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，共54张，主题为不稳定型心绞痛和非ST段抬高心梗的治疗。
Acute Coronary Syndromes: Management of UA/NSTEMI
Overview of 2003 Updates to the ACC/AHA Guideline for UA/NSTEMI
Assess likelihood of CAD
Risk stratification
Target therapy: more aggressive treatment in higher-risk patients
Anti-ischemic, antithrombotic therapy
Invasive vs conservative strategy
Discharge planning (risk factor modification and long-term medical therapy)
ACC/AHA, American College of Cardiology/American Heart Association; UA, unstable angina; NSTEMI, non–ST-segment elevation myocardial infarction. Braunwald E, et al. J Am Col. Cardiol. 2000;36:970-1062.
Acute Management of UA/NSTEMI
Anti-Ischemic Therapy
Oxygen, bed rest, ECG monitoring
Nitroglycerin
?-Blockers
ACE inhibitors
UA, unstable angina; NSTEMI, non-ST-segment elevation myocardial infarction; ECG, electrocardiogram; ACE, angiotensin-converting enzyme.
Braunwald E, et al. J Am Coll Cardiol. 2000;36:970-1062.
Antithrombotic Therapy
Antiplatelet therapy
Anticoagulant therapy
Possible ACS
Aspirin
Aspirin
+
IV Heparin
+
IV Platelet GP IIb/IIIa
Antagonist
Definite ACS With Invasive Strategy (Catheterization/PCI)
or High Risk (IIa)*
Clopidogrel
Aspirin
+
SQ LMWH*
or
IV Heparin
Likely/Definite ACS
Clopidogrel
* Class IIa: enoxaparin preferred over UFH unless CABG planned within 24 hours.
ACC, American College of Cardiology; AHA, American Heart association; ACS, acute coronary syndrome; PCI, percutaneous coronary intervention; SQLMWH, subcutaneous low molecular-weight heparin; IV, intravenous.
Braunwald E, et al. J Am Coll Cardiol. 2000;36:970-1062.
ACC/AHA Class I Recommendations for Antithrombotic Therapy*
17.1
6.5*
Placebo
ASA
0
5
10
15
20
Patients (%)
Unstable Angina
25.0
11.0*
ASA
0
10
20
30
3.3
1.9*
ASA
0
1
2
3
4
11.8
9.4*
ASA
0
5
10
15
Acute MI
Aspirin in Acute Coronary Syndromes
*P<.0001
Death or MI
*P=.003
Reocclusion
*P=.012
MI
*P<.001
Death
N= 397 399 513 419 8587 8600 8587 8600
MI, myocardial infarction; ASA, acetylsalicylic acid; RISC, Research on InStability in Coronary artery disease.
RISC Group. Lancet. 1990;336:827-830.
Roux S, et al. J Am Coll Cardiol. 1992;19:671-677.
ISIS-2. Lancet. 1988;2:349-360.
Placebo
Placebo
Placebo
Aspirin in Acute Coronary Syndromes
12.9
3.9*
ASA
0
5
10
15
11.9
3.3*
ASA
0
5
10
15
12.9
6.2*
ASA
0
5
10
15
2.2
1.3*
ASA
0
0.5
1
1.5
2
2.5
UA/NSTEMI
Primary Prevention
Stable Angina
*P<.0001 MI
*P=.0003 MI
*P=.008 Death or MI
*P=.012 Death or MI
N= 11034 11037 155 178 279 276 118 121
MI, myocardial infarction; ASA, acetylsalicylic acid; RISC, Research on InStability in Coronary artery disease; ISIS-2, Second International Study of Infarct Survival.
PHS. N Engl J Med. 1989;321:129-35.
Ridker PM, et al. AJC. 1991;114:835-839.
Cairns JA, et al. N Engl J Med. 1985;313:1369-1375.
Theroux P, et al. N Engl J Med. 1988;319:1105-1111.
Placebo
Placebo
Placebo
Placebo
Patients (%)
Indirect Comparisons of ASA Doses on Vascular Events in High-Risk Patients
* Odds reduction.
Treatment effect P<.0001.
ASA, acetylsalicylic acid.
Adapted with permission from BMJ Publishing Group. Antithrombotic Trialists’ Collaboration. BMJ. 2002;324:71-86.
0.5
1.0
1.5
2.0
500-1500 mg 34 19
160-325 mg 19 26
75-150 mg 12 32
<75 mg 3 13
Any aspirin 65 23
Antiplatelet Better
Antiplatelet Worse
Aspirin Dose No. of Trials (%)
Odds Ratio
0
OR*
BRAVO: Bleeding By ASA dose
Topol EJ, et al. Circulation. 2003;108:399-406. (with permission)
Outcomes by Aspirin Dose in Placebo Study Drug Patients
Low Dose, 75-162 mg/d (n=2410)
Higher Dose, >162 mg/d (n=2179)
Primary end point 16.4 18.6
Death, MI, stroke 6.2 6.1
Death 2.8 1.7
MI 2.0 2.1
Stroke 2.1 2.8
Urgent hospital care 9.5 10.6
Urgent resuscitation 7.3 10.0
Internal bleeding 2.4 3.3
Any bleeding 11.1 15.4
Transfusion 1.0 2.0
Clopidogrel
+ ASA?
(N=6259)
Placebo
+ ASA*
(N=6303)
CURE: Major Bleeding at 1 year by ASA Dose
<100 mg (N=5320) 1.9% 3.0%
100-199 mg (N=3109) 2.8% 3.4% >200 mg (N=4110) 3.7% 4.9%
P value for trend .0001 .0009
* P=.0001.
? P=.0009.
Adapted from Peters RJG, et al. Circulation. 2003;108:1682-1687.
ASA Dose
RR:
Death/MI
ASA Alone 68/655=10.4%
Heparin + ASA 55/698=7.9%
B
B
B
B
B
B
B
0.1
1
10
Summary Relative Risk
0.67 (0.44-0.1.02)
Theroux
RISC
Cohen 1990
ATACS
Holdright
Gurfinkel
Comparison of Heparin + ASA vs ASA Alone
ASA, acetylsalicylic acid; RISC, Research on InStability in Coronary artery disease; ATACS, Antithrombotic Therapy in Acute Company Syndromes; RR, relative risk; MI, myocardial infarction.
Oler A, et al. JAMA. 1996;276:811-815. (with permission)
TIMI, Thrombosis in Myocardial Infarction; ESSENCE, Efficacy and Safety of Subcutaneous Enozapam in Non–Q-Wave Coronary Events; UHF, unfractionated heparin; ENOX, enoxaparin; MI, myocardial infarction; OR, odds ratio.
Antman EM, et al. Circulation. 1999;100:1602-1608. (with permission)
TIMI IIB/ESSENCE Metanalysis: Enoxaparin vs Unfractionated Heparin
UHF, unfractionated heparin; ENOX, enoxaparin; RRR, relative risk ratio.
Antman EM. Circulation. 1999;100:1593-1601. (with permission)
TIMI IIB: Early Phase Death/MI/Urgent Revasc
UFH
Enoxaparin
P=.03
Major Bleeds—96 Hours
INTERACT: Enoxaparin vs Unfractionated Heparin With GP IIb/IIIa Inhibitors
Goodman SG, et al. Circulation. 2003;107:238-244.
Death/MI—30 Days
P=.031
UFH
Enoxaparin
Percent
A-Phase Study Design
UA/
NSTEMI
Final A visit 30 days
Randomize
- 24 hours
Chest pain
Min 0 hour Max 120 hour
Tirofiban
+ ASA
Hour 0
Aggressive or conservative
care per local practice
2026
1961
ENOX
1mg/kg q12 hr
UFH
Weight-adjusted
Z
Z
Treat & Evaluate for Z-Phase
2018
1952
3987
1? endpoint
7 days
Blazing M. presented at ACC 2003.
0
10
20
30
0
2
4
6
8
10
12
UFH
Enoxaparin
UFH
ENOX
Days From Randomization
Event Rates (%)
Day 7
8.4% (169 events)
9.4% (184 events)
7- and 30-Day Primary Endpoint Composite Death, MI and Refractory Ischemia
Blazing M. presented ACC 2003.
Enox Test vs Outcomes
Moliterno DJ, et al. JACC. 2003;42:1132-1139. (with permission)
Death/MI/Urg TVR Bleeding
30
25
20
15
10
5
0
200
250
300
350
400
450
500
550
600
200
250
300
350
400
450
500
550
600
Probability of MACE (%)
Probability of Any Bl