1、编辑课件Is early invasive the answer for ACSDr.Ben He MD/PhD/FSCAI/FAPSICDirector of Cardiology DepartmentRenji Hospital Affiliated to Shanghai Jiaotong university编辑课件编辑课件ACS is an Important Manifestation of ACS is an Important Manifestation of AtherothrombosisAtherothrombosis1 11.Cannon CP.J Thromb Thr
2、ombolysis 1995;2:205218.AntithrombotictherapyStable anginaUANon-Q-wave MIThrombolysisprimary PCIQ-wave MIMinutes hoursDaysweeksSTEMIUA/NSTEMIAtherothrombosisNew termOld termPlaquerupture编辑课件编辑课件Relation of TIMI risk score and MACE rate编辑课件Hot topic in ACSIs early invasive superior to conservative st
3、rategy in ACS?Should invasive be deferred for cooling off?1.What is the optimal time for invasive?编辑课件编辑课件Optimal Strategy for UA/NSTEMITIMI IIIB2005ConservativeInvasiveVANQWISHFRISC IITACTICS-TIMI 18RITA-3编辑课件FRICS-II:high risk get more编辑课件TIMI-18:high risk get more编辑课件RITA-3:1&3 yrs outcome编辑课件RIT
4、A-3:5yrs outcome编辑课件编辑课件编辑课件编辑课件In 2005,It seems we found answerIn ACS,early invasive superior to early conservativeThis is particular true in high risk patients编辑课件ESC Guideline 2005编辑课件编辑课件Is the problem settled?编辑课件ICTUS Designed编辑课件编辑课件编辑课件编辑课件编辑课件编辑课件编辑课件4 yrs ICTUS Lancet 2007;369:827-835Howev
5、er,most of selective pts were performed PCISo,the long-term f/u results do not inflect Inv/Cons strategy 编辑课件4 yrs ICTUS Lancet 2007;369:827-835编辑课件ICTUSs criticismICTUSs criticism Liberty definition of MI(only 1*ULN)causing the early MI increase in early invasive group 3yrs revascularization rate w
6、as equal in 2 group(81%PCI)1year mortality rate in ACS in both arm are very low(2.5%),Is it a real high risk?编辑课件Even put ICTUS into pool,Inv Cons编辑课件Inv vs Cons/All cause death High risk?编辑课件编辑课件编辑课件2007 ESC Guideline Urgent Coronary angiography is recommended in Pts with refractory or recurrent an
7、gina associated with dynamic ST deviation,heart failure,life threatening arrhythmias,or haemodynamic instability (I-C)Early(72h)angiography followed by revascularization(PCI or CABG)in patients with intermediate to high risk features is recommended(I-A)编辑课件MonocyteLDL-CAdhesion moleculeMacrophageFoa
8、m cellOxidizedLDL-CPlaque ruptureSmooth muscle cellsCRP2编辑课件ISAR-COOL Trial编辑课件ISAR-COOL Antithrombotic Regimen编辑课件编辑课件ISAR-COOL编辑课件编辑课件编辑课件编辑课件What is the optimal time for PCI?编辑课件编辑课件Methods for Optimal trial编辑课件Results of Optimal trial编辑课件Conclusion from Optimal trial编辑课件Whats the difference betw
9、een ISAR-Cool&Optimal?2.5 vs 84 +0.5 vs 25 -编辑课件Time to Coronary Angiography and Outcomes Among Patients With High-Risk NonST-SegmentElevation Acute Coronary Syndromes:Results From the SYNERGY Trial Pierluigi Tricoci,MD,MHS,PhD;Yuliya Lokhnygina,PhD;Lisa G.Berdan,PA-C,MHS;Steven R.Steinhubl,MD;Dietr
10、ich C.Gulba,MD;Harvey D.White,MD;Neal S.Kleiman,MD;Philip E.Aylward,MD;Anatoly Langer,MD;Robert M.Califf,MD;James J.Ferguson,MD;Elliott M.Antman,MD;L.Kristin Newby,MD,MHS;Robert A.Harrington,MD;Shaun G.Goodman,MD;Kenneth W.Mahaffey,MD Division of Cardiology,Duke Clinical Research Institute,Durham,NC
11、 编辑课件Background 2007 ACC/AHA Guidelines for NSTE ACS recommend the use of an early invasive strategy for high-risk patients Randomized clinical trials on early vs.conservative strategy used different timing of cardiac catheterization Optimal timing of cardiac catheterization in NSTE ACS not yet esta
12、blished(expedited vs.deferred)Expedited catheterization increasingly adopted in the US编辑课件Study Objective To evaluate the association between time from hospital admission to cardiac catheterization and adverse outcomes among high-risk patients with NSTE ACS treated with an early invasive strategy(ca
13、rdiac catheterization 48h of hospital admission)编辑课件Study Population Patients randomized in the SYNERGY trial Ischemic symptoms 60 years ST-segment depression or transient elevation Positive troponin and/or CK-MB Use of coronary angiography in SYNERGY 10,027 pts randomized in the SYNERGY trial9,188
14、pts underwent cardiac catheterization6,352 pts underwent cardiac catheterization 48h编辑课件Adjusted Estimates of 30-day Death/MI Rates(with 95%CI).0.0编辑课件Landmark Analysis:Adjusted OR of 30-day Death/MI(with 95%CI)编辑课件Adjusted Estimates of In-hospital Transfusion Rates(with 95%CI)编辑课件Study Limitations
15、Non-randomized observational analysisPropensity-based models used to deal with lack of randomization Time to cath is a post-baseline and“dynamic”variableStatistical methodologies attempted to address these issues Events from hospital admission to randomization not availableEvents unlikely prior to r
16、andomization Myocardial infarction in the first hours following the hospitalization is more difficult to adjudicate编辑课件Conclusions from Synergy-1 Observational analysis among high-risk NSTE ACS patients enrolled in the SYNERGY trial treated with an early invasive strategy Reduced time to cardiac cat
17、heterization was associated with decreased probability of 30-day death/MI and no changes in bleeding No signals suggesting benefits of delaying the cardiac catheterization were observed编辑课件Conclusions from Synergy-2 Randomized clinical trials to establish optimal timing of catheterization in NSTE AC
18、S are needed but challenging Delaying cath is problematic for hospital adopting expedited cath strategyLag from hospitalization to randomization may confound actual time to catheterization intervals Early re-MI adjudication complex Well-designed observational studies may be of value in the debate on
19、 optimal timing of cardiac catheterization among NSTE ACS patients编辑课件Conclusion&Prospective ACS,early invasive is superior to early conservative in most Pts especially high risk Immediate invasive strategy is recommended in very high risk(instability of hemodynamic or electricity)In high risk pts,short-term(24hrs)cooling-off may be benefited(but no more than 48hs)In low risk,esp in women,early conservative can be chosen New antiplatelet drug may change practice编辑课件Thank you for your attention
