急性冠脉综合征评估及危险分层课件

AcuteCoronarySyndromesEvaluationandRiskStratificationNewTerminologyinACSACS,acutecoronarysyndrome;MI,myocardialinfarction;UA,unstableangina;NSTEMI,non–ST-segmentelevationmyocardialinfarction;STEMI,ST-segmentelevationmyocardialinfarction;PCI,percutaneouscoronaryintervention.CannonCP.JThrombThrombolysis.1995;2:205-218.AntithromboticTherapyStableAnginaUnstableAnginaNon–Q-waveMIThrombolysisPrimaryPCIQ-waveMIMinutes-hoursDays-weeksSTEMIUA/NSTEMIAtherothrombosisNewtermOldtermPlaqueRuptureTroponinI(TnI),C-ReactiveProtein(CRP),andB-typeNatriureticPeptide(BNP)asDeterminantsof30-DayMortalityRisksinAcuteCoronaryIschemia:AMultimarkerApproachP=.014P<.001671501557850471732490SabatineM,etal.Circulation.2002;105:1760-1763.(withpermission)ProgressivemechanicalobstructionSecondaryUA(bMVO2)Inflammation/infectionDynamicobstructionNonocclusivethrombusonpre-existingplaqueBraunwaldE.Circulation.1998;98:2219-2222.BraunwaldEtiologicClassificationofUATIMI,thrombosisinmyocardialinfarction;UA,unstableangina;NSTEMI,non–ST-segmentelevationmyocardialinfarction;CAD,coronaryarterydisease.AntmanEM,etal.JAMA.2000;284:835-842.TIMIRiskScoreforUA/NSTEMI:7IndependentPredictorsAged≥65years≥3CADriskfactorsPriorCAD(stenosis>50%)Aspirininlast7days>2anginaleventsin≤24hoursSTdeviationElevatedcardiacmarkers(CK-MBortroponin)TIMIRiskScoreForUA/NSTEMIAntmanEM,etal.JAMA.2000;284:835-442.(withpermission)Age>65years>3CADRiskFactorsPriorStenosis>50%STdeviation>2Anginalevents<24hoursASAinlast7daysElevCardiacMarkers(CK-MBortroponin)4.78.313.219.926.240.9010203040500/123456/7D/MI/UrgRevasc(%)NumberofRiskFactorsPopulation(%):4.317.332.029.313.03.4CStatistic=0.65c2trendP<.001P<.001P=.004P<.001P<.001SciricaBM,etal.AmJCardiol.2002;90:303-305.(withpermission)TIMIRiskScorevsPrognosisinUnselectedPatients(TIMI3Registry)TRS0-2TRS3-4TRS5-70%10%20%30%40%50%DeathMIDeath/MIDeath/MI/RIEventRateat1year(%)TIMIIIIB:TroponinILevelsPredictMortalityInUA/NSTEMI1.01.73.43.76.07.5024680to<0.40.4to<1.01.0to<2.02.0to<5.05.0to<9.0>9.08311741481346750RiskCardiacTroponinI(ng/ml)Ratio1.01.83.53.96.27.8Mortalityat42Days(%ofPatients)AntmanEA,etal.NEnglJMed.1996;335:1342-1349.(withpermission)LindahlB,etal.NEnglJMed.2000;343:1139-1147.(withpermission)PredictiveValueofTroponinTandhs-CRPforMortalityfromACSinFRISCSubstudy201000612182430364248CumulativeProbabilityofDeath(%)MonthsTroponinT>0.60µg/l(n=377)TroponinT0.60-0.59µg/l(n=367)TroponinT<0.60µg/l(n=173)P=.007P=.001CRP2-10mg/l(n=294)201000612182430364248CRP>10mg/l(n=309)CRP<2mg/l(n=314)P=.001P=.29CRPTroponinMonthsWBCCount(x103)30-DayMortality0510152005%10%15%20%WhiteBloodCellCountvsMortalityCannonCP,etal.AmJCardiol.2001;87:636-639.(withpermission)STMINon-STMIUnstableAngina8255651133P=.02P<.0001P=.001deLemosJA,etal.NEnglJMed.2001;345:1014-1021.(withpermission)BNPandRiskofDeathinACSMultimarkerApproach:TroponinI,CRP,andBNPtoPredict30-DayMortalityinACSSabatineM,etal.Circulation.2002;105:1760-1763.(withpermission)P=.014P=.00167150155785047173249030DayMortality(%)30-DayMortalityRelRiskSolubleCD-40LinACSHeeschenC,etal.NEnglJMed.2003;348:1104-1111.(withpermission)AssociationbetweensolubleCD40ligandlevelsandtherateofcardiacevents(deathornonfatalmyocardialinfarction)at24hours,72hours,30days,and6monthsamong544patientsreceivingplacebo.TimeDeathorNonfatalMyocardialInfarction(%)24hours72hours30hours6monthsP=.13P=.003P=.004P=.0011stquartile2ndquartile3rdquartile4thquartile5thquartileClopidogrel,butnotASA,ReducesADP-InducedExpressionofCD40LHermannA,etal.Platelets.2001;12:74-82.(withpermission)ADP,30MControl00.10.20.30.40.5CD40LExpression(MnX)ControlASAClopidogrelASA+ClopidogrelP<.05vsADP-stimulatedcontrolsEffectofTreatmentwithAbciximabAccordingtotheLevelsofTroponinTandSolubleCD40LigandHeeschenC,etal.NEngJMed.2003;348:1104-1111.(withpermission)0.00.51.01.52.02.5QuintileofSolubleCD40Ligand12345AllpatientsHazardRatioforDeathorNonfatalMyocardialInfarctionP=.10P=.50P=.48P=.02P=.02P=.04VascularDamageInflammationMyocyteNecrosisAcceleratedAtherosclerosisHemodynamicStressHbA1cBloodglucoseCrClMicroalbuminuriaTroponinBNP,NT-proBNPhs-CRP,CD40LMorrowDA,etal.Circulation.2003;108:250-252.MultimarkerStrategyinACS