不稳定型心绞痛和非ST段抬高心梗的治疗课件_2

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1、Acute Coronary Syndromes: Management of UA/NSTEMIAcute Coronary Syndromes: MaOverview of 2003 Updates to the ACC/AHA Guideline for UA/NSTEMIAssess likelihood of CADRisk stratificationTarget therapy: more aggressive treatment in higher-risk patientsAnti-ischemic, antithrombotic therapyInvasive vs con

2、servative strategyDischarge planning (risk factor modification and long-term medical therapy)ACC/AHA, American College of Cardiology/American Heart Association; UA, unstable angina; NSTEMI, nonST-segment elevation myocardial infarction.Braunwald E, et al. J Am Col. Cardiol. 2000;36:970-1062.Overview

3、 of 2003 Updates to thAcute Management of UA/NSTEMIAnti-Ischemic TherapyOxygen, bed rest, ECG monitoringNitroglycerin -BlockersACE inhibitorsUA, unstable angina; NSTEMI, non-ST-segment elevation myocardial infarction; ECG, electrocardiogram; ACE, angiotensin-converting enzyme.Braunwald E, et al. J A

4、m Coll Cardiol. 2000;36:970-1062. Antithrombotic TherapyAntiplatelet therapyAnticoagulant therapyAcute Management of UA/NSTEMIAPossible ACSAspirinAspirin+IV Heparin+IV Platelet GP IIb/IIIa AntagonistDefinite ACS With Invasive Strategy (Catheterization/PCI) or High Risk (IIa)* ClopidogrelAspirin+SQ L

5、MWH*orIV HeparinLikely/Definite ACSClopidogrel* Class IIa: enoxaparin preferred over UFH unless CABG planned within 24 hours. ACC, American College of Cardiology; AHA, American Heart association; ACS, acute coronary syndrome; PCI, percutaneous coronary intervention; SQLMWH, subcutaneous low molecula

6、r-weight heparin; IV, intravenous.Braunwald E, et al. J Am Coll Cardiol. 2000;36:970-1062.ACC/AHA Class I Recommendations for Antithrombotic Therapy*Possible ACSAspirinAspirinDef17.16.5*PlaceboASA05101520Patients (%)Unstable Angina 25.011.0*ASA01020303.31.9*ASA0123411.89.4*ASA051015Acute MIAspirin i

7、n Acute Coronary Syndromes*P.0001Death or MI*P=.003Reocclusion*P=.012MI*P.001DeathN=3973995134198587860085878600MI, myocardial infarction; ASA, acetylsalicylic acid; RISC, Research on InStability in Coronary artery disease.RISC Group. Lancet. 1990;336:827-830.Roux S, et al. J Am Coll Cardiol. 1992;1

8、9:671-677.ISIS-2. Lancet. 1988;2:349-360.PlaceboPlaceboPlacebo17.16.5*PlaceboASA05101520PatiAspirin in Acute Coronary Syndromes12.93.9*ASA05101511.93.3*ASA05101512.96.2*ASA0510152.21.3*ASA00.511.522.5UA/NSTEMIPrimary PreventionStable Angina*P.0001MI*P=.0003MI*P=.008Death or MI*P=.012Death or MIN= 11

9、03411037155178279276118121MI, myocardial infarction; ASA, acetylsalicylic acid; RISC, Research on InStability in Coronary artery disease; ISIS-2, Second International Study of Infarct Survival.PHS. N Engl J Med. 1989;321:129-35.Ridker PM, et al. AJC. 1991;114:835-839.Cairns JA, et al. N Engl J Med.

10、1985;313:1369-1375.Theroux P, et al. N Engl J Med. 1988;319:1105-1111.PlaceboPlaceboPlaceboPlaceboPatients (%)Aspirin in Acute Coronary SyndIndirect Comparisons of ASA Doses on Vascular Events in High-Risk Patients* Odds reduction. Treatment effect P.0001.ASA, acetylsalicylic acid.Adapted with permi

11、ssion from BMJ Publishing Group. Antithrombotic Trialists Collaboration. BMJ. 2002;324:71-86.0.51.01.52.0500-1500 mg34 19160-325 mg19 2675-150 mg12 32162 mg/d(n=2179)Primary end point16.418.6Death, MI, stroke6.26.1Death2.81.7MI2.02.1Stroke2.12.8Urgent hospital care9.510.6Urgent resuscitation7.310.0I

12、nternal bleeding2.43.3Any bleeding11.115.4Transfusion1.02.0BRAVO: Bleeding By ASA doseToClopidogrel+ ASA(N=6259)Placebo+ ASA*(N=6303)CURE: Major Bleeding at 1 year by ASA Dose 200 mg (N=4110)3.7%4.9% P value for trend.0001.0009* P=.0001.P=.0009.Adapted from Peters RJG, et al. Circulation. 2003;108:1

13、682-1687.ASA DoseClopidogrelPlaceboCURE: Major RR: Death/MIASA Alone 68/655=10.4%Heparin + ASA 55/698=7.9%BBBBBBB0.1110Summary Relative Risk0.67 (0.44-0.1.02)TherouxRISCCohen 1990ATACSHoldrightGurfinkelComparison of Heparin + ASA vs ASA AloneASA, acetylsalicylic acid; RISC, Research on InStability i

14、n Coronary artery disease; ATACS, Antithrombotic Therapy in Acute Company Syndromes; RR, relative risk; MI, myocardial infarction.Oler A, et al. JAMA. 1996;276:811-815. (with permission)RR: ASA Alone 68/655=10.4%HepaTIMI, Thrombosis in Myocardial Infarction; ESSENCE, Efficacy and Safety of Subcutane

15、ous Enozapam in NonQ-Wave Coronary Events; UHF, unfractionated heparin; ENOX, enoxaparin; MI, myocardial infarction; OR, odds ratio.Antman EM, et al. Circulation. 1999;100:1602-1608. (with permission)TIMI IIB/ESSENCE Metanalysis:Enoxaparin vs Unfractionated Heparin8.6 7.1 0.82 (0.69-0.97) 18 .026.5

16、5.2 0.79 (0.65-0.96) 21 .025.3 4.1 0.77(0.62-0.95) 23 .021.81.4 0.80 (0.55-1.16) 20 .24 0.512Day281443UFH(%)ENOX(%)OR(95 CI)Favors ENOXFavors UFHPORDeath or MI%TIMI, Thrombosis in Myocardial 0123456789081624324048566472Patients (%)Hours from Randomization7.3 %5.5 %RRR 24%P=.026UFH (n=1957)ENOX (n=19

17、53)UHF, unfractionated heparin; ENOX, enoxaparin; RRR, relative risk ratio.Antman EM. Circulation. 1999;100:1593-1601. (with permission)TIMI IIB: Early Phase Death/MI/Urgent Revasc0123456789081624324048566472Patients (%)Hours from Randomization7.3 %5.5 %RRR 24%P=.026UFH (n=1957)ENOX (n=1953) 0123456

18、789081624324048566472UFHEnoxaparinPP=.03=.03Major BleedsMajor Bleeds96 Hours96 HoursINTERACT: Enoxaparin vs Unfractionated Heparin With GP IIb/IIIa InhibitorsGoodman SG, et al. Circulation. 2003;107:238-244.Death/MIDeath/MI30 Days30 DaysPP=.031=.031UFHEnoxaparinPercentUFHEnoxaparinP=.03Major BleedsA

19、-Phase Study DesignUA/NSTEMIFinal A visit 30 days Randomize- 24 hours Chest pain Min 0 hourMax 120 hourTirofiban + ASA Hour 0Aggressive or conservativecare per local practice20261961ENOX1mg/kg q12 hrUFHWeight-adjustedZZ Treat & Evaluate for Z-Phase2018195239871 endpoint 7 daysBlazing M. presented at

20、 ACC 2003.A-Phase Study DesignUA/Final A0102030024681012UFHEnoxaparinUFHENOXDays From RandomizationEvent Rates (%)Day 78.4% (169 events)9.4% (184 events)7- and 30-Day Primary EndpointComposite Death, MI and Refractory IschemiaComposite Death, MI and Refractory IschemiaBlazing M. presented ACC 2003.0

21、102030024681012UFHEnoxaparinUEnox Test vs OutcomesMoliterno DJ, et al. JACC. 2003;42:1132-1139. (with permission)Death/MI/Urg TVRBleeding302520151050200 250 300 350 400 450 500 550 600200 250 300 350 400 450 500 550 600Probability of MACE (%)Probability of Any Bleeding (%)302520151050ENOX Time (sec)

22、ENOX Time (sec)Enox Test vs OutcomesMoliternoDirect Thrombin Inhibitor Trialists CollaborationDirect Thrombin Inhibitor Trialists Collaborative Group. Lancet. 2002;359:294-302. (with permission)11 RCTS36,000 PtsACS, PCI Death orMyocardialInfarctionDirect ThrombinInhibitorHeparin(N=18,736) (N=17,184)

23、OR(95% Cl)End of treatment7 days30 daysEnd of treatment7 days3 daysDeathMyocardialInfarctionEnd of treatment7 days30 daysEnd of treatment7 days30 daysStrokeMajor bleedingduring treatmentIntracranial bleeding during treatment815 (4.3%)883 (5.1%)947 (5.0%)990 (5.8%)1399 (7.4%)1409 (8.2%)355 (1.9%)346

24、(2.0%)422 (2.2%)395 (2.3%)685 (3.6%)642 (3.7%)522 (2.8%)596 (3.5%)601 (3.2%)672 (3.9%)876 (4.7%)917 (5.3%)62 (0.33%)60 (0.35%)72 (0.38%)70 (0.41%)120 (0.64%)110 (0.64%)360 (1.90%)403 (2.30%) 21 (0.11%)28 (0.16%)0.01.02.0Direct ThrombinInhibitorHeparin Better0.85(0.77-0.94%)0.88(0.80-0.96%)0.91(0.84-

25、0.99%)0.97(0.83-1.13%)1.00(0.87-1.16%)1.01(0.90-1.12%)0.80(0.71-0.90%)0.81(0.72-0.91%)0.87(0.79-0.95%)0.95(0.66-1.35%)0.94(0.68-1.31%)1.01(0.78-1.31%)0.75(0.65-0.87%) 0.72(0.42-1.23%)Direct Thrombin Inhibitor TriaEarly invasive strategy+/- GP IIb/IIIa Catheterization within 8 hours of last subcutane

26、ous doseUA/NSTEMIIdentified, LMWH- GP IIb/IIIa + GP IIb/IIIa Catheterization between 8-12 hours of last subcutaneous doseNo additionalUFH or LMWHAdditionalEnoxaparin0.3 mg/kg IV bolusSupplementwith UFH 50U/kg, aim forACT 200-250Supplementwith UFH 0.1 g/LCAPTUREPRISM14.810.27.59.105101520TnI 0.1 g/LP

27、0.1P.0014.919.65.25.80510152025HeparinTirofibanHeparinAbciximab + HeparinDeath or MI at 30 days (%)Benefit of IIb/IIIa inhibitorsGP IIb/IIIa Inhibition in TnI + Patients by Revascularization: PRISM StudyTnI, troponin I; PRISM, Platelet Receptor Inhibition for Ischemic Syndrome Management study; MI,

28、myocardial infarction. Heeschen C, et al. Lancet. 1999;354:1757-1762. (with permission)Death/MI at 30 Days0.37 (0.15-0.93)P =.020.30 (0.10-0.84)P =.0041612840051015202530Event rate (%)Follow-up (days)No revascularizationRevascularizationHeparinHeparinTirofiban TirofibanGP IIb/IIIa Inhibition in TnI

29、GP IIb/IIIa Inhibition in DiabeticsRoffi M, et al. Circulation. 2001;104:2767-2771. (with permission)30-Day Mortality in Diabetic Patients2163687362167741211576458PURSUITPRISMPRISM-PLUSGUSTO IVPARAGON APARAGON BPooled6.1%4.2%6.7%7.8%6.2%4.8%6.2%5.1%1.8%3.6%5.0%4.6%4.9%4.6%P=.33P=.07P=.17P=.022P=.51P

30、=.93P=.007TrialNOdds Ratio & 95% ClPlaceboIIb/IIIaBreslow-Day: P=.50IIb/IIIa BetterPlacebo BetterOR=0.7400.511.52GP IIb/IIIa Inhibition in DiabIntravenous GP IIb/IIIa Antagonists in ACS: Death or MI (at 30 Days) in PCI/CABG 5 Days Cohort and in Medical Treatment Cohort17.310.514.310.1024681012141618

31、20InterventionMedical TreatmentDeath or MIPlaceboIV GP IIb/IIIaP=.001P=NS(N=5847)(N=25,555)ACS, acute coronary syndrome; MI, myocardial infarction; PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft; NS, not significant.Boersma E, et al. Lancet. 2002;359:189-198.Interaction

32、P.02Intravenous GP IIb/IIIa AntagoGP Iib/IIIa Inhibitor NSTE ACS Trials Analysis Risk-Adjusted Mortality at 30 DaysPeterson ED, et al. J Am Coll Cardiol. 2003;42:45-53.Boersma E, et al. Lancet. 2002;359:189-198.0.52.01.0NRMI1Boersma20.83-1.010.910.79-0.970.8895% CIOdds RatioOdds Ratio for Mortality

33、at 30 DaysGP IIb/IIIa Inhibitor Favored (aspirin + heparin)Control Arm Favored (aspirin + heparin)GP Iib/IIIa Inhibitor NSTE ACSMortality by Hospitals Use of Early GP IIb/IIIa Inhibitors (N=1189 Hospitals)Hospital Use of Early GP IIb/IIIa inhibitors in NRMI (%)In-Hospital Mortality (%)3014121086420N

34、RMI, National Registry of Myocardial Infarction. Peterson ED, et al. J Am Coll Cardiol. 2003;42:45-53. (with permission)In-Hospital Mortality (%)Mortality by Hospitals Use ofEfficacy of Clopidogrel or Ticlopidine in Reducing Coronary Events After StentingCLASSICS, Clopidogrel Aspirin Stent Intervent

35、ion Coopoerative Study. Bhatt DL, et al. J Am Coll Cardiol. 2002;39:9-14. (with permission)30-Day Major Adverse Cardiac EventsOdds Ratio & 95% CITiclopidine BetterClopidogrel BetterTrialClopid. (%) Ticl. (%)NOverall13,9552.03.90.1110TOPPSCLASSICS101610202.61.33.50.9Lenox HillCCF256523692.45.73.88.9M

36、ller7003.11.7Wessex-3613.45.2N. Memorial13780.82.2S. Illinois8752.11.4Wash. Hosp.8442.00.5Mayo28270.61.6OR=.73, P=.003Efficacy of Clopidogrel or TicCURE, Clopidogrel in Unstable Angina to Prevent Recurrent Ischemic Events; MI, myocardial infarction; CV, cardiovascular; RRR, relative risk reduction.P

37、lavix package insert; 2002. Adapted with permission (2002) from the Massachusetts Medical Society.Yusuf S, et al. N Engl J Med. 2001;345:494-502.0.000.020.040.060.080.100.120.14Cumulative Hazard RateClopidogrel + Aspirin369Placebo + AspirinFollow-up (mo)P=.00009(N=12,562)01220%RRRCURE: Primary End P

38、oint MI/Stroke/CV DeathCURE, Clopidogrel in UnstableCURE: MI/Stroke/CV Death/Severe Ischemia Within 24 Hours of RandomizationCURE, Clopidogrel in Unstable Angina to Prevent Recurrent Ischemic Events; MI, myocardial infarction; CV, cardiovascular; RRR, relative risk reduction; RR, relative risk.Adapt

39、ed from Yusuf S, et al. Circulation. 2003;107:966-972.Hours After RandomizationCumulative Hazard Rates0.00.0050.0100.0150.0200.025024681012141618202224RR=0.67P=.003Placebo+ AspirinClopidogrel+ Aspirin33%RRRCURE: MI/Stroke/CV Death/SeverCURE, clopidogrel in Unstable Angina to Prevent Ischemic Events;

40、 TIMI, Thrombosis in Myocardial Infarction; CV, cardiovascular; MI, myocardial infarction; RRR, relative risk reduction; ARR, Absolute risk reduction.* In addition to other standard therapies.Budaj A, et al. Circulation. 2002;106:1622-1626. (with permission)Primary Composite End Point (CV Death, MI,

41、 Stroke)0510152025304.19.815.95.711.420.7Low (0-2)Intermediate (3-4)High (5-7)Patients (%)TIMI Risk Stratification29% RRRP.04ARR1.61.64.8 15% RRRP.0327% RRRP.004 Placebo + Aspirin* Clopidogrel + Aspirin* CURE: Benefit of Clopidogrel + Aspirin Across All TIMI Risk Score GroupsCURE, clopidogrel in Uns

42、tablePCI-CURE: Study DesignCLOPIDOGREL+ ASA*PCIPLACEBO + ASA*Open-label thienopyridinePretreatmentOpen-label thienopyridinePretreatmentN=2658 patients undergoing PCIN=1345N=1313CUREPCI-CURERMehta SR, et al. Lancet. 2001;358:527-533.30 days post-PCIEnd of follow-upup to 12 months after randomizationP

43、CI-CURE: Study DesignCLOPIDOGPCI CURE: Benefit of Pretreatment With Clopidogrel at 30 Days051015202530Follow-up (days)0.00.020.040.060.0830% RRRP=.03N=2658Cumulative Hazard RateMehta SR, et al. Lancet. 2001;358:527-533. (with permission)6.4%4.5%Clopidogrel+ ASAPlacebo + ASACardiovascular Death, MI,

44、or Urgent RevascularizationPCI CURE: Benefit of PretreatAdapted from Mehta SR, et al. Lancet. 2001;358:527-533. (with permission)CV Death or MI From Randomization to End of Follow-upPCI-CURE: Long-term Results0.150.100.050.00100200300400Follow-up (days)12.6%8.8%P=.002N=2658Clopidogrel+ AspirinPlaceb

45、o+ AspirinCumulative Hazard Rates31%Relative RiskReductionAdapted from Mehta SR, et al. Steinhubl S, et al. JAMA. 2002;288:2411-2420.Credo Study: Study Design Clopidogrel ArmPlacebo ArmPCI28 DaysPlacebo + aspirin (325 mg)Pretreatment3-24 h before PCIClopidogrel 300 mg+ aspirin (325 mg)Clopidogrel 75

46、 mg QD+ aspirin 325 mg QDClopidogrel 75 mg QD+ aspirin 325 mg QD12 MonthsPlacebo QD+ aspirin (81-325 mg) QDClopidogrel 75 mg QD+ aspirin (81-325 mg) QDRObjective: To assess the benefit of 1 year vs 1 month of clopidogrel plus aspirin in patients undergoing PCISteinhubl S, et al. JAMA. 2002Effect of

47、Timing of Loading Dose:28-Day EndpointDeath, MI, UTVR0.40.60.81.01.2Hazard ratio (95% CI)3 to 6 hrs7.97.0893 6 to 24 hr5.89.4 851 RRR -13.4P=NSRRR 38.6P=.05RRR 18.5P=.23Overall CREDO ResultsN PT-Clopidogrel*No-PT*Events (%)No-PTBetterPT-ClopidogrelBetterPT, pretreatment; UTVR, urgent target vessel r

48、evascularization.* Plus ASA and other standard therapies.Steinhubl S, et al. JAMA. 2002;288:2411-2420.Effect of Timing of Loading DoCREDO: Benefits of Clopidogrel Plus Aspirin to 1 Year Following PCI CV Death, MI or Stroke* Plus ASA and other standard therapies .Steinhubl S, et al. JAMA. 2002;288:24

49、11-2420. (with permission)Combined Endpoint Occurrence (%)Months From Randomization27% RRRP=.02Placebo*Clopidogrel*0510158.5%11.5%036912CREDO: Benefits of ClopidogrelCURE: Bleeding ResultsCURE, Clopidogrel in Unstable Angina to Prevent Ischemic Events; * Other standard therapies were used as appropr

50、iate.Life-threatening and other major bleeding .Plavix package insert 2003.Event Clopidogrel + Aspirin* (n=6259)(%) Placebo + Aspirin* (n=6303)(%)P ValueMajor bleeding3.7 2.7.001Life-threateningbleeding 2.21.8.13Minor bleeding5.12.4.001CURE: Bleeding ResultsEvent ClPlacebo + ASA (%)Clopidogrel + ASA

51、 (%)From PCI to 30 daysMajor1.41.6Life threatening0.70.7 Minor0.70.9 From PCI to end of follow-upMajor2.52.7 Life threatening1.31.2 Minor2.13.5P=NS, P=0.03Adapted from Mehta SR, et al. Lancet. 2001;358:527-533.PCI-CURE: Bleeding OutcomesPlacebo + ASA (%)Clopidogrel Major/Life-Threatening Bleeds With

52、in 7 Days of CABG SurgeryPlaceboClopidRRPStopped 5 days prior to CABGN=454N=456Pts with Maj/LT Bld TIMI Major5.3%2.4%4.4%1.8%0.830.72.53NSCURE investigators. N Engl J Med. 2001; Fox KM. Presented at ESC 2002.Major/Life-Threatening Bleeds CURE: Outcomes by CABG in Initial Hospitalization (CV death/MI

53、/StrokePlaceboClopidogrelN (%)N (%)RRCICABG During Initial Hospitalization: No. of Patients528485 CV death/MI/stroke16.713.20.780.57-1.08No CABG: No. of Patients57755774 CV death/MI/stroke11.08.90.800.71-0.89CURE investigators. N Engl J Med. 2001; Fox KM. Presented at ESC 2002.CURE: Outcomes by CABG

54、 in IniEarly Clopidogrel Timing in ACSPCI-CURE and CREDO: Need to start clopidogrel early (6 h) to get post-PCI benefit50%-60% of patients get PCI, 8%-20% get CABG (half of whom are 5 d postcatheterization anyway)Tradeoff per 1000 UA/NSTEMI patient Rx:Early Rx prevents additional 10 major cardiac ev

55、ents vs creating 1.5 TIMI minor bleed post-CABGACS, acute coronary syndrome; PCI, percutaneous coronary intervention; CURE, Clopidogrel in Unstable Angina to Prevent Recurrent Events; CREDO, Clopidogrel for Reduction of Events During Observation; CABG, coronary artery bypass graft; UA, unstable angi

56、na; NSTEMI, nonST-segment myocardial infarction; TIMI Thrombosis in Myocardial Infarction.Boersma E, et al. Lancet. 2002;359:189-198.Early Clopidogrel Timing in ACPRONTO Study: Effect of Co-Administration of Various Statins With ClopidogrelPRONTO Study100 Patients Undergoing Elective StentingBaselin

57、eDay 2Day 5Atorvastatin (n=9)60.8 10.440.4 8.638.1 8.0Any statin (n=26)58.7 10.736.0 9.137.3 7.3No statin (n=74)59.4 11.538.7 10.535.8 7.7Induced Platelet Aggregation% SD(5 M ADP induced Platelet Aggregation)PRONTO, Plavix Reduction Of New Thrombus Occurrence.Gurbel PA, et al. Am Heart J. 2003;145:2

58、39-247.PRONTO Study: Effect of Co-AdmNo Interaction of Clopidogrel and AtorvastatinSaw P, et al. Circulation. 2003;108:921-924. (with permission)Clopidogrel (%)Control (%)181614121084201-Year Death/MI/Stroke Event Rate (%)All patients(n=2116)No statin(n=944)Any statin (n=1172)CYP3A4-MET statin (n=10

59、01)Atorvastatinstatin (n=564)Prevastatin (n=142)Non-CYP3A4-MET statin (n=158)RRR 26.9%P=.02RRR 12.4%P=.51RRR 38.6%P=.01RRR 36.4%P=.03RRR 60.6%P=.11RRR 49.8%P=.02RRR 63.3%P=.13No Interaction of Clopidogrel 2159 low-risk patients undergoing elective stenting, excluding patients with:Abciximab(n=1079)P

60、lacebo(n=1080)Endpoints:Primary: 30 day death/MI/urgent target vessel revascularizationSecondary: 30-day bleeding complicationsISAR-REACT TrialACC 2003, Late Breaking Trials. Acute coronary syndromeAcute coronary syndrome Acute MI with 14 daysAcute MI with 14 days ST-segment depressionST-segment dep

61、ression Positive biomarkersPositive biomarkers Insulin-dependent diabetesInsulin-dependent diabetes Chronic total occlusionsChronic total occlusions EF EF 30%30% Thrombus presenceThrombus presence Lesions in bypass graftsLesions in bypass graftsClopidogrel(600-mg loading dose, 2 x 75 mg/d through di

62、scharge, 75 mg/d for 4 weeks)2159 low-risk patients undergoISAR-REACT: 30 Day Endpoints4.04.20246Death/MI/Urgent TVR (%) P=.82AbciximabPlaceboACC 2003, Late Breaking Trials.Death (%)P=NS0.30.30246AbciximabPlaceboUrgent TVR (%)P=NS0.90.70246AbciximabPlaceboISAR-REACT: 30 Day Endpoints4.CRP, C-reactiv

63、e protein; MI, myocardial infarction; PCI, percutaneous coronary intervention; RRR, relative risk ratio. Chew DP, et al. Am J Cardiol. 2001;88:672-674.Death or MI by Day 30 in Patients Undergoing PCI With Stenting58% RRRP=.0020510152025Total Population011 mg/L13(n=295)10(n=565)24(n=74)10.2(n=136)Per

64、centThienopyridinepretreatmentNo ThienopyridinepretreatmentClopidogrel Therapy May Reduce the Risk Associated With Elevated Baseline CRP StatusCRP, C-reactive protein; MI, m30-Day Death or MI in Patients Undergoing PCI with StentingAdapted from Chew DP, et al. Am J Cardiol. 2001;88:672-674.Clopidogr

65、el Therapy Attenuates the Risk Associated With Baseline CRP Status7.97.724.012.35.711.812.510.205101520251st Quartile 2nd Quartile 3rd Quartile4th Quartilen=216n=218n=22758% RRRP=.002n=216 Clopidogrel pretreatmentNo pretreatmentCRP Quartiles (mg/dl)Patients (%)30-Day Death or MI in PatientsInvasive

66、vs Conservative Strategy for UA/NSTEMIUA, unstable angina, NSTEMI, nonST-segment myocardial infarction; ISAR, Intracoronary Stenting and Antithrombic Regimen Trial; RITA, Randomized Intervention Treatment of Angina; VANQWISH, Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital study; MATE,

67、 Medicine vs Angioplasty for Thrombolytic Exclusions trial; TACTICS-TIMI18, Treat Angina with Aggrestat and Determine Cost of Therpay with Invasive or Conservative Strategy; FRISC, Fragmin during InStability in Coronary artery disease.TIMI IIIB2003ConservativeInvasiveVANQWISHMATEFRISC IITACTICS-TIMI

68、 18VINORITA-3No. of Patients: 92016747018 TRUCS ISAR-COOL Invasive vs Conservative StratTnT, troponin T; ST, ST segment.Morrow DA. JAMA. 2001;286:2405-2412; Cannon CP. N Engl J Med. 2001;344:1879-1887.Benefit of Invasive Strategy by Troponin and ST ChangesDeath, MI, Rehosp ACS at 6 Months12.425.0*16

69、.015.3*051015202530TnT -TnT + CV Events (%)P=NS15.124.5*16.616.4*051015202530No ST changeST changeP=NSP.001P.001Conservative InvasiveTnT, troponin T; ST, ST segmen2000 ACC/AHA UA/NSTEMI Guidelines:Early Invasive StrategyClass IAny of the high-risk indicators (Level of Evidence: A) a) Recurrent angin

70、a at rest/low-level activity despite Rx b) Elevated TnT or TnI c) New ST-segment depression d) Rec. angina/ischemia with CHF symptoms, rales, MR e) Positive stress test f) EF 0.40 g) BP h) Sustained VT i) PCI 6 mos, prior CABGBraunwald E, et al. J Am Col Cardiol. 2000;36:970-1062.2000 ACC/AHA UA/NST

71、EMI Guideli$13,2660.079$10,1750.103$1048Troponin T 0.01$39820.217$38060.227$864ST changes$13,0220.045$12,7390.046$586Overall populationCE Ratio $ per life-year gained Life-years(I-C)CE Ratio $ per life-year gained Life-years(I-C) Costs(I-C)FraminghamPURSUITAdapted from Mahoney EM, et al. JAMA. 2002;

72、288:1851-1858.Long-Term Cost-Effectiveness AnalysisLong-Term Cost-Effectiveness Analysis$13,2660.079$10,1750.103$1048TSIRIUS: Drug Eluting StentsMoses, et al. N Engl J Med. 2003;349:1315-1323. (with permission)Actuarial Rate of Survival Free from Target-Vessel FailureAmong Patients Who Received Eith

73、er a Sirolimus-Eluting Stent or a Standard StentThe rate of event-free survival was significantly higher in the sirolimus-stent group than in the standard-stent group (P.001 by the Wilcoxon and log-rank tests).Event-free Survival (%)Days After Initial ProcedureNo. at RiskSirolimus StentStandard Sten

74、tSirolimus-stent groupStandard-stent group91.1%10090800030609012015018021024027053352952752452051550950549347752552352151450648147446545143678.6%SIRIUS: Drug Eluting StentsMos0123456Time (months)048121620% PatientsCONSINVO.R 0.7895% CI (0.62, 0.97)P=.02519.4%15.9%TACTICS Primary EndpointDeath, MI, Rehosp for ACS at 6 MonthsCannon CP. N Engl J Med. 2001;344:1879-1887. (with permission)0123456Time (months)048121620%