ACS是否應該早期介入治療

IsearlyinvasivetheanswerforACSDr.BenHeMD/PhD/FSCAI/FAPSICDirectorofCardiologyDepartmentRenjiHospitalAffiliatedtoShanghaiJiaotonguniversityPathophysiologyofAcuteCoronarySyndromeACSisanImportantManifestationofAtherothrombosis11.CannonCP.JThrombThrombolysis1995;2:205–218.AntithrombotictherapyStableanginaUANon-

Q-waveMIThrombolysisprimaryPCIQ-waveMIMinutes–

hoursDays–weeksSTEMIUA/NSTEMIAtherothrombosisNewtermOldtermPlaque

ruptureRelationofTIMIriskscoreandMACErateHottopicinACSIsearlyinvasivesuperiortoconservativestrategyinACS?Shouldinvasivebedeferredforcoolingoff?

Whatistheoptimaltimeforinvasive?OptimalStrategyforUA/NSTEMITIMIIIIB2005ConservativeInvasiveVANQWISHFRISCIITACTICS-

TIMI18RITA-3FRICS-II:highriskgetmoreTIMI-18:highriskgetmoreRITA-3:1&3yrsoutcomeRITA-3:5yrsoutcomeIn2005,ItseemswefoundanswerInACS,earlyinvasivesuperiortoearlyconservativeThisisparticulartrueinhighriskpatientsESCGuideline2005Istheproblemsettled?ICTUSDesigned4yrsICTUSLancet2007;369:827-835However,mostofselectiveptswereperformedPCISo,thelong-termf/uresultsdonotinflectInv/Consstrategy4yrsICTUSLancet2007;369:827-835ICTUS’scriticism

LibertydefinitionofMI(only1*ULN)causingtheearlyMIincreaseinearlyinvasivegroup3yrsrevascularizationratewasequalin2group(81%PCI)1yearmortalityrateinACSinbotharmareverylow(2.5%),Isitarealhighrisk?EvenputICTUSintopool,Inv>ConsInvvsCons/AllcausedeathHighrisk?2007ESCGuidelineUrgentCoronaryangiographyisrecommendedinPtswithrefractoryorrecurrentanginaassociatedwithdynamicSTdeviation,heartfailure,lifethreateningarrhythmias,orhaemodynamicinstability(I-C)Early(<72h)angiographyfollowedbyrevascularization(PCIorCABG)inpatientswithintermediatetohighriskfeaturesisrecommended(I-A)MonocyteLDL-CAdhesion

moleculeMacrophageFoamcellOxidized

LDL-CPlaqueruptureSmoothmuscle

cellsCRP2ISAR-COOLTrialISAR-COOLAntithromboticRegimenISAR-COOLWhatistheoptimaltimeforPCI?MethodsforOptimaltrialResultsofOptimaltrialConclusionfromOptimaltrialWhat’sthedifferencebetweenISAR-Cool&Optimal?2.5vs84+0.5vs25-TimetoCoronaryAngiographyandOutcomesAmongPatientsWithHigh-RiskNon–ST-Segment–ElevationAcuteCoronarySyndromes:ResultsFromtheSYNERGYTrial

PierluigiTricoci,MD,MHS,PhD;YuliyaLokhnygina,PhD;LisaG.Berdan,PA-C,MHS;StevenR.Steinhubl,MD;DietrichC.Gulba,MD;HarveyD.White,MD;NealS.Kleiman,MD;PhilipE.Aylward,MD;AnatolyLanger,MD;RobertM.Califf,MD;JamesJ.Ferguson,MD;ElliottM.Antman,MD;L.KristinNewby,MD,MHS;RobertA.Harrington,MD;ShaunG.Goodman,MD;KennethW.Mahaffey,MDDivisionofCardiology,DukeClinicalResearchInstitute,Durham,NCBackground2007ACC/AHAGuidelinesforNSTEACSrecommendtheuseofanearlyinvasivestrategyforhigh-riskpatientsRandomizedclinicaltrialsonearlyvs.conservativestrategyuseddifferenttimingofcardiaccatheterizationOptimaltimingofcardiaccatheterizationinNSTEACSnotyetestablished(expeditedvs.deferred)ExpeditedcatheterizationincreasinglyadoptedintheUSStudyObjectiveToevaluatetheassociationbetweentimefromhospitaladmissiontocardiaccatheterizationandadverseoutcomesamonghigh-riskpatientswithNSTEACStreatedwithanearlyinvasivestrategy(cardiaccatheterization<48hofhospitaladmission)StudyPopulationPatientsrandomizedintheSYNERGYtrial

Ischemicsymptoms<24handatleast2of3high-riskfeatures

Age>60yearsST-segmentdepressionortransientelevationPositivetroponinand/orCK-MBUseofcoronaryangiographyinSYNERGY10,027ptsrandomizedintheSYNERGYtrial9,188ptsunderwentcardiaccatheterization6,352ptsunderwentcardiaccatheterization<48hAdjustedEstimatesof30-dayDeath/MIRates(with95%CI).0.0LandmarkAnalysis:AdjustedORof30-dayDeath/MI(with95%CI)AdjustedEstimatesofIn-hospitalTransfusionRates

(with95%CI)StudyLimitationsNon-randomizedobservationalanalysisPropensity-basedmodelsusedtodealwithlackofrandomizationTimetocathisapost-baselineand“dynamic〞variableStatisticalmethodologiesattemptedtoaddresstheseissuesEventsfromhospitaladmissiontorandomizationnotavailableEventsunlikelypriortorandomizationMyocardialinfarctioninthefirsthoursfollowingthehospitalizationismoredifficulttoadjudicateConclusionsfromSynergy-1Observationalanalysisamonghigh-riskNSTEACSpatientsenrolledintheSYNERGYtrialtreatedwithanearlyinvasivestrategyReducedtimetocardiaccatheterizationwasassociatedwithdecreasedprobabilityof30-daydeath/MIandnochangesinbleedingNosignalssuggestingbenefitsofdelayingthecardiaccatheterizationwereobservedConclusionsfromSynergy-2RandomizedclinicaltrialstoestablishoptimaltimingofcatheterizationinNSTEACSareneededbutchallengingDelayingcathisproblematicforhospitaladoptingexpeditedcathstrategyLagfromhospitalizationtorandomizationmayconfoundactualtimetocatheterizationintervalsEarlyre-MIadjudicationcomplexWell-designedobservationalstudiesmaybeofvalueinthedebateonoptimaltimingofcardiaccatheterizationamongNSTEACSpatientsConclusion&ProspectiveACS,earlyinvasiveissuperiortoearlyconservativeinmostPtsespeciallyhighriskImmediateinvasivestrategy