该幻灯为美国哈佛医学院B&W医院心血管科“动脉硬化血栓”系列幻灯之一。主题为急性冠脉综合征(ACS)评估和危险分层，内容涉及不稳定型心绞痛的发病机制及研究进展、不稳定型心绞痛和非ST段抬高心肌梗死的TIMI风险评分、使用多重生物标志的风险分层（troponin, BNP, HbA1c, CRP, and CD40L等）。
Acute Coronary Syndromes Evaluation and Risk Stratification
New Terminology in ACS
ACS, acute coronary syndrome; MI, myocardial infarction; UA, unstable angina; NSTEMI, non–ST-segment elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction; PCI, percutaneous coronary intervention.
Cannon CP. J Thromb Thrombolysis. 1995;2:205-218.
Troponin I (TnI), C-Reactive Protein (CRP), and B-type Natriuretic Peptide (BNP) as Determinants of 30-Day Mortality Risks in Acute Coronary Ischemia: A Multimarker Approach
P=.014
P<.001
67
150
155
78
504
717
324
90
Sabatine M, et al. Circulation. 2002;105:1760-1763. (with permission)
Braunwald E. Circulation. 1998;98:2219-2222.
Braunwald Etiologic Classification of UA
GUSTO IIb: Correlation of 6-Month Mortality With Baseline ECG Findings in Patients With ACS
GUSTO, Global Use of Strategies To Open Occluded Arteries in Acute Coronary Syndromes; ECG, electrocardiogram; ACS, acute coronary syndrome; STEMI, ST-segment elevation myocardial infarction. Savonitto S, et al. JAMA. 1999;281:707-713. (with permission)
TIMI, thrombosis in myocardial infarction; UA, unstable angina; NSTEMI, non–ST-segment elevation myocardial infarction; CAD, coronary artery disease. Antman EM, et al. JAMA. 2000;284:835-842.
TIMI Risk Score for UA/NSTEMI: 7 Independent Predictors
Aged ≥65 years
≥3 CAD risk factors
Prior CAD (stenosis >50%)
Aspirin in last 7 days
>2 anginal events in ≤24 hours
ST deviation
Elevated cardiac markers (CK-MB or troponin)
TIMI Risk Score For UA/NSTEMI
Antman EM, et al. JAMA. 2000;284:835-442. (with permission)
Age >65 years
>3CAD Risk Factors
Prior Stenosis >50 %
ST deviation
>2 Anginal events <24 hours
ASA in last 7 days
Elev Cardiac Markers (CK-MB or troponin)
4.7
8.3
13.2
19.9
26.2
40.9
0
10
20
30
40
50
0/1
2
3
4
5
6/7
D/MI/Urg Revasc (%)
Number of Risk Factors
Population (%):
4.3
17.3
32.0
29.3
13.0
3.4
C Statistic=0.65
c2 trend P<.001
P<.001
P=.004
P<.001
P<.001
Scirica BM, et al. Am J Cardiol. 2002;90:303-305.
(with permission)
TIMI Risk Score vs Prognosis in Unselected Patients (TIMI 3 Registry)
0%
10%
20%
30%
40%
50%
Death
MI
Death/MI
Death/MI/RI
Event Rate at 1 year (%)
Prognostic Value of Troponin T or I in ACS: A Meta-analysis
%
RR 3.9 (2.9-5.3)
RR 3.8 (2.6-5.5)
No. Studies: 13 6
Neg Pos (Trop I + T)
3634
1849
737
322
Heidenreich PA, J Am Coll Cardiol. 2001;38:478-485.
TIMI IIIB: Troponin I Levels Predict Mortality In UA/NSTEMI
1.0
1.7
3.4
3.7
6.0
7.5
0
2
4
6
8
0 to <0.4
0.4 to <1.0
1.0 to <2.0
2.0 to <5.0
5.0 to <9.0
>9.0
831
174
148
134
67
50
Risk Cardiac Troponin I (ng/ml)
Ratio 1.0 1.8 3.5 3.9 6.2 7.8
Mortality at 42 Days (% of Patients)
Antman EA, et al. N Engl J Med. 1996;335:1342-1349. (with permission)
Risk Stratification With CRP and Troponin T
Morrow DA, et al. J Am Coll Cardiol. 1998;31:1460-1465.
B-type Natriuretic Peptide (BNP) and Mortality in ACS Patients
de Lemos JA, et al. N Engl J Med. 2001;345:1014-1021. (with permission)
ST ? MI Non-ST ? MI Unstable Angina
825 565 1133
P=.02 P<.0001 P=.001
de Lemos JA, et al. N Engl J Med. 2001;345:1014-1021. (with permission)
BNP and Risk of Death in ACS
Multimarker Approach: Troponin I, CRP, and BNP to Predict 30-Day Mortality in ACS
Sabatine M, et al. Circulation. 2002;105:1760-1763. (with permission)
P=.014
P=.001
67
150
155
78
504
717
324
90
30 Day Mortality (%)
30-Day Mortality Rel Risk
Inflammation, ACS, and CD-40L
Andre P, et al. Circulation. 2002;106:896-899. (with permission)
Varo N, et al. Circulation. 2003;108:1049-1052. (with permission)
Clinical Investigation Reports
Soluble CD40L Risk Prediction After Acute Coronary Syndromes
3.5
3
2.5
2
1.5
1
0.5
0
Death
MI
DIMI
CHF
DIMI CHF
Hazard Ratios (HR)
*
*
*
?
?
?
*P<.01 compared to first quartile ?P<.03 compared to first quartile
Soluble CD-40L in ACS
Heeschen C, et al. N Engl J Med. 2003;348:1104-1111. (with permission)
Association between soluble CD40 ligand levels and the rate of cardiac events (death or nonfatal myocardial infarction) at 24 hours, 72 hours, 30 days, and 6 months among 544 patients receiving placebo.
Time
Death or Nonfatal Myocardial Infarction (%)
24 hours
72 hours
30 hours
6 months
P=.13
P=.003
P=.004
P=.001
1st quartile
2nd quartile
3rd quartile
4th quartile
5th quartile
Clopidogrel, but not ASA, Reduces ADP-Induced Expression of CD40L
Hermann A, et al. Platelets. 2001;12:74-82. (with permission)
Effect of Treatment with Abciximab According to the Levels of Troponin T and Soluble CD40 Ligand
Heeschen C, et al. N Eng J Med. 2003;348:1104-1111. (with permission)
Vascular Damage
Inflammation
Myocyte Necrosis
Accelerated
Atherosclerosis
Hemodynamic Stress
HbA1c
Blood glucose
CrCl
Microalbuminuria
Troponin
BNP, NT-proBNP
hs-CRP, CD40L
Morrow DA, et al. Circulation. 2003;108:250-252.
Multimarker Strategy in ACS