高危病人北京朝阳医院BeijingChaoyangHospitalAntmanEM,etal.JAMA.2000;284:835-442.(withpermission)Population(%):4.78.313.219.926.240.9010203040500/123456/7D/MI/UrgRevasc(%)NumberofRiskFactors4.317.332.029.313.03.4CStatistic=0.65c2trendP.001TIMI积分与死亡、心梗、急诊血管再建术复合终点的关系北京朝阳医院BeijingChaoyangHospital治疗－－基于循征医学的证据药物治疗早期介入治疗北京朝阳医院BeijingChaoyangHospitalVascularDamageInflammationMyocyteNecrosisAcceleratedAtherosclerosisHemodynamicStressHbA1cBloodglucoseCrClMicroalbuminuriaTroponinBNP,NT-proBNPhs-CRP,CD40LMorrowDA,etal.Circulation.2003;108:250-252.MultimarkerStrategyinACS北京朝阳医院BeijingChaoyangHospitalAge653CADriskfactors(FHx,HTN,chol,DM,activesmoker)STdeviation0.5mmcardiacmarkersRecent(24H)severeanginaHISTORICALPRESENTATIONRISKSCORE=TotalPoints(0-7)KnownCAD(stenosis50%)ASAuseinpast7days0/123456/7RISKSCORERISKOFCARDIACEVENTS(%)BY14DAYSINTIMI11B*33571219AntmanetalJAMA2000;284:835-8421111111TIMIRISKSCOREforUA/NSTEMIPOINTSDEATHORMIDEATH,MIORURGENTREVASC5813202641*Entrycriteria:UAorNSTEMIIdefinedasischemicpainatrestwithinpast24H,withevidenceofCAD(STsegmentdeviationor+marker)北京朝阳医院BeijingChaoyangHospitalACS的治疗目标病理生理改变治疗进程ACS(非阻塞性)斑块破裂血栓形成减少血栓负荷限制血栓进展促进斑块愈合和内环境稳定AMI(阻塞性)血栓性阻塞开通阻塞性血管限制损伤范围北京朝阳医院BeijingChaoyangHospital症状提示急性冠脉综合征评价12导联ECE慢性稳定性心绞痛可能ACS确定ACS药物治疗抗凝治疗阻滞剂非心脏病诊断其它可疑疾病诊断北京朝阳医院BeijingChaoyangHospital评价再灌注症状提示急性冠脉综合征可疑ACS确诊ACSNSTEACSSTEACSECG无特异改变心肌标志物阴性ST-T改变胸痛持续心肌标志物阳性血流动力学不稳定观察、随访证实ACS收入院急性心肌缺血路经门诊随访北京朝阳医院BeijingChaoyangHospitalUA/NSTEMI的急性期处理抗缺血治疗吸氧、卧床、ECG监测硝酸酯类-阻滞剂ACEIUA,unstableangina;NSTEMI,non-ST-segmentelevationmyocardialinfarction;ECG,electrocardiogram;ACE,angiotensin-convertingenzyme.BraunwaldE,etal.JAmCollCardiol.2000;36:970-1062.抗栓治疗抗血小板治疗抗凝治疗北京朝阳医院BeijingChaoyangHospitalNSTEMI的药物治疗首选用药抗缺血治疗低分子肝素(LMWH)阿司匹林/赛氯匹啶/氯比格雷次选用药GPIIbIIIa阻滞剂替代治疗凝血酶抑制剂其他ACS的抗缺血治疗EarlybenefitReductionischaemiaEarlybenefitPreventionDeath/MISustainedEffectofEarlybenefitAdditionalLong-termDeath/MI