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：稳定型冠心病的诊断和治疗：从循证医学到临床指南从循证医学到临床指南SIHD：常见诊疗误区：常见诊疗误区诊断诊断 推侧性诊断推侧性诊断 过度过度使用使用CTA 过度使用冠脉造影过度使用冠脉造影 无创性缺血检查使用不足无创性缺血检查使用不足治疗治疗 介入治疗降低病人风险？死亡、心梗介入治疗降低病人风险？死亡、心梗 强化药物治疗已经足够？强化药物治疗已经足够？冠心病的诊断冠心病的诊断检查前冠心病可能性评估检查前冠心病可能性评估病人是否有冠心病？病人是否有冠心病？-缺血的客观依据缺血的客观依据 -可视性冠状动脉狭窄可视性冠状动脉狭窄 严重症状严重症状诊断流程诊断流程疑冠心病，疑冠心病，PTP15-85%思考：思考：病人适应证病人适应证设备条件设备条件/医生经验医生经验PTP15-50%病人冠脉病人冠脉CTA检查检查-如病人合适如病人合适-如有设备和足够的经验如有设备和足够的经验病人是否有冠心病？病人是否有冠心病？-缺血的客观依据缺血的客观依据 -可视性冠状动脉狭窄可视性冠状动脉狭窄 严重症状严重症状强化药物治疗强化药物治疗评估危险性（死亡率？评估危险性（死亡率？)-缺血范围缺血范围 -冠脉解剖冠脉解剖有创性冠脉造影有创性冠脉造影血运重建血运重建冠心病的治疗冠心病的治疗SIHD药物治疗药物治疗:从经验到循证从经验到循证-改善症状改善症状 硝酸甘油硝酸甘油 B-阻断剂阻断剂 钙离子拮抗剂钙离子拮抗剂-改善预后改善预后 阿斯匹林阿斯匹林 他他丁类药物丁类药物 ACEICABG对死亡率的影响对死亡率的影响0 02020404060608080100100CABGCABGYear 5Year 5Year 7Year 7Year10Year10Medical TherapyMedical TherapyActual CABG Rate(%)Total 2649 stable CAD patients(not severe enough to necessitate surgery)between 1972-1884.0 05 51010151520202525303035355 yrs5 yrs7 yrs7 yrs10 yrs10 yrsMortalityMedical TherpayMedical TherpayCABGCABG(%)P=0.0001P0.001P=0.03Yusuf,et al.Lancet 1994Odds Ratios of Morality at 5 years(CABG over MT)0 00.20.20.40.40.60.60.80.8LMLM3VD3VD1/2VD1/2VDTotal 2649 stable CAD patients(not severe enough to necessitate surgery)between 1972-1884.Yusuf,et al.Lancet 1994不同亚组不同亚组CABG 10年后对寿命延长年后对寿命延长的影响的影响Yusuf,et al.Lancet 1994COURAGE研究研究:PCI与药物治疗没有差异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.药物的使用药物的使用强化药物治疗对稳定性冠心病已经足够！强化药物治疗对稳定性冠心病已经足够！结论对吗结论对吗?COURAGE研究研究:OMT组组1/3强的强的病人接受血运重建病人接受血运重建OMT GroupPCI Group25.5%PCI7.1%CABG4%No PCINagajoth,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！把很多重冠心病排除在外！Meta 分析分析:死亡率死亡率7513 patients with stable IHDSchmig,et al.JACC2008Shaw,et al.Circulation 2008SPECT检查：负荷诱发心肌缺血检查：负荷诱发心肌缺血PCI+OMT(N=159)OMT(N=155)P=0.0004P0.0001Shaw,et al.Circulation 2008心肌缺血面积减少对预后的影响心肌缺血面积减少对预后的影响86.6%75.3%Shaw,et al.Circulation 2008残存缺血对预后影响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单纯药物治疗对不同冠心病严重程度预后影响度预后影响Non-Invasive Stratification(1)Non-Invasive Stratification(2)Indications for Revascularization in Stable Angina or Silent Ischemia男性，男性，48岁，下壁心梗岁，下壁心梗3周，周，LCX 介入失败介入失败DEFERFAMEFAMEOutcomeAngiography GuidedFFR GuidedDifference(95%CI)MACEs,%18.313.25.2(0.79.7)MI,%8.75.73.0(0.26.2)Death,%3.01.81.3(0.63.2)MI or death,%11.17.33.8(0.37.4)QALY0.8380.8530.015(0.0080.037)$of initial procedure60075332$of initial hospitalization14 87813 1821697(2893510)$of events during 12-mo f/u18211134668(138325)Overall$16 70014 3152384(38261011)3-VD 14%1-VD 34%2-VD 43%0-VD9%Proportions of functionally diseased coronary arteries in patients with angiographic 3-vessel disease(n=115)FAME:Angiography versus FFRTonino,et al.JACC 2010FFR-guided SYNTAX Score(FSS)versus Conventional SYNTAX Score(SS)FSSSS32%of patients moved to a lower-risk group 497 patients of the FFR-arm of FAMENam,et al.JACC 2011SYNTAX scoreFunctional SYNTAX scoreLowMediumHighp ValueLowMediumHighp ValueDeath1(0.6)3(1.8)5(3.1)0.241(0.3)5(4.7)3(3.0)0.01MI8(4.8)7(4.2)15(9.2)0.1113(4.5)4(3.8)13(12.9)0.005Repeat PCI/CABG 6(3.6)7(4.2)17(10.4)0.0213(4.5)4(3.8)13(12.9)0.005Death/MI 9(5.4)10(6.0)19(11.7)0.0614(4.8)8(7.5)16(15.8)0.005MACE14(8.4)17(10.2)34(20.9)0.00126(9.0)12(11.3)27(26.7)0.001FSS vs.SS and Clinical Outcome 497 patients of the FFR-arm of FAMENam,et al.JACC 2011FAME II:Inclusion Criteria Patients with stable angina or,stabilized angina pectoris or,atypical chest pain or no chest pain but with documented silent ischemia at 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 consenthttp:/clinicaltrials.gov NCT01132495FAME II:Study FlowPts w/stable agina or silent ischemia scheduled for 1,2 or 3 vessel DES stentingOMTPCI+OMTEnrollment stopped due to more MACEs in OMT alone groupinterim analysis FFR in indicated stenoses1 stenosis with an FFR 0.80No stenosis with an FFR 0.80OMThttp:/clinicaltrials.gov NCT01132495RN=1600N=200Rate 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-kinesis cardiac MR perfusion(12%myocardium).Verified February 2012 by NHLBI,not yet open for participant recruitment.Cath Revasc+OMTOMT男性，男性，48岁，下壁心梗岁，下壁心梗3周，周，LCX 介入失败介入失败FFR=0.80-0.82小结小结-诊断应按照规范流程诊断应按照规范流程-SIHD
