陈纪言 广东省人民医院 从最新欧洲指南看 ACS 诊疗进展. ESC Guidelines for the...
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Transcript of 陈纪言 广东省人民医院 从最新欧洲指南看 ACS 诊疗进展. ESC Guidelines for the...
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陈纪言
广东省人民医院
从最新欧洲指南看 ACS诊疗进展
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ESC Guidelines for the management of NSTEMI
• Management strategy
• Step one: initial evaluation
• Step two: diagnosis validation and risk assessment
• Step three: invasive strategy
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ESC Guidelines for the management of NSTEMI
• Treatment
– Anti-ischaemic agents
– Antiplatelet agents
– Anticoagulants
– Coronary revascularization
– Special populations and conditions
– Long-term management
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ESC Guidelines for the management of NSTEMI
• Anti-ischaemic agents
– decrease myocardial oxygen demand
– increase myocardial oxygen supply
b-Blockers
Nitrates
Calcium channel blockers
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ESC Guidelines for the management of NSTEMI
• Antiplatelet agents
– Aspirin
– Clopidogrel\Prasugrel
– glycoprotein IIb/IIIa receptor inhibitors
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P2y12拮抗剂的建议
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ESC Guidelines for the management of NSTEMI
clopidogrel treatment was recommended to be
withheld for 5 days and ticagrelor for 1–3 days
before CABG ( PLATO trial)
Withdrawal of clopidogrel in high risk cohorts such
as those with ongoing ischaemia in the presence of
high risk anatomy (e.g. left main or severe proximal
multivessel disease) is not recommended
The optimal timing of restarting medication
following CABG surgery remains uncertain.
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ESC Guidelines for the management of NSTEMI
• Upstream vs procedural initiation of
glycoprotein IIb/IIIa receptor inhibitors
– ACUITY Timing trial\EARLY-ACS trial
– no advantage with a routine upstream use
• may be considered if there is active
ongoing ischaemia among high risk
patients or DAPT is not feasible
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ESC Guidelines for the management of NSTEMI
• Coronary revascularization
– Invasive versus conservative approach
– Timing of angiography and intervention
– Percutaneous coronary intervention
versus coronary artery bypass surgery
– Risk stratification should be performed
as early as possible
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ESC Guidelines for the management of NSTEMI
• Urgent invasive strategy (<120 min after first medical contact)– Refractory angina (indicating evolving MI
without ST abnormalities)– Recurrent angina despite intense
antianginal treatment, associated with ST depression (2 mm) or deep negative T waves.
– Clinical symptoms of heart failure or haemodynamic instability (‘shock’).
– Life-threatening arrhythmias (ventricular fibrillation or ventricular tachycardia).
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ESC Guidelines for the management of NSTEMI
• Early invasive strategy (<24 h after first
medical contact)
– High risk patients as identified by a GRACE
risk score >140 and/or the presence of at
least one primary high risk criterion (Table 9)
should undergo invasive evaluation within 24
h.
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ESC Guidelines for the management of NSTEMI
• Invasive strategy (<72 h after first medical contact)– less acute risk, GRACE risk score <140
• Conservative strategy (no or elective angiography)– No recurrence of chest pain.– No signs of heart failure.– No abnormalities in the initial ECG or a
second ECG (at 6–9 h).– No rise in troponin level (at arrival and at
6–9 h).– No inducible ischaemia.
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特殊人群的治疗
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ESC Guidelines for the management of NSTEMI
Special populations and conditions- The elderly: >75 years
one of the most important predictors of riskat higher risk of side effects from medical
treatment: bleeding• SYNERGY trial: enoxaparin>UFH• OASIS-5 trial: enoxaparin>fondaparinux
(TACTICS)\TIMI 18 trial: patients>75 years
with NSTE-ACS derived the largest benefit
from PCI
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ESC Guidelines for the management of NSTEMI
• Gender issues– older than men– higher bleeding risk than men– Contradictory results have been published
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ESC Guidelines for the management of NSTEMI
• Diabetes mellitus
• independent predictor of mortality:two-fold
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ESC Guidelines for the management of NSTEMI
• Chronic kidney disease
– independent predictor of mortality and of
major bleeding
– dose adjustment
– hydration and low- or iso-osmolar contrast
– medium at low volume (<4 mL/kg) are
recommended
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ESC Guidelines for the management of NSTEMI
• heart failure
• independent predictors of mortality
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ESC Guidelines for the management of NSTEMI
• Step five: hospital discharge and post-discharge management
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ESC Guidelines for the management of NSTEMI
谢 谢谢 谢