稳定型冠心病的诊断和治疗：从循证医学到临床指南.ppt
稳定型冠心病的诊断和治疗：从循证医学到临床指南,SIHD：常见诊疗误区,诊断推侧性诊断过度使用CTA过度使用冠脉造影无创性缺血检查使用不足治疗介入治疗降低病人风险？死亡、心梗强化药物治疗已经足够？,冠心病的诊断,检查前冠心病可能性评估,病人是否有冠心病？-缺血的客观依据-可视性冠状动脉狭窄,严重症状,诊断流程,疑冠心病，PTP15-85%,思考：病人适应证设备条件/医生经验,PTP15-50%病人冠脉CTA检查-如病人合适-如有设备和足够的经验,病人是否有冠心病？-缺血的客观依据-可视性冠状动脉狭窄,严重症状,强化药物治疗评估危险性（死亡率？)-缺血范围-冠脉解剖,有创性冠脉造影血运重建,冠心病的治疗,SIHD药物治疗:从经验到循证,-改善症状硝酸甘油B-阻断剂钙离子拮抗剂-改善预后阿斯匹林他丁类药物ACEI,CABG对死亡率的影响,Total 2649 stable CAD patients(not severe enough to necessitate surgery)between 1972-1884.,Yusuf,et al.Lancet 1994,Odds Ratios of Morality at 5 years(CABG over MT),Total 2649 stable CAD patients(not severe enough to necessitate surgery)between 1972-1884.,Yusuf,et al.Lancet 1994,不同亚组CABG 10年后对寿命延长的影响,Yusuf,et al.Lancet 1994,COURAGE研究:PCI与药物治疗没有差异,Totally 2287 patients with stable CAD and those in whom initial CCS IV angina subsequently stabilized medically.,药物的使用,强化药物治疗对稳定性冠心病已经足够！结论对吗?,COURAGE研究:OMT组1/3强的病人接受血运重建,Nagajoth,et al.NEJM 2007,357:416.,The data were analyzed in a intend-to-treat style.,COURAGE:把很多重冠心病排除在外！,Meta 分析:死亡率,7513 patients with stable IHD,Schmig,et al.JACC2008,Shaw,et al.Circulation 2008,SPECT检查：负荷诱发心肌缺血,Shaw,et al.Circulation 2008,心肌缺血面积减少对预后的影响,Shaw,et al.Circulation 2008,残存缺血对预后影响,100%,84.4%,77.7%,60.7%,Hachamovitch,et al.Circulation 2003,心肌缺血范围与疗效关系,10 627 patients who underwent stress Myocardial Perfusion Stress SPECT and had no prior MI or revascularization,心肌缺血对死亡危险性的影响,不是非常明确，也许与下述因素有关.缺血的不良作用 Adverse effect of ischemia严重狭窄病变闭塞 Occlusion of severe stenosis恶性心律失常 Arrhythmia严重缺血往往提示动脉硬化负荷较大、更可能有更多不稳定斑块 More severe ischemia as a marker of atherosclerotic burden with more vulnerable plaques,单纯药物治疗对不同冠心病严重程度预后影响,Non-Invasive Stratification(1),Non-Invasive Stratification(2),Indications for Revascularization in Stable Angina or Silent Ischemia,男性，48岁，下壁心梗3周，LCX 介入失败,DEFER,FAME,FAME,Proportions of functionally diseased coronary arteries in patients with angiographic 3-vessel disease(n=115),FAME:Angiography versus FFR,Tonino,et al.JACC 2010,FFR-guided SYNTAX Score(FSS)versus Conventional SYNTAX Score(SS),32%of patients moved to a lower-risk group,497 patients of the FFR-arm of FAME,Nam,et al.JACC 2011,FSS vs.SS and Clinical Outcome,497 patients of the FFR-arm of FAME,Nam,et al.JACC 2011,FAME II:Inclusion Criteria,Patients withstable angina or,stabilized angina pectoris or,atypical chest pain or no chest pain but with documented silent ischemiaat least one stenosis is present of at least 50%in one major native epicardial coronary artery and supplying viable myocardium Eligible for PCI Signed written informed consent,http:/clinicaltrials.gov NCT01132495,FAME II:Study Flow,Pts w/stable agina or silent ischemia scheduled for 1,2 or 3 vessel DES stenting,OMT,PCI+OMT,Enrollment stopped due to more MACEs in OMT alone group,interim analysis,FFR in indicated stenoses,1 stenosis with an FFR 0.80,No stenosis with an FFR 0.80,OMT,http:/clinicaltrials.gov NCT01132495,R,N=1600,N=200,Rate of Any Revascularisation,International Study of Comparative Health Effectiveness With Medical&Invasive Approaches(ISCHEMIA),Population:8000 patients with moderate/high ischemia on stress imaging nuclear myocardial perfusion(10%myocardium)echo or cardiac magnetic resonance wall motion(3/16 segments with stress-induced severe hypo-/a-kinesiscardiac MR perfusion(12%myocardium).,Verified February 2012 by NHLBI,not yet open for participant recruitment.,Cath Revasc+OMT,OMT,男性，48岁，下壁心梗3周，LCX 介入失败FFR=0.80-0.82,小结,-诊断应按照规范流程-SIHD包含着差异很大的各种病人-不能用一种 方式治疗所有的病人-药物治疗和二级预防是SIHD的基础-了解病人的具体情况，评估死亡风险症状缺血的依据心功能SYNTAX评分STS评分并存疾病 其他-高危病人应选择血运重建治疗（PCI/CABG）-了解循证依据/指南-新的评价方式（FFR),Summary 2,CABG saved more patients compared with MTPCI not definitely superior to OMT in CRTs,due toUnder-representativeHigh crossover rateVariant ischemic berdunLack of functional evaluationPerformance of PCI improvesIn patients with higher ischemiaWith FFR guidanceBig spectrum of IHD may manifest stablyPCI SIHD in high risk is appropriateStudy for the ideal management is on the way,
