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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 2008-05-23,2,老年冠心病临床特点 Clinical Features of Elderly CHD,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 试
2、验)(75岁CHD发病率:男18.6%,女6.1%)(PCI,出血并发症16.6%)治疗目的:缓解症状/改善功能/提高生活质量,3,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,4,Luminal 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
4、 CHD Treatment,5,Degree 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,?,6,急性心梗前的冠脉狭窄程度 Coronary Artery Stenosis pre-AMI,70%,% of Diameter Stenosis,% of the Patients,Bar graph shows severity of coronary artery stenosis before AMI (n=195, 4 studies)
5、68% patients had stenosis less than 50% at baseline 86% patients had stenosis less than 70% at baseline Falk et al. Circulation. 1995;92:657.,7,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 Stenosis,Levine GN, Keaney JF Jr, Vita JA. Cholesterol reduction in cardiovascu
6、lar disease: clinical benefits and possible mechanisms. N Engl J Med 1995;332:512-521. Philbin EF, Pearson TA. How does lipid-lowering therapy rapidly reduce ischemic events? J Myocard Ischemia 1994;6:13-18. Pitt B, Mancini GBJ, Ellis SG, Rosman HS, Park J-S, McGovern ME, for the PLAC I investigator
7、s. Pravastatin limitation of atherosclerosis in the coronary arteries (PLAC I): reduction in atherosclerosis progression and clinical events. J Am Coll Cardiol 1995;26:1133-1139,8,Coronary Artery Stenosis And Cardiac Events 冠脉狭窄与心脏事件,Plaque volume or severity of coronary artery stenosis may not be t
8、he key factor for inducing cardiac events.提示:冠脉狭窄并非心血管事件关键原因,9,Concept of Vulnerable Plaque 易损斑块概念的提出,In 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A vulnerable plaque often has a l
9、arge lipid pool, a thin cap, and macrophage-dense inflammation on or beneath its surface. 特征Vulnerable 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. C
10、ircadian variation and triggers of onset of acute cardiovascular disease. Circulation. 1989; 79:733743.,11,多方位策略演变 Many sided strategic changes,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； 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； 二级预防重点：也将由治疗冠脉狭窄转为易损斑块的干预。,12,CHD develops in 2030 years 冠心病慢性病程 Plaque rupture occur
11、s in 23 hrs 斑块破裂快过程,Dyslipidemia,Atherosclerosis,Plaque formation,CHD,ACS,Heart failure,LV dysfunction,心脏事件的发生 Progression of Cardiac Events,AMI,LV reconstruction,13,冠脉介入治疗的短处 Limitations of PCI,Although PCI could relieve severe stenosis of coronary artery, it wouldnt change the biologic course of A
12、S, thus the problem of “unstable” is still unresolved. 尚未能解决斑块不稳定问题,14,COURAGE临床试验,Boden WE, et al. Optimal Medical Therapy with or without PCI for Stable coronary Disease (NEJM.356:1503-1516;April 12,2007),15,COURAGE 研究设计 Study design of COURAGE trial,加PCI 组,不加PCI组,死亡率/ MACE/ACS,2287例稳定型心绞痛患者 ( 他汀类
13、, 抗血小板, ACEI/ARB, -受体阻滞剂),随机化,随访 2.5-7 Y,16,两组主要终点比较 The comparison of endpoints with two groups,平均随访4.6年所有原因死亡或非致死性心肌梗死数单纯优化药物治疗组:18.5%优化药物治疗+PCI组:19.0%P=0.62,17,随访心绞痛缓解率 Freedom from Angina During Long-Term Follow-up,The comparison between the PCI group and the medical-therapy group was significan
14、t at 1 year ( P0.001) and 3 years (P=0.02) but not at baseline or 5 years.,18,震撼全球心血管病学界 Grobal impact on cardiological field,慢性稳定性冠心病/临界狭窄病变者:现代药物治疗效果理想/病人依从性好COURAGE trial:医生应该有信心面对这些病人保护病人效果和利益的最大化在病人身上做有证据的治疗中西医结合应受理解和提倡,19,两组总生存率 Overall Survival,Number at Risk,Medical Therapy 1138 1073 1029 91
15、7 717 468 302 38 PCI 1149 1094 1051 929 733 488 312 44,Years,0,1,2,3,4,5,6,0.0,0.5,0.6,0.7,0.8,0.9,1.0,PCI + OMT,OMT,7,Hazard ratio: 0.87 95% CI (0.65-1.16) P = 0.38,20,稳定易损斑块的重要作用 Stabilization of Vulnerable Plaques,The vascular pathophysiological research has focused on stabilizing the vulnerable
16、plaque and inhibiting thrombosis after plaque rupture. The secondary prevention of CHD also focused on intervention of the vulnerable plaque in addition to treating luminal stenosis of coronary artery. 防治重点应是易损斑块+狭窄问题,Kullo IJ, Edwards WD, Schwartz RS. Vulnerable plaque: pathobiology and clinical implications. Ann Intern Med 1998; 129(12):1050-60. Ozer K, Cilingiroglu M. Vulnerable plaque: definition, detection, treatment, and future implications. Curr Atheroscler Rep. 2005; 7(2):121-6,
