急性冠脉综合征(ACS)及其治疗进展培训课件.ppt

急性冠脉综合征（ACS）及其治疗进展,急性冠脉综合征（ACS）及其治疗进展,急性冠状动脉综合征的定义和分类,定义：急性冠状动脉综合征(acute coronary syndomes , ACS) 是从不稳定性心绞痛到Q波心肌梗死的一组临床综合征 ，通常(但并非总是)由于CAD所致，在病理生理上有很多相似之处。急性冠状动脉综合征的分类 ： ST段不抬高的急性冠状动脉综合征 非Q波心肌梗死NSTEMI（CK-MB大于正常上限的2倍） 不稳定性心绞痛UAP（CK-MB小于正常上限的2倍） ST段抬高的急性冠状动脉综合征 急性Q波心肌梗死STEMI,5/98,2,急性冠脉综合征（ACS）及其治疗进展,急性冠状动脉综合征的定义和分类 定义：急性冠状动脉综合征(,国际现状,每年: 4 million patients are admitted with unstable angina and acute MI 900,000 patients undergo PTCA with or without stent,5/98,3,急性冠脉综合征（ACS）及其治疗进展,国际现状每年:5/983急性冠脉综合征（ACS）及其治疗进展,Ischemic Heart Diseaseevaluation,Based on the patientshistory / physical examelectrocardiogramPatients are categorized into 3 groupsnon-cardiac chest painunstable anginamyocardial infarction,5/98,4,急性冠脉综合征（ACS）及其治疗进展,Ischemic Heart Diseaseevaluat,急性冠脉综合征（ACS）,ACS,非 ST-segment抬高,ST-segment抬高,不稳定 非-Q波Q-Wave心绞痛 AMI AMI,ECG,AcuteReperfusion,HistoryPhysical Exam,5/98,5,急性冠脉综合征（ACS）及其治疗进展,急性冠脉综合征（ACS）ACS非 ST-segment抬,Acute Coronary Syndrome,The spectrum of clinical conditions ranging from:unstable anginanon-Q wave MIQ-wave MIcharacterized by the common pathophysiology of a disrupted atheroslerotic plaque,5/98,6,急性冠脉综合征（ACS）及其治疗进展,Acute Coronary SyndromeThe spe,5/98,7,急性冠脉综合征（ACS）及其治疗进展,5/987急性冠脉综合征（ACS）及其治疗进展,STEMI和UA/NSTEMI病理,5/98,8,急性冠脉综合征（ACS）及其治疗进展,STEMI和UA/NSTEMI病理5/988急性冠脉综合征（,不稳定心绞痛 定义,angina at rest ( 20 minutes)new-onset ( 2 months) exertional angina (at least CCSC III in severity)recent ( 2 months) acceleration of angina (increase in severity of at least one CCSC class to at least CCSC class III),Agency for Health Care Policy Research - 1994,Canadian Cardiovascular Society Classification,5/98,9,急性冠脉综合征（ACS）及其治疗进展,不稳定心绞痛 定义angina at rest ( 2,Non-Q-Wave MIclues to diagnosis,Prolonged chest painAssociated symptoms from the autonomic nervous systemnausea, vomiting, diaphoresisPersistent ST-segment depression after resolution of chest pain,5/98,10,急性冠脉综合征（ACS）及其治疗进展,Non-Q-Wave MIclues to diagnos,5/98,11,急性冠脉综合征（ACS）及其治疗进展,5/9811急性冠脉综合征（ACS）及其治疗进展,NSTEACS诱发因素,Inappropriate tachycardiaanemia, fever, hypoxia, tachyarrhythmias, thyrotoxicosisHigh afterloadaortic valve stenosis, LVHHigh preloadhigh cardiac output, chamber dilatationInotropic statesympathomimetic drugs, cocaine intoxication,5/98,12,急性冠脉综合征（ACS）及其治疗进展,NSTEACS诱发因素Inappropriate tach,NSTEACS预后预测因素,Presence of ST-T-wave changes with painHemodynamic deteriorationpulmonary edema, new mitral regurgitation,3rd heart sound, hypotensionOther predictorsleft ventricular dysfunction, extensive CAD, age, comorbid conditions (diabetes mellitus, obstructive pulmonary disease, renal failure, malignancy),5/98,13,急性冠脉综合征（ACS）及其治疗进展,NSTEACS预后预测因素 Presence of ST,非ST段抬高ACS（NSTEACS）,Plaque disruption斑块破裂Acute thrombosis急性血栓Vasoconstriction血管收缩,5/98,14,急性冠脉综合征（ACS）及其治疗进展,非ST段抬高ACS（NSTEACS）5/9814急性冠脉综合,NSTEACSpathogenesis,斑块破裂Passive plaque disruptionsoft plaque with high concentration of cholesteryl esters and a thin fibrous capActive plaque disruptionmacrophage-rich area with enzymes that may degrade and weaken the fibrous cap; predisposing it to rupture,5/98,15,急性冠脉综合征（ACS）及其治疗进展,NSTEACSpathogenesis斑块破裂5/9815,NSTEACS pathogenesis,急性血栓Vulnerable plaquedisrupted plaque with ulcerationoccurring in 2/3 of unstable patientsthe exposed lipid-rich core abundant in cholesteryl ester is highly thrombogenic Systemic Hypercoagulable Statedisrupted plaque with erosionoccurring in 1/3 of unstable patients,5/98,16,急性冠脉综合征（ACS）及其治疗进展,NSTEACS pathogenesis急性血栓5/981,NSTEACS pathogenesis,血管收缩the culprit lesion in response to deep arterial damage or plaque disruptionarea of dysfunctional endothelium near the culprit lesionplatelet-dependent and thrombin-dependent vasoconstriction, mediated by serotonin and thromboxane A2,5/98,17,急性冠脉综合征（ACS）及其治疗进展,NSTEACS pathogenesis血管收缩5/981,Risk Stratification by ECG,The risk of death or MI at 30 days is strongly related to the ECG at the time of chest pain.ST depression 10%T-wave inversion 5%No ECG changes1-2%,5/98,18,急性冠脉综合征（ACS）及其治疗进展,Risk Stratification by ECGThe,有以下表现者为高危险性：(1) 危险性随病变血管支数、病变弥漫程度、小血管病变、闭 塞血管病变数而增高。(2) 左主干病变(3) 含血栓性病变(见图1) (4) 病变形态复杂,行介入治疗难以或无法植入支架。(见图2) 图1 图2,冠脉造影,5/98,19,急性冠脉综合征（ACS）及其治疗进展,有以下表现者为高危险性：(1) 危险性随病变血管支数、,NSTEACS治疗目标,Therapeutic Goals减少心肌缺血 控制症状 预防心肌梗死和猝死Medical Management抗缺血 therapy抗血栓 therapy,5/98,20,急性冠脉综合征（ACS）及其治疗进展,NSTEACS治疗目标Therapeutic Goals5,药物治疗,抗缺血 therapynitrates, beta blockers, calcium antagonists抗血栓 therapy抗血小板 therapyaspirin, ticlopidine, clopidogrel, GP IIb/IIIa inhibitors抗凝 therapy heparin, low molecular weight heparin (LMWH), warfarin, hirudin, hirulog,5/98,21,急性冠脉综合征（ACS）及其治疗进展,药物治疗抗缺血 therapy5/9821急性冠脉综合征（,5/98,22,急性冠脉综合征（ACS）及其治疗进展,5/9822急性冠脉综合征（ACS）及其治疗进展,NSTEACSAnti-thrombotic Therapy,不适宜溶栓“lytic agents may stimulate the thrombogenic process and result in paradoxical aggravation of ischemia and myocardial infarction”,TIMI IIIB InvestigatorsCirculation 1994; 89:1545-1556,5/98,23,急性冠脉综合征（ACS）及其治疗进展,NSTEACSAnti-thrombotic Therap,5/98,24,急性冠脉综合征（ACS）及其治疗进展,5/9824急性冠脉综合征（ACS）及其治疗进展,Unstable AnginaAnti-platelet Therapy,阿司匹林是“金标准”irreversible inhibition of the cyclooxygenase pathway in platelets, blocking formation of thromboxane A2, and platelet aggregationin AMI, ASA reduced the risk of death by 20-25%in UA, ASA reduced the risk of fatal or nonfatal MI by 71% during the acute phase, 60% at 3 months, and 52% at 2 yearsbolus dose of 160-325 mg, followed by maintenance dose of 80-160 mg/d,5/98,25,急性冠脉综合征（ACS）及其治疗进展,Unstable AnginaAnti-platelet,缺血事件发生率,无阿司匹林(early 1980s),阿司匹林,Aspirin + Heparin,16%,12%,9%,Incidence of death and MI,5/98,26,急性冠脉综合征（ACS）及其治疗进展,缺血事件发生率无阿司匹林(early 1980s)阿司匹林,Unstable AnginaAnti-platelet Therapy,Clopidogrel氯比格雷CAPRIE (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events)19,000 patients randomly assigned to clopidogrel (75 mg/d) or to aspirin (325 mg/d)there was an 8.7% reduction in the combined incidence of stroke, MI, or death (P=.043)patients with MI did better with aspirinpatients with PVD or stroke did better with clopidogrel,Lancet 1996;348:1329-1339Circulation 1998;97:1107,5/98,27,急性冠脉综合征（ACS）及其治疗进展,Unstable AnginaAnti-platelet,GP IIb/IIIa Receptor血小板聚集的最终通路,Platelet activation and aggregation are early events in the development of coronary thrombosisGP IIb/IIIa receptors on activated platelets undergo a conformational change allowing recognition and binding of fibrinogenFibrinogen “acts like glue”, bridging GP IIb/IIIa receptors on adjacent platelets, leading to platelet aggregation,5/98,28,急性冠脉综合征（ACS）及其治疗进展,GP IIb/IIIa Receptor血小板聚集的最终通,Unstable AnginaAnti-platelet Therapy,Tirofiban (Aggrastat; Merk & Co.)PRISM (Platelet Receptor Inhibition for Ischemic Syndrome Management)3,200 patients with unstable angina were treated with either heparin or tirofibanAt 48 hours, there was significant risk reduction (5.9% to 3.6%) in the rate of death, MI, or refractory ischemia. The benefit was lost at 30 days.,N Engl J Med 1998;338:1498-505,5/98,29,急性冠脉综合征（ACS）及其治疗进展,Unstable AnginaAnti-platelet,5/98,30,急性冠脉综合征（ACS）及其治疗进展,5/9830急性冠脉综合征（ACS）及其治疗进展,调脂治疗他汀类药物,5/98,31,急性冠脉综合征（ACS）及其治疗进展,调脂治疗5/9831急性冠脉综合征（ACS）及其治疗进展,急性冠脉综合征(ACS)及其治疗进展培训课件,ACS 的治疗策略进展,冠脉综合征治疗策略进展主要表现在以下三个方面：(1) 抗血小板制剂：包括阿斯匹林,ADP受体拮抗剂(抵克力得Ticlopidine、氯吡格雷Clopidogrel )和GPb / a 受体拮抗剂(Rrepro)(2) 抗凝制剂：包括肝素、低分子肝素(LMWH)、凝血酶抑制剂(水蛭素 Hirudin )和戊聚糖钠(3) 介入治疗,5/98,33,急性冠脉综合征（ACS）及其治疗进展,ACS 的治疗策略进展冠脉综合征治疗策略进展主要表现在以下三,Unstable Angina 介入治疗,TIMI 3B early intervention vs conservative strategy(coronary angiography within 24-48 hrs, followed by angioplasty or bypass surgery)1473 patients with UA or non-Q-wave MI were randomized, there were no difference between the groups in the rates of death or MI at 1 year,Circulation 1994;89:1545-1556,5/98,34,急性冠脉综合征（ACS）及其治疗进展,Unstable Angina 介入治疗TIMI 3B C,非ST段抬高ACS的PCI,复发静息心绞痛 动态ST段改变：ST压低0.1mv或一过性抬 高 0.1mv TnT、TnIC或CK-MB升高血流动力学不稳定室速、室颤AMI后不稳定心绞痛糖尿病 高危患者可能迅速发生血栓事件，进展为严重AMI或死亡，专家建议常规置入支架,5/98,35,急性冠脉综合征（ACS）及其治疗进展,非ST段抬高ACS的PCI 复发静息心绞痛5/9835急性冠,AMI的再灌注治疗, 溶栓治疗 介入治疗,5/98,36,急性冠脉综合征（ACS）及其治疗进展,AMI的再灌注治疗 溶栓治疗,再灌注策略危险和获益,时间,静脉溶栓,5/98,37,急性冠脉综合征（ACS）及其治疗进展,再灌注策略危险和获益 时间,再灌注开始的时间与获益,5/98,38,急性冠脉综合征（ACS）及其治疗进展,再灌注开始的时间与获益5/9838急性冠脉综合征（ACS）及,ST段抬高ACS的再灌注-溶栓,优先溶栓治疗： AMI患者来院3小时 不能行PCI PCI慢（D-TO-B90分钟）,5/98,39,急性冠脉综合征（ACS）及其治疗进展,ST段抬高ACS的再灌注-溶栓优先溶栓治疗：5/9,介入治疗的优点,梗塞相关血管（IRA）开通率 开通率 95% TIMI-3级率 90% 死亡率低 30天3% 脑卒中率低 再闭塞率低 适应症范围广,5/98,40,急性冠脉综合征（ACS）及其治疗进展,介入治疗的优点 5/9840急性冠脉综合征（A,ST段抬高ACS的再灌注-PCI,优先PCI治疗： AMI患者来院3小时 PCI条件好（D-TO-B90分钟） 高危STEMI患者: 心源性休克或合并心衰 溶栓禁忌者 疑诊AMI,5/98,41,急性冠脉综合征（ACS）及其治疗进展,ST段抬高ACS的再灌注-PCI优先PCI治疗：5,ACCAHA有关AMI直接PCI治疗心肌梗死指南,类 在ST段抬高和新出现或怀疑新出现左束支传导阻滞的AMI患者，可首选直接PCI治疗 。直接PCI必须由有经验的术者和相关医务人员，在有适宜条件的导管室于发病12小时内或虽超过12小时但缺血症状仍持续时急性ST段抬高Q波或新出现左束支传导阻滞的AMI并发心原性休克患者，AMI发病在36小时内，并且血运重建术可在休克发生18小时内完成者，应首选直接PTCA治疗,5/98,42,急性冠脉综合征（ACS）及其治疗进展,ACCAHA有关AMI直接PCI治疗心肌梗死指南类 5/,补救性PCI的指征,对溶栓治疗未再通的患者使用PCI恢复前向血流即为 补救性PCI。其目的在于尽早开通梗死相关动脉，挽救缺血但仍存活的心肌，从而改善生存率和心功能。对溶栓治疗后仍有明显胸痛，ST段抬高无显著回 落，临床提示未再通者，应尽快进行急诊冠脉造 影，若TIMI血流02级，应立即行补救性PCI， 使梗死相关动脉再通 对发病12小时内、广泛前壁心肌梗死、再次梗死 及血流动力学不稳定的高危患者意义更大。,5/98,43,急性冠脉综合征（ACS）及其治疗进展,补救性PCI的指征 对溶栓治疗未再通的患者使用PCI恢,溶栓治疗再通者 PCI的指征,对溶栓治疗成功的患者可以在24小时内立 即行PCI 对溶栓治疗成功的患者，且无缺血复发， 也可以在710天后进行择期冠脉造影，若 病变适宜可行P CI,5/98,44,急性冠脉综合征（ACS）及其治疗进展,溶栓治疗再通者 PCI的指征对溶栓治疗成功的患者可以在24,STEMI患者恢复期常规冠脉造影检查,明确冠脉 解剖及心功能-为PCICABG提供科学依据未行再灌注治疗者出院前应当行冠脉造影+PCI溶栓治疗中,LVEF40%+高危者溶栓治疗后运动诱发心肌缺血(不管其他情况如何),5/98,45,急性冠脉综合征（ACS）及其治疗进展,STEMI患者恢复期常规冠脉造影检查,明确冠脉 5/98,THANK YOU FOR YOUR ATTENTION谢谢,5/98,46,急性冠脉综合征（ACS）及其治疗进展,THANK YOU FOR YOUR ATTENTION5/,