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1、老年冠心病治疗策略的演变 The Strategic Changes of Elderly Coronary Heart Disease Treatment陈可冀 Chen Ke-ji 徐浩 Xu Hao中国中医科学院西苑医院心血管病中心 卫生部中日友好医院全国中西医结合心血管病中心 2008-05-23 1老年冠心病临床特点 Clinical Features of Elderly CHDn严重心绞痛多/多支血管病变多/复杂病变多/ 弥漫和钙化病变多/陈旧心梗多/左室功能受累多 /并存病多/无症状多/合并糖尿病多/严重心律失 常多/病死率高(高龄者三支病变60%-TIME/APPROACH
2、试验)(75岁CHD发病率:男18.6%,女6.1%)(PCI,出血并发症16.6%)n治疗目的:缓解症状/改善功能/提高生活质量2冠心病治疗观念的改变 Novel Changes in Concept of Elderly CHDTreatment Luminal stenosis to vulnerable plaque formation 从重视管腔狭窄到易损斑块 Lipid deposit to inflammatory response从注意脂质沉积到炎症反应 Vulnerable plaque to vulnerable patient 从重视易损斑块到易损病人Epicardial
3、 vessel open to myocardial perfusion从注意心外膜冠脉开通到心肌组织水平灌注Outshine others to trio从一枝独秀到三驾马车Single RF control to multi-RF intervention从单一危险因素控制到多个危险因素联合干预Standardized treatment to individualized therapy从注重规范化治疗到个体化治疗3Luminal Stenosis 管腔狭窄Vulnerable Plaque 易损斑块冠心病治疗观念改变之一 First Change in Concept of CHD T
4、reatment4Degree of Coronary Stenosis 冠脉狭窄程度Risk of CHD 冠心病严重度动脉粥样硬化的传统观念 Traditional Concept of Atherosclerosis?5急性心梗前的冠脉狭窄程度 Coronary Artery Stenosis pre-AMI70% of Diameter % of Diameter StenosisStenosis% of the Patientsof the PatientsBar graph shows severity of coronary artery stenosis before AMI
5、(n=195, 4 studies) 68% patients had stenosis less than 50% at baseline86% patients had stenosis less than 70% at baselineFalk et al. CirculationFalk et al. Circulation. 1995;92:657 1995;92:657.6降脂疗法降低心脏事件但并不改变管腔狭窄 Lipid-lowering Therapies Decrease Cardiac Events but Not StenosisTrialCholesterol Decr
6、ease, %Cardiac Event Decrease, %Change in Stenosis, %FATS2380-1.1 3.7STARS1469-0.53.6STARS2389-1.5 4.0SCRIP16390.32.5PLAC 119740.691.Levine GN, Keaney JF Jr, Vita JA. Cholesterol reduction in cardiovascular disease: clinical benefits and possible mechanisms. N Engl J Med 1995;332:512-521. 2.Philbin
7、EF, Pearson TA. How does lipid-lowering therapy rapidly reduce ischemic events? J Myocard Ischemia 1994;6:13-18. 3.Pitt B, Mancini GBJ, Ellis SG, Rosman HS, Park J-S, McGovern ME, for the PLAC I investigators. Pravastatin limitation of atherosclerosis in the coronary arteries (PLAC I): reduction in
8、atherosclerosis progression and clinical events. J Am Coll Cardiol 1995;26:1133-11397Coronary Artery Stenosis And Cardiac Events 冠脉狭窄与心脏事件nPlaque volume or severity of coronary artery stenosis may not be the key factor for inducing cardiac events.n提示:冠脉狭窄并非心血管事件关键原因8Concept of Vulnerable Plaque 易损斑块
9、概念的提出nIn 1989, Muller and colleagues first used “vulnerable plaques” to describe rupture-prone plaques as the underlying cause of most clinical coronary events. 首倡易损斑块破裂观念nA vulnerable plaque often has a large lipid pool, a thin cap, and macrophage-dense inflammation on or beneath its surface. 特征nVu
10、lnerable plaque rupture or disruption causes bleeding into the plaque, luminal thrombosis, and/or vasospasm that may cause sudden flow obstruction and ischemic injury. 破裂致血栓形成Muller J, Tofler G, Stone P. Circadian variation and triggers of onset of acute cardiovascular disease. Circulation. 1989; 79
11、:733743. 910多方位策略演变Many sided strategic changesn诊断进步：由以CAG为主导，到重视斑块检测技术的发展如IVUS、OCT ；n基础研究方向：逐渐以稳定易损斑块以及减少斑块破裂后血栓形成为方 向；n二级预防重点：也将由治疗冠脉狭窄转为易损斑块的干预。0.05）-33%(P=0.0003)CARE vs. CCSPS 38CCSPS亚组分析 血脂康广泛适用于特殊人群的调脂治疗n合理积极谨慎n老年人群n高血压人群n糖尿病人群39日本MEGA STUDY结果表明:东方人群温和调脂即可明显获益,与CCSPS结果一致MEGA Studys result : s
12、imilar to CCSPS对日本人的一级预防:服用10-20mg的pravastatin可使冠心病危险33%;与美欧用20-40mg效益相当对轻中度Tc增高的东方人群低剂量是安全有效的Atheroscler Suppl. 2007 Aug;8(2):13-7. Epub 2007 Jun 22. LinksPrimary prevention of cardiovascular diseases among hypercholesterolemic Japanese with a low dose of pravastatin. Nakamura H; MEGA Study Group.T
13、okyo, Japan - Results of the Management of Elevated Cholesterol in the Primary Prevention Group of Adult Japanese (MEGA) study, the first large-scale primary-prevention trial in a Japanese population that showed statin therapy reduces the risk of coronary heart disease (CHD), have now been published
14、 in the September 30, 2006 issue of the Lancet. MEGA, first presented by lead author Dr Haruo Nakamura (National Defense Medical College, Saitama, Japan) at the American Heart Association Scientific (AHA) Sessions 2005 in Dallas, TX, showed that the addition of pravastatin 10 mg to a low-fat diet ri
15、ch in omega-3 fatty acids reduces the risk of CHD in Japanese individuals with moderately elevated cholesterol levels by 33%, approximately the same reduction observed in US and European primary-prevention trials that have used larger statin doses.40Platelets are inflammatory cells 血小板实乃炎症细胞41EBM 研究
16、所得(Aspirin) Experience from EBM42抗血小板治疗的困惑 Certain puzzled problem on anti-platelet therapyn颅内出血胃肠道出血鼻腔出血胸膜腔出血皮 下出血（aspirin 75-100mg/d, clopidogril 75mg/d)n高龄尤多见; 远超1.8-2.1（CURE 研究）n可适当减量（包括首剂负荷量）43Aspirin resistance概念的争议n临床Aspirin resistance :减少事件/未能消除事件AA基因多态性/无效或不利结果n生化Aspirin resistance :出血时间延长/TXA2抑制合成/刺激血小板聚集0.4-83.0%Dalen JE,et al:Am J Med,2007,120:1-4Loordkipandize M,et al:Pharmaco Ther,2006,112:733-74344川芎嗪抗血小板作用 Anti-platelet
