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1、冠状动脉血运重建的适宜标准 武警医学院附属医院心脏外科 于洪泉教授美国八个心脏内外科学/协会联合发布 American College of Cardiology Foundation Appropriateness Criteria Task Force Society for Cardiovascular Angiography and Intervention Society of Thoracic Surgeons American Association for Thoracic Surgery American Heart Association American Society
2、of Echocardiolograghy Heart Failure Society of America Society of Cardiovascular Computed TomographyBackground 冠心病的新发病例在增加 CABG 53:530-553严重冠心病并有症状的患者 选择PCI VS CABG的适应症A 适合 U 不确定 I 不适合接受CABG治疗适宜标准无论有无糖尿病或有无LVEF下降合并下 列情况之一： 二支冠脉病变，累及前降支近段 三支冠脉病变（PCI治疗未证明远期获益 ） 左主干狭窄合并其他冠脉病变 孤立左主干病变接受PCI治疗适宜标准无论有无糖尿病或
3、LVEF下降合并下列情况： 二支冠脉病变，累及前降支近段无论有无糖尿病或LVEF下降合并下列情况： 左主干狭窄合并其他冠脉病变 孤立左主干病变PCI治疗非适应证标准的作用 做为临床医生决定治疗方案的依据 作为临床医生的教育工具 作为医生和患者讨论治疗方案的依据 作为医师推荐需要再血管化患者的依据 作为保险支付单位预付的依据（支付，附 加说明） 作为质量控制的依据 确保患者接受必须的，有益的，价效相当 的治疗，而不是其它目的（rather than other purposes)Stent use in CHINA20072002- 20051997- 20011996DES use 90% ,
4、partially 100%胡大一教授指出 加强CABG力度-因为为患者带来 长期存活的益处 规范PCI应用-尽管创伤较小，但不 适当使用没有给患者带来益处。COURAGE StudyBoden WE et al. Am Heart J. 2006;151:1173-9. Boden WE et al. N Engl J Med. 2007;356:1503-16.Optimal medical therapy* + PCI (n = 1149)Optimal medical therapy (n = 1138)AHA/ACC Class I/II indications for PCI, s
5、uitable coronary artery anatomy + 70% stenosis in 1 proximal epicardial vessel + objective evidence of ischemia (or 80% stenosis + CCS class III angina without provocation testing) Primary outcomes: All-cause mortality, nonfatal MIFollow-up: Median 4.6 yearsRandomized*Intensive pharmacologic therapy
6、 + lifestyle intervention CCS = Canadian Cardiovascular SocietySecondary outcomes: Death, MI, stroke; ACS hospitalizationNumber at Risk Medical Therapy 1138 1017 959 834 638 408 192 30 PCI 1149 1013 952 833 637 417 200 35Years01234560.00.50.60.70.80.91.0PCI + OMTOptimal Medical Therapy (OMT)Hazard r
7、atio: 1.05Hazard ratio: 1.05 95% CI (0.87-1.27)95% CI (0.87-1.27) P = 0.62P = 0.627Survival Free from Death and MI (median FU 4.6 yrs)BodenBoden WE et al. WE et al. NEJMNEJM 2007;356:1503-16 2007;356:1503-16Freedom from Death or MI (%)Death/MI at 4.6 yrs 19.0% 18.5%COURAGE: Treatment effect on angin
8、aBoden WE et al. N Engl J Med. 2007;356:1503-16.P 0.001P = 0.02NSAngina-free (%)NSOAT 主要复合终点(HR=1.16, p=0.20)死亡、MI NYHA IV 级Hochman JS, et al. NEJM 2006, 355:2395-407)061220400Months Since AllocationCumulative Event Rate (%)TAXUS (N=118)CABG (N=103)P=0.19*7.7%13.0%Event rate 1.5 SE, *Fisher exact te
9、stCalculated by core laboratory; ITT populationMACCE to 12 Months by SYNTAX Score Tertile Low Scores (0-22) LM SubsetMean baseline SYNTAX Score CABG15.5 4.3 TAXUS15.7 4.4061220400Months Since AllocationCumulative Event Rate (%)TAXUS (N=195)CABG (N=92)Event rate 1.5 SE, *Fisher exact testCalculated b
10、y core laboratory; ITT populationP=0.54*15.5% 12.6%MACCE to 12 Months by SYNTAX Score Intermediate Scores (23-32) LM Subset Mean baseline SYNTAX Score CABG27.2 3.0 TAXUS27.0 2.7MACCE to 12 MonthsP=0.0015*061210200Months Since AllocationCumulative Event Rate (%)ITT population12.1% 17.8% Event Rate 1.
11、5 SE. *Fishers Exact TestTAXUS* (N=903)CABG (N=897)MACCE to 12 Months 3VD Subset061220400Months Since AllocationCumulative Event Rate (%)P0.001*19.1%11.2%ITT populationEvent Rate 1.5 SE, *Fisher exact testTAXUS (n=546)CABG (n=549)MACCE to 12 Months vs SYNTAX ScoreSYNTAX Score22P P=0.10=0.10P P0.0010
12、.001P P=0.71=0.7112-month MACCE, %SYNTAX ScoreKM Estimates, Event Rate 1.5 SE; *chi square test; raw SYNTAX score for illustrative purposes only RCT ITT pts; site-reported dataSYNTAX Score23-32SYNTAX Score33TAXUS* (N=903)CABG (N=897)Patient 1Patient 1Patient 1Patient 1Patient 2Patient 2Patient 2Pati
13、ent 2SYNTAX SCORE 21SYNTAX SCORE 21SYNTAX SCORE 52SYNTAX SCORE 52LCxLCx 70-90% 70-90%LAD 70-90%LAD 70-90%RCA2 70-90%RCA2 70-90%RCA3 70-90%RCA3 70-90%LM 99%LM 99%LCxLCx 100% 100%LAD 99%LAD 99%RCA 100%RCA 100%There is 3-vessel disease and 3-vessel disease规范和发展 执业者-非强制性自我提高，继续教育，学术交流 学会协会-非强制性（中国）强制性（美
14、国 ）指南，临床路径，执业管理 政府行政-强制性行政法规，行业管理Doctor = offer the medical service for the patient Offer: full medical Knowledgeexcellent skillhealthy advice But we cant to cater to anothers pleasure （取其所好） Rather than for other purposesWhat the CAD Patient Real Want? Free from the angina Free from the menace of m
15、yocardial infarction Long term survival Less invasive if possible Less cost Avoid REDOWhat does the Doctor do can meet the CAD patient wantedPCI as indicationCABG as indicationIn the real world of CADPatient want less invasive treatment Use appropriated PCI can be very effectiveWhen there are the optimal indication, Not all. Patient is assuming that PCI as effective as CABG, Even many physician consented it too. Intervention Operation CABG offer no argue long time survival & few RedoPCI & CABG 当今PCI发展的技术，可以达到冠状动脉的如 何一
