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1、2013 ESC 冠心病热点聚焦冠心病热点聚焦华中科技大学同济医院心内科华中科技大学同济医院心内科华中科技大学同济医院心内科华中科技大学同济医院心内科国家教育部国家教育部国家教育部国家教育部&卫计部重点学科卫计部重点学科卫计部重点学科卫计部重点学科郭郭郭郭 小小小小 梅梅梅梅 最新最新ESC,AHAESC,AHA指南引入指南引入FMC-DeviceFMC-Device概念概念2012 ESC STEMI guideline2012 ESC STEMI guidelineFMC(First Medical Contact)FMC(First Medical Contact)2013 ACCF/A
2、HA STEMI2013 ACCF/AHA STEMI2013 ACCF/AHA STEMI2013 ACCF/AHA STEMI患者治疗策略选择患者治疗策略选择患者治疗策略选择患者治疗策略选择 新指南新指南新指南新指南3 3 3 3个要点内容个要点内容个要点内容个要点内容uu90909090分钟内急诊分钟内急诊分钟内急诊分钟内急诊PCIPCIPCIPCIuu2 2 2 2小时内转诊小时内转诊小时内转诊小时内转诊PCIPCIPCIPCIuu2 2 2 2小时以上溶栓后转诊小时以上溶栓后转诊小时以上溶栓后转诊小时以上溶栓后转诊PCIPCIPCIPCI30 30 天复合终点荟萃分析：死亡率、再发心
3、梗、心肌缺血天复合终点荟萃分析：死亡率、再发心梗、心肌缺血天复合终点荟萃分析：死亡率、再发心梗、心肌缺血天复合终点荟萃分析：死亡率、再发心梗、心肌缺血DSouza S P et al.Eur Heart J 2011;32:972-982DSouza S P et al.Eur Heart J 2011;32:972-982 Impact of immediate multivessel intervention on outcome of patients with multivessel disease undergoing primary PCI for STEMI without ca
4、rdiogenic shock(Results of the prospective ALKK PCI registry)Results I AnalysisResults I AnalysisPresent data from 2008-2011,immediate multivessel PCI vs culprit lesion PCIPresent data from 2008-2011,immediate multivessel PCI vs culprit lesion PCIAlmost 6000 consecutive patients with STEMI and multi
5、vessel disease includedAlmost 6000 consecutive patients with STEMI and multivessel disease includedImpact of multivessel PCI in STEMIImpact of multivessel PCI in STEMI Results II Treated coronary arteries(%)Results II Treated coronary arteries(%)p0,01p0,01p0,01p0,01p0,01p0,01Impact of multivessel PC
6、I in STEMIResults III Minimal TIMI Flow before and after PCIResults III Minimal TIMI Flow before and after PCI Impact of multivessel PCI in STEMI Results IV Intrahospital events Results IV Intrahospital eventsp0,01p0,01Results V Multivariate analysis on predictors ofResults V Multivariate analysis o
7、n predictors of intrahospital mortality in STEMI patients intrahospital mortality in STEMI patients Impact of multivessel PCI in STEMISummarySummaryImmediate multivessel PCI for STEMI without Immediate multivessel PCI for STEMI without cardiogenic shock is used in a minority of patients(10%)cardioge
8、nic shock is used in a minority of patients(10%)There are no differences in procedural success rates(TIMI 3 There are no differences in procedural success rates(TIMI 3 flow;90,0%vs 90,9%)flow;90,0%vs 90,9%)MV PCI needs significantly more contrast agent(220 vs MV PCI needs significantly more contrast
9、 agent(220 vs 170ml)and fluoroscopy time(12,2 vs 7,8min)170ml)and fluoroscopy time(12,2 vs 7,8min)MV PCI is associated with higher intrahospital mortality as culprit MV PCI is associated with higher intrahospital mortality as culprit lesion PCI(8,5 vs 4,6%)lesion PCI(8,5 vs 4,6%)Impact of multivesse
10、l PCI in STEMI Should We Perform an Immediate Coronary Angiogram in All Survivors of Out-of Hospital Cardiac Arrest With No Obvious Extra-Cardiac Cause?Insights from the PROCAT registryJanuary 2003-December 20086766 cases of OHCACPR attemptedCPR attempted34943494CPR not attemptedCPR not attempted327
11、23272Stable hemodynamic stateStable hemodynamic state11981198Fatal arrest during transportationFatal arrest during transportation484484Successfully transported to hospitalSuccessfully transported to hospital714714714 OHCA successfully transported tothe hospital Obvious non cardiac cause of Obvious n
12、on cardiac cause ofarrestarrest279279Respiratory failure 131Respiratory failure 131Brain injury 17Brain injury 17Metabolic disorders 15Metabolic disorders 15Hemorrhage 10Hemorrhage 10Miscellaneous 103Miscellaneous 103No obvious non cardiacNo obvious non cardiaccause of arrestcause of arrest435435Imm
13、ediate coronary angiogram atImmediate coronary angiogram atadmissionadmissionST segment elevationST segment elevation134(31%)134(31%)Other ECG patternsOther ECG patterns301(69%)301(69%)In-hospital survival rates174/435:39%174/435:39%CPC levels CPC levels 1/2:1/2:160/174:92%160/174:92%Multivariable l
14、ogistic regression analysisMultivariable logistic regression analysisof predictors of survivalof predictors of survivalLong term prognosisAngioplasty(PCI)and hypothermia(HT)Angioplasty(PCI)and hypothermia(HT)Dumas F,Dumas F,et alet al.J Am Coll Cardiol.2012.J Am Coll Cardiol.2012PCI+HT+PCI+HT+PCI+HT
15、 PCI+HT PCI-HT+PCI-HT+PCI HT-PCI HT-Years2013 ESC 2013 ESC 稳定性冠状动脉疾病稳定性冠状动脉疾病管理指南管理指南“更新要点更新要点”稳定性冠状动脉疾病（稳定性冠状动脉疾病（SCAD）的定义）的定义2006200620062006年指南年指南年指南年指南稳定性稳定性心绞痛心绞痛，仅包括冠脉仅包括冠脉粥样硬化性狭窄粥样硬化性狭窄2013201320132013年指南年指南年指南年指南稳定性稳定性冠状动脉疾病冠状动脉疾病，包括，包括，冠脉粥样硬化性狭窄冠脉粥样硬化性狭窄 微血管功能失调微血管功能失调 冠脉痉挛冠脉痉挛SCAD的主要临床表现的主
16、要临床表现劳力型心绞痛心外膜血管狭窄微血管功能失调动态狭窄处的血管收缩以上因素的混合静息性心绞痛血管痉挛（局灶性或弥漫性）心外膜血管局灶性心外膜血管弥漫性微血管以上因素的混合无症状无缺血和/或无左室功能不全无症状的缺血和/或左室功能不全缺血性心肌病European Heart Journal Advance Access published,2013European Heart Journal Advance Access published,2013SCAD的诊断流程的诊断流程European Heart Journal Advance Access published,2013Europe
17、an Heart Journal Advance Access published,2013验前概率（验前概率（PTP）疾病的临床可能性如果选择错误检查多于正确检查，这可能对患者有害。采用无创性影像学检查来诊断CAD，典型的敏感性和特异性约85%，所有诊断结果中有15%会出错在PTP低于15%、高于85%的患者中，不做任何检查时极少会有错误的诊断，检查只为了有可信的理据European Heart Journal Advance Access published,2013European Heart Journal Advance Access published,2013患者的患者的PTP典
18、型心绞痛典型心绞痛不典型心绞痛不典型心绞痛无心绞痛症状无心绞痛症状年龄年龄男性女性男性女性男性女性30-395928291018540-496937381425850-5977474920341260-6984585928441770-7989686937542480937678476532Genders TS,Steyerberg EW,Alkadhi H.Eur Heart J 2011;32:13161330Genders TS,Steyerberg EW,Alkadhi H.Eur Heart J 2011;32:13161330PTP15%PTP85%PTP85%在在PTP基础上形成
19、了基础上形成了SCAD的的3步决策流程步决策流程一旦确诊一旦确诊SCAD，即开始最优化药物治疗，即开始最优化药物治疗确定疾病的临床可能性确定疾病的临床可能性NothingNothing15%22需要加药或换药需要加药或换药二线药物二线药物依伐布雷定依伐布雷定长效硝酸酯类长效硝酸酯类尼可地尔尼可地尔雷诺嗪雷诺嗪曲美他嗪曲美他嗪干预生活方式干预生活方式控制危险因素控制危险因素健康宣教健康宣教阿司匹林阿司匹林他汀类他汀类ACEIACEI或或ARBARB和：考虑血运重建和：考虑血运重建（PCIPCI或或CABGCABG）BBBB -受体阻滞剂受体阻滞剂CCB CCB 钙离子拮抗剂钙离子拮抗剂DHP D
20、HP 二氢吡啶二氢吡啶ACEIACEI 血管紧张素转化酶抑制剂血管紧张素转化酶抑制剂ARBARB血管紧张素血管紧张素IIII受体拮抗剂受体拮抗剂PCIPCI 经皮冠状动脉介入治疗经皮冠状动脉介入治疗CABG CABG 冠状动脉旁路移植术冠状动脉旁路移植术血运重建：指南重新讨论了血运重建在低危患者中的治疗价血运重建：指南重新讨论了血运重建在低危患者中的治疗价值，并制定了血运重建的决策流程值，并制定了血运重建的决策流程根据症状根据症状/缺血的严重程度制定决策缺血的严重程度制定决策The Task Force on the management of stable coronary artery d
21、isease of the European Society of Cardiology.The Task Force on the management of stable coronary artery disease of the European Society of Cardiology.Eur Heart J.2013 Aug 30Eur Heart J.2013 Aug 30新指南新指南强调导管室的重要性管室的重要性有创血管造影有创血管造影(ICA)(ICA)评估冠脉评估冠脉血流储备分数血流储备分数(FFR)(FFR)血管内超声血管内超声光学相干层析成像光学相干层析成像指导是否进
22、行指导是否进行PCIPCI，有，有狭窄且狭窄且FFR FFR 0.80.8，药，药物治疗比介入血运重建物治疗比介入血运重建更好。更好。与在导管室氯吡格雷运用的管理相比，在稳定的患者择期与在导管室氯吡格雷运用的管理相比，在稳定的患者择期PCIPCI予以氯吡予以氯吡格雷预处理未能降低死亡率或主要不良心脏事件（格雷预处理未能降低死亡率或主要不良心脏事件（MACEMACE）。）。与进行与进行PCIPCI患者相比，进行导管又无需植入支架的患者接受常规双重抗患者相比，进行导管又无需植入支架的患者接受常规双重抗血小板治疗的出血风险与缺血性事件上获益并不一致。血小板治疗的出血风险与缺血性事件上获益并不一致。European Heart Journal Advance Access published,2013European Heart Journal Advance Access published,2013总结：新指南的更新要点总结：新指南的更新要点对SCAD的定义除了包括粥样斑块引起的冠脉狭窄，还包括微血管功能异常和冠脉痉挛区别诊断性检查和预后评价强调验前概率对诊断的重要性关注治疗策略及其对患者预后的影响其他包括更新诊疗技术的进展，强调在导管室中对CAD生理学评价的重要性，及指出血管重建对预后的益处少于预期