急性冠脉综合征评估及危险分层.ppt

Acute Coronary Syndromes Evaluation and Risk Stratification New Terminology in ACS ACS,acute coronary syndrome;MI,myocardial infarction;UA,unstable angina;NSTEMI,nonST-segment elevation myocardial infarction;STEMI,ST-segment elevation myocardial infarction;PCI,percutaneous coronary intervention.Cannon CP.J Thromb Thrombolysis.1995;2:205-218.Antithrombotic Therapy Stable Angina Unstable Angina Non Q-wave MI Thrombolysis Primary PCI Q-wave MI Minutes-hours Days-weeks STEMI UA/NSTEMI Atherothrombosis New term Old term Plaque Rupture Troponin I(TnI),C-Reactive Protein (CRP),and B-type Natriuretic Peptide(BNP)as Determinants of 30-Day Mortality Risks in Acute Coronary Ischemia:A Multimarker Approach OPUS-TIMI 1611.83.5601234560123No.of Elevated Biomarkers30-Day Mortality Relative Risk TACTICS-TIMI 1812.15.713024681012140123No.of Elevated BiomarkersP=.014 P50%)Aspirin in last 7 days 2 anginal events in 24 hours ST deviation Elevated cardiac markers (CK-MB or troponin)TIMI Risk Score For UA/NSTEMI Antman EM,et al.JAMA.2000;284:835-442.(with permission)Age 65 years 3CAD Risk Factors Prior Stenosis 50%ST deviation 2 Anginal events 24 hours ASA in last 7 days Elev Cardiac Markers(CK-MB or troponin)4.7 8.3 13.2 19.9 26.2 40.9 0 10 20 30 40 50 0/1 2 3 4 5 6/7 D/MI/Urg Revasc(%)Number of Risk Factors Population(%):4.3 17.3 32.0 29.3 13.0 3.4 C Statistic=0.65 c c2 trend P.001 4.13.97.119.56.54.910.835.121.010.749.624.4P.001 P=.004 P.001 P.001 Scirica BM,et al.Am J Cardiol.2002;90:303-305.(with permission)TIMI Risk Score vs Prognosis in Unselected Patients(TIMI 3 Registry)TRS 0-2 TRS 3-4 TRS 5-7 0%10%20%30%40%50%Death MI Death/MI Death/MI/RI Event Rate at 1 year(%)Prognostic Value of Troponin T or I in ACS:A Meta-analysis 1.96.76.420.80510152025DeathDeath/MI%RR 3.9(2.9-5.3)RR 3.8(2.6-5.5)No.Studies:13 6 Neg Pos(Trop I+T)3634 1849 737 322 Heidenreich PA,J Am Coll Cardiol.2001;38:478-485.TIMI IIIB:Troponin I Levels Predict Mortality In UA/NSTEMI 1.0 1.7 3.4 3.7 6.0 7.5 0 2 4 6 8 0 to 0.4 0.4 to 1.0 1.0 to 2.0 2.0 to 5.0 5.0 to 9.0 831 174 148 134 67 50 Risk Cardiac Troponin I(ng/ml)Ratio 1.0 1.8 3.5 3.9 6.2 7.8 Mortality at 42 Days(%of Patients)Antman EA,et al.N Engl J Med.1996;335:1342-1349.(with permission)Lindahl B,et al.N Engl J Med.2000;343:1139-1147.(with permission)Predictive Value of Troponin T and hs-CRP for Mortality from ACS in FRISC Substudy 20 10 0 0 6 12 18 24 30 36 42 48 Cumulative Probability of Death(%)Months Troponin T 0.60 g/l(n=377)Troponin T 0.60-0.59 g/l(n=367)Troponin T 10mg/l(n=309)CRP 2mg/l(n=314)P=.001 P=.29 CRP Troponin Months Risk Stratification With CRP and Troponin T Chi Square:P=.0007 9.1%4.7%0.4%0 1 2 3 4 5 6 7 8 9 10 RcTnT Neg AND CRP 1.55 RcTnT(early+)AND CRP 1.55 14-Day Mortality(%)N=277 N=129 N=22 Morrow DA,et al.J Am Coll Cardiol.1998;31:1460-1465.WBC Count(x103)30-Day Mortality 0 5 10 15 20 0 5%10%15%20%White Blood Cell Count vs Mortality Cannon CP,et al.Am J Cardiol.2001;87:636-639.(with permission)B-type Natriuretic Peptide(BNP)and Mortality in ACS Patients de Lemos JA,et al.N Engl J Med.2001;345:1014-1021.(with permission)0 2 4 6 8 10 Mortality(%)0 50 100 150 200 250 300 Days After Randomization P.001 Quartile 4(n=630)Quartile 3(n=632)Quartile 2(n=632)Quartile 1(n=631)05101520Mortality at 10 mo(%)Q1Q2Q3Q4 ST MI Non-ST MI Unstable Angina 825 565 1133 P=.02 P.0001 P=.001 de Lemos JA,et al.N Engl J Med.2001;345:1014-1021.(with permission)BNP and Risk of Death in ACS Multimarker Approach:Troponin I,CRP,and BNP to Predict 30-Day Mortality in ACS Sabatine M,et al.Circulation.2002;105:1760-1763.(with permission)OPUS-TIMI 1611.83.5601234560123No.of Elevated BiomarkersTACTICS-TIMI 1812.15.713024681012140123No.of Elevated BiomarkersP=.014 P=.001 67 150 155 78 504 717 324 90 30 Day Mortality(%)30-Day Mortality Rel Risk Inflammation,ACS,and CD-40L*SCD40L=soluble CD40L Andre P,et al.Circulation.2002;106:896-899.(with permission)Varo N,et al.Circulation.2003;108:1049-1052.(with permission)Clinical Investigation Reports Soluble CD40L Risk Prediction After Acute Coronary Syndromes 3.5 3 2.5 2 1.5 1 0.5 0 Death MI DIMI CHF DIMI CHF Q1 Q2 Q3 Q4 Hazard Ratios(HR)*P.01 compared to first quartile P.03 compared to first quartile Soluble CD-40L in ACS Heeschen C,et al.N Engl J Med.2003;348:1104-1111.(with permission)Association between soluble CD40 ligand levels and the rate of cardiac events(death or nonfatal myocardial infarction)at 24 hours,72 hours,30 days,and 6 months among 544 patients receiving placebo.Time Death or Nonfatal Myocardial Infarction(%)24 hours 72 hours 30 hours 6 months P=.13 P=.003 P=.004 P=.001 1st quartile 2nd quartile 3rd quartile 4th quartile 5th quartile Clopidogrel,but not ASA,Reduces ADP-Induced Expression of CD40L Hermann A,et al.Platelets.2001;12:74-82.(with permission)ADP,30 M Control 0 0.1 0.2 0.3 0.4 0.5 CD40L Expression(Mn X)Control ASA Clopidogrel ASA+Clopidogrel P.05 vs ADP-stimulated controls Effect of Treatment with Abciximab According to the Levels of Troponin T and