急性冠脉综合征评估及危险分层-课件.ppt

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1、Acute Coronary SyndromesEvaluation and Risk Stratification,New Terminology in ACS,ACS,acute coronary syndrome;MI,myocardial infarction;UA,unstable angina;NSTEMI,nonST-segment elevation myocardial infarction;STEMI,ST-segment elevation myocardial infarction;PCI,percutaneous coronary intervention.Canno

2、n CP.J Thromb Thrombolysis.1995;2:205-218.,Troponin I(TnI),C-Reactive Protein(CRP),and B-type Natriuretic Peptide(BNP)as Determinants of 30-Day Mortality Risks in Acute Coronary Ischemia:A Multimarker Approach,P=.014,P.001,67,150,155,78,504,717,324,90,Sabatine M,et al.Circulation.2002;105:1760-1763.

3、(with permission),Braunwald E.Circulation.1998;98:2219-2222.,Braunwald Etiologic Classification of UA,GUSTO IIb:Correlation of 6-Month Mortality With Baseline ECG Findings in Patients With ACS,GUSTO,Global Use of Strategies To Open Occluded Arteries in Acute Coronary Syndromes;ECG,electrocardiogram;

4、ACS,acute coronary syndrome;STEMI,ST-segment elevation myocardial infarction.Savonitto S,et al.JAMA.1999;281:707-713.(with permission),TIMI,thrombosis in myocardial infarction;UA,unstable angina;NSTEMI,nonST-segment elevation myocardial infarction;CAD,coronary artery disease.Antman EM,et al.JAMA.200

5、0;284:835-842.,TIMI Risk Score for UA/NSTEMI:7 Independent Predictors,Aged 65 years3 CAD risk factors Prior CAD(stenosis 50%)Aspirin in last 7 days2 anginal events in 24 hoursST deviation Elevated cardiac markers(CK-MB or troponin),TIMI Risk Score For UA/NSTEMI,Antman EM,et al.JAMA.2000;284:835-442.

6、(with permission),Age 65 years3CAD Risk FactorsPrior Stenosis 50%ST deviation2 Anginal events 24 hoursASA in last 7 daysElev Cardiac Markers(CK-MB or troponin),4.7,8.3,13.2,19.9,26.2,40.9,0,10,20,30,40,50,0/1,2,3,4,5,6/7,D/MI/Urg Revasc(%),Number of Risk Factors,Population(%):,4.3,17.3,32.0,29.3,13.

7、0,3.4,C Statistic=0.65c2 trend P.001,P.001,P=.004,P.001,P.001,Scirica BM,et al.Am J Cardiol.2002;90:303-305.(with permission),TIMI Risk Score vs Prognosis in Unselected Patients(TIMI 3 Registry),0%,10%,20%,30%,40%,50%,Death,MI,Death/MI,Death/MI/RI,Event Rate at 1 year(%),Prognostic Value of Troponin

8、 T or I in ACS:A Meta-analysis,%,RR 3.9(2.9-5.3),RR 3.8(2.6-5.5),No.Studies:136,NegPos(Trop I+T),3634,1849,737,322,Heidenreich PA,J Am Coll Cardiol.2001;38:478-485.,TIMI IIIB:Troponin I Levels Predict Mortality In UA/NSTEMI,1.0,1.7,3.4,3.7,6.0,7.5,0,2,4,6,8,0 to 0.4,0.4 to 1.0,1.0 to 2.0,2.0 to 5.0,

9、5.0 to 9.0,9.0,831,174,148,134,67,50,Risk Cardiac Troponin I(ng/ml)Ratio1.0 1.83.5 3.96.27.8,Mortality at 42 Days(%of Patients),Antman EA,et al.N Engl J Med.1996;335:1342-1349.(with permission),Lindahl B,et al.N Engl J Med.2000;343:1139-1147.(with permission),Predictive Value of Troponin T and hs-CR

10、P for Mortality from ACS in FRISC Substudy,20,10,0,0,6,12,18,24,30,36,42,48,Cumulative Probability of Death(%),Months,Troponin T 0.60 g/l(n=377),Troponin T 0.60-0.59 g/l(n=367),Troponin T 0.60 g/l(n=173),P=.007,P=.001,CRP 2-10mg/l(n=294),20,10,0,0,6,12,18,24,30,36,42,48,CRP 10mg/l(n=309),CRP 2mg/l(n

11、=314),P=.001,P=.29,CRPTroponin,Months,Risk Stratification With CRP and Troponin T,Morrow DA,et al.J Am Coll Cardiol.1998;31:1460-1465.,WBC Count(x103),30-Day Mortality,0,5,10,15,20,0,5%,10%,15%,20%,White Blood Cell Count vs Mortality,Cannon CP,et al.Am J Cardiol.2001;87:636-639.(with permission),B-t

12、ype Natriuretic Peptide(BNP)and Mortality in ACS Patients,de Lemos JA,et al.N Engl J Med.2001;345:1014-1021.(with permission),ST MINon-ST MIUnstable Angina,8255651133,P=.02P.0001P=.001,de Lemos JA,et al.N Engl J Med.2001;345:1014-1021.(with permission),BNP and Risk of Death in ACS,Multimarker Approa

13、ch:Troponin I,CRP,and BNP to Predict 30-Day Mortality in ACS,Sabatine M,et al.Circulation.2002;105:1760-1763.(with permission),P=.014,P=.001,67,150,155,78,504,717,324,90,30 Day Mortality(%),30-Day Mortality Rel Risk,Inflammation,ACS,and CD-40L,Andre P,et al.Circulation.2002;106:896-899.(with permiss

14、ion)Varo N,et al.Circulation.2003;108:1049-1052.(with permission),Clinical Investigation Reports,Soluble CD40LRisk Prediction After Acute Coronary Syndromes,3.5,3,2.5,2,1.5,1,0.5,0,Death,MI,DIMI,CHF,DIMI CHF,Hazard Ratios(HR),*,*,*,*P.01 compared to first quartile P.03 compared to first quartile,Sol

15、uble CD-40L in ACS,Heeschen C,et al.N Engl J Med.2003;348:1104-1111.(with permission),Association between soluble CD40 ligand levels and the rate of cardiac events(death or nonfatal myocardial infarction)at 24 hours,72 hours,30 days,and 6 months among 544 patients receiving placebo.,Time,Death or No

16、nfatal Myocardial Infarction(%),24 hours,72 hours,30 hours,6 months,P=.13,P=.003,P=.004,P=.001,1st quartile2nd quartile3rd quartile4th quartile5th quartile,Clopidogrel,but not ASA,Reduces ADP-Induced Expression of CD40L,Hermann A,et al.Platelets.2001;12:74-82.(with permission),Effect of Treatment wi

17、th Abciximab According to the Levels of Troponin T and Soluble CD40 Ligand,Heeschen C,et al.N Eng J Med.2003;348:1104-1111.(with permission),Vascular Damage,Inflammation,Myocyte Necrosis,Accelerated Atherosclerosis,Hemodynamic Stress,HbA1cBlood glucose,CrClMicroalbuminuria,Troponin,BNP,NT-proBNP,hs-CRP,CD40L,Morrow DA,et al.Circulation.2003;108:250-252.,Multimarker Strategy in ACS,