1、Berger China 10/051Berger China 10/052Berger China 10/053NSTE ACS:a high risk population patient risk benefit from treatment with medications,an invasive strategyInteraction between invasive strategy and pharmacologic txAntithrombotics cornerstone of treatmentAnticoagulants:heparin,LMWH,direct throm
2、bin inhibitorsAntiplatelet agents:aspirin,IIb/IIIa,ADP inhibitorsBerger China 10/054Q2 2003PURSUITCUREGUSTO-IV ACSCRUSADE Characteristic(n=9,461)(n=12,562)(n=7,800)(n=5,426)Mean age SD(yrs)63 1163 1265 1167 14Diabetes mellitus(%)23232233Prior CHF(%)11 8819Prior PCI(%)13-1022Prior CABG(%)1218*820Antm
3、an EM et al N Engl J Med 1996;335:1342-9Berger China 10/056Berger China 10/057Berger China 10/058Berger China 10/059Death/(re)Infarction Berger China 10/0510CP971744-4514.524.216.914.3051015202530TnT -TnT+%TACTICSTIMI 18TnT cut point=0.01 ng/mL (54%of pt TnT+)Troponin T:Death,MI,Rehosp ACS,6 Monthsn
4、=414n=396n=463n=495Berger China 10/0511Berger China 10/0512Berger China 10/0513Medical Tx for 72-170 hrThen,cath labn=207Cath lab 6 hrn=203CP1107655-467%had troponin,65%had ST depressionAspirin500 mg,100 mg bidClopidogrel600 mg,75 mg bidTirofiban 10 mg/kg bolus,0.10 mg/kg/min infusionHeparin(PTT 60-
5、85 seconds)Non-ST Acute Coronary Syndrome troponin or ST depressionn=410Berger China 10/0514CP1107655-210.13.45.95.91.511.6200246810121430-day event rate(%)Berger China 10/0515CP1107655-31311111051015Death and MI(%)Berger China 10/0516Berger China 10/0517.OR*0.51.01.52.05001500 mg34 19160325 mg19 26
6、75150 mg12 3275 mg3 13Any aspirin65 23Antiplatelet BetterAntiplatelet WorseAspirin DoseNo.of Trials(%)Odds Ratio0P=0.0001Berger China 10/0518CP999547-2Yusuf S et al NEJM 2001;16:494-502Berger China 10/05198.59.29.99.710.913.7051015200mg2.63.54.922.34012345200mgBerger China 10/0520Berger China 10/052
7、1CP999731-3CV death,MI,stroke(%)Clopidogrel(n=6,303)Placebo(n=6,259)P=0.00003Days after enrollment024681012140100200300400Berger China 10/052211.476.681.49.285.065.191.20.670.705.40024681012CP995058-6Berger China 10/0523Berger China 10/0524Berger China 10/0525Berger China 10/0526 UFH or LMWH Control
8、OR95%CITheroux2/122(1.6%)4/121(3.3%)0.500.10-2.53Cohen0/371/32(3.1%)0.120.01-5.89RISC3/210(1.4%)7/189(3.7%)0.400.11-1.39Cohen4/105(3.8%)9/109(8.2%)0.460.15-1.41Holdright*42/154(27.3%)40/131(30.5%)0.850.51-1.43Gurfinkel4/70(5.7%)7/73(9.6%)0.580.17-1.98(UFH)Gurfinkel0/687/73(9.6%)0.130.03-0.60(LMWH)FR
9、ISC4/70(5.7%)36/757(4.8%)0.390.22-0.68UFH vs55/698(7.9%)68/655(10.4%)0.670.45-0.99placebo/controlLMWH vs13/809(1.6%)43/830(5.2%)0.340.20-0.58placeboTotal68/1507(4.5%)104/1412(7.4%)0.530.38-0.73CP951342-1Berger China 10/0527EnoxaparinUFH(n=4993)(n=4985)Cath during hosp(%)9292 Time to cath*2221 (hours
10、)(6,44)(6,43)PCI4747 Time to PCI*2322 (hours)(6,49)(6,48)CABG(%)1918 Time to CABG*9189 (hours)(44,167)(45,166)Days hospitalized*54(3,8)(3,8)*Median(25th,75th)Berger China 10/052830-Day Death/MI30-Day Death/MI0.80.81 11.21.2Hazard Ratio(95%CI)EnoxaparinBetterUFHBetter0510152025300.80.850.90.951.0Free
11、dom from Death/MIDays from RandomizationUFHEnoxaparinHR 0.96(0.86-1.06)1.1Berger China 10/0529 Enoxaparin UFH(n=4993)(n=4985)P-valueGUSTO severe2.92.40.107TIMI major-clinical:9.17.60.008 CABG-related6.85.90.081 Non-CABG-related 2.41.70.025Any RBC transfusion 17.016.00.155ICH 0.1 0.1NSBerger China 10
12、/0530EnoxaparinUFH(n=2321)(n=2364)Unsuccessful PCI(%)3.63.4Threatened abrupt closure(%)1.11.0Abrupt closure(%)1.31.7Emergency CABG(%)0.30.3Berger China 10/0531Berger China 10/0532P=0.007P=0.005P=0.315P=0.53057%1.24.92.85.41.25.9Major bleedingMinor bleedingP=0.007P=0.005P=0.315P=0.53057%1.24.92.85.41
13、.25.9Major bleedingMinor bleedingP=0.052P=0.0146.06.68.7012345678910Minor or majorbleedingPatients(%)P=0.052P=0.0146.06.68.7012345678910Minor or majorbleedingPatients(%)Enoxaparin0.5(n=1046)Enoxaparin0.75(n=1206)UFH(n=1212)Berger China 10/0533Berger China 10/0534Berger China 10/0535Berger China 10/05364-6 wks7 days4-6 wks7 daysp=0.008p=0.024p=NSp=NSBerger China 10/0537Berger China 10/0538CP999731-7Berger China 10/0539Berger China 10/0540Berger China 10/0541Berger China 10/0542Berger China 10/0543Berger China 10/0544Berger China 10/0545Berger China 10/0546
