非ST段抬高急性冠脉综合征的危险分层和治疗策略

临床上，非ST段抬高急性冠脉综合征（ACS）包括不稳定型心绞痛和非Q波心肌梗死，极为常见，根据临床，心电图，血清生化，左心功能状态和冠状动态（冠脉）病变作危险分层对治疗策略的制定尤为重要。尽管内科保守治疗已普遍采用，但对心绞痛反复发作，ST段压低，TnT或TnI增高，血流动力学或心电不稳定，心肌梗死后早期不稳定型心绞痛等高危患者，应尽早行冠脉造影，并根据冠脉病变情况决定行介入治疗（最好联合应用血小板GPⅡb/Ⅲa受体阻滞剂），以改善患者的临床预后。     

非ST段抬高型急性冠状动脉综合征最新进展

对非ST段抬高急性冠状动脉综合征病理生理机制深入了解、诊断工具的进步和危险分层标准的更新．为选择治疗方案提供更好的依据。三联抗血小板药、普拉格雷、磺达肝癸钠、比伐卢定对高危的患者均显示强大的临床益处。ICTUS试验结果的公布及药物洗脱球囊的开发使我们对介入时机的选择及防治支架内再狭窄等都有最新的认识。     

非ST段抬高型急性冠状动脉综合征最新进展

对非ST段抬高急性冠状动脉综合征病理生理机制深入了解、诊断工具的进步和危险分层标准的更新．为选择治疗方案提供更好的依据。三联抗血小板药、普拉格雷、磺达肝癸钠、比伐卢定对高危的患者均显示强大的临床益处。ICTUS试验结果的公布及药物洗脱球囊的开发使我们对介入时机的选择及防治支架内再狭窄等都有最新的认识。     

非ST段抬高性急性冠状动脉综合征介入治疗的远期随访

目的　探讨非ST段抬高性急性冠状动脉 (冠脉 )综合征介入治疗的远期疗效。方法　对 1991年 1月至 2 0 0 0年 1月 2 2 4例进行冠脉介入治疗的病人进行了随访研究 ,随访时间 10～ 10 8个月 ,平均 ( 32 4± 19 5 )个月。根据临床资料分非ST段抬高性急性冠脉综合征组 (n =12 6 )和稳定型心绞痛组 (n =98)。将全部病例的随访情况进行了对比研究。结果　非ST段抬高性急性冠脉综合征组和稳定型心绞痛组之间的胸痛 ( 0 71± 0 79和 0 36± 0 5 7,P >0 0 5 ) ,气急、气短 ( 0 2 4± 0 4 8和 0 13± 0 34,P >0 0 5 )和心悸症状 ( 0 89± 1 0 3和 0 36± 0 5 7,P >0 0 5 )的积分差异无显著性。两组间超声心动图局部室壁运动异常发生率 ( 6 5 %和 5 9% ,P >0 0 5 )和次极量负荷实验阳性率 ( 19%和 13% ,P>0 0 5 )差异无显著性 ,两组的无心脏事件生存率和死亡率差异无显著性 ( 6 2 %和 91% ,P >0 0 5 ;5 %和 1% ,P >0 0 5 )。两组患者的主观满意率分别是 84 %和 94 % (P >0 0 5 )。结论　非ST段抬高性急性冠脉综合征的介入治疗可获得较好的远期效果 ,并与稳定型心绞痛的介入治疗效果相同。     

介入治疗非ST段抬高的急性冠状动脉综合征

目的　观察介入治疗非ST段抬高的急性冠状动脉综合征 (acutecoronarysyndromes ,ACS)的安全性及临床效果。方法　 16 5例ACS患者 ,接受急诊介入治疗的 89例 ,经内科治疗病情改善后再介入治疗的 76例。所有“罪犯”病变均予治疗 ,其中 4 1例患者同时接受了“罪犯”与非“罪犯”病变血管的治疗。介入方法有经皮冠状动脉腔内成形术 (PTCA) +支架、直接植入支架及切割球囊扩张。结果　 16 5处“罪犯”病变PTCA后植入支架 134枚 ,直接植入支架 4 8枚。术后残余狭窄均 <10 % ;前向血流达TIMI 3级 ;136例患者心绞痛消失 ,11例有不典型胸痛 ,2 4h后消失 ;术前仅有胸闷症状的 18例患者 ,术后 15例消失 ,3例减轻 ;无术中死亡及急诊冠状动脉旁路移植术 (CABG)病例。随访 139例患者 2～ 18个月 ,2 0例再发心绞痛 ,有 14例冠状动脉造影提示再狭窄 ,其中 11例再次行PTCA ,1例PTCA +支架 ,2例接受外科CABG ;无急性心肌梗死、猝死及心功能恶化发生。结论　在条件具备的介入中心 ,由经验丰富和技术娴熟的介入治疗医生施行或在其指导下 ,对非ST段抬高的ACS患者进行介入治疗是积极有效的治疗措施 ,近、远期临床效果较满意 ,手术成功率及安全性较高     

重视无ST段抬高的急性冠状动脉综合征的防治

一、急性冠状动脉综合征分类的演变　　 2 0世纪 80年代以前人们将急性冠状动脉综合征分为“透壁”和“非透壁”心肌梗死 ,对不稳定心绞痛的重视不够。 80～ 90年代初 ,急性冠状动脉综合征被分为“Ｑ波”和“无Ｑ波”心肌梗死 ,对不稳定型心绞痛有了进一步认识。 90年代以来 ,急性冠状动脉综合征按照早期的心电图表现有无ＳＴ段抬高分类 ,分为ＳＴ段抬高的心肌梗死和无ＳＴ段抬高的急性冠状动脉综合征 ,后者包括无Ｑ波心肌梗死和不稳定型心绞痛 ,这二者又被称为不稳定性冠状动脉疾病 ,十分重视不稳定心绞痛。以有无ＳＴ段抬高作为分类的标准…     

非ST段抬高型急性冠脉综合征的危险分层和处理策略

急性冠脉综合征(ACS)是一组由于冠状动脉急性缺血引起的临床综合征.尽管具有共同的病理生理基础,但不同ACS患者缺血和出血风险不同,其死亡和心血管不良事件发生率也存在明显差异.及时准确地对ACS患者进行危险分层,采取及时有效的处理策略,对改善患者预后具有重要意义.我们对非ST段抬高型ACS(NSTE-ACS)的危险分层及处理策略进行阐述.     

非ST段抬高型急性冠状动脉综合征介入治疗的最佳时机

非ST段抬高型急性冠状动脉综合征(NSTEACS)中高危患者,早期介入和强化抗栓药物治疗是最佳选择,对于低危患者,早期介入或选择介入都可行。欧洲心脏病协会指南认为NSTEACS症状反复发作,并有高危因素,Grace风险评分>109分,推荐于发病72h内行介入治疗;Grace风险评分>140分,建议24h内行介入治疗;对并发难治性心绞痛、心力衰竭、恶性心律失常者建议发病2h内介入治疗。     

非ST段抬高急性冠状动脉综合征介入治疗时机选择

非ST段抬高急性冠状动脉综合征(NSTE-ACS)是由于不稳定的冠状动脉粥样硬化斑块破裂和(或)激发血栓形成所致的急性心肌缺血综合征,包括不稳定性心绞痛(UA)和非ST段抬高心肌梗死(NSTEMI)．具有发病急、变化快、临床表现与危险性不均一等特征。     

冠状动脉经皮介入术治疗高龄非ST段抬高型急性冠脉综合征的疗效

目的 评价经皮冠状动脉介入（PCI）治疗在高龄（>80岁）非ST段抬高型急性冠脉综合征(NSTE-ACS)中的安全性和有效性。方法 经冠状动脉造影检查证实冠脉狭窄程度在70%~90%的NSTE-ACS患者175例,根据是否介入治疗分为,介入组84例（发病后3~7 d接受择期PCI）,药物组91例（未行PCI术,单纯优化药物治疗）。观察记录两组患者临床特征、1年随访期间主要心血管不良事件。结果 介入组与药物组相比,介入组能显著降低心因住院、血运重建、心绞痛复发风险,在全因死亡、脑梗死、严重的出血事件方面差异无统计学意义。结论 对于高龄NSTE-ACS患者接受PCI术是安全、有效的。     

The magnitude of percutaneous coronary intervention treatment in high and medium risk non-ST elevation acute coronary syndrome

IntroductionCurrent ESC guideline supported invasive treatment of non-ST elevation acute coronary syndrome (NSTE-ACS) is guided by GRACE risk model.ObjectiveThe aim of this study was to determine whether the percutaneous coronary intervention treatment in (NSTE-ACS) ameliorates the long-term mortality assessed by GRACE risk score.MethodsWe conducted a retrospective study of a consecutive sample of 680 patients with (NSTE-ACS) treated by PCI in Heart Center of Semmelweis University. The GRACE risk score was calculated for each patient at admission. The mean of relative risk in each group was assessed and compared with the long-term clinical outcomes (observed 6-month mortality).ResultsThe mean of calculated GRACE amounts to 1.6% for low risk patients, 5.0% for medium risk patients, and 21.3% for patients with high risk. In contrast, the observed risk of 6-month death was 0.42% for low risk patients, 1.1% for medium risk patients, and 12.6% for patients with high risk. The difference between assessed and observed 6-month mortality in high risk and medium risk groups was significant (medium risk p = 0.004; high risk p = 0.0097). Observed risk of death in low risk patients was also lower, but not significant than assessed risk.ConclusionThe risk of death in patients with NSTE-ACS treated in a high volume center is significantly lower than predicted by the GRACE risk model. Our results suggest that percutaneous coronary intervention treatment guided by the GRACE risk model in medium and high risk patents with (NSTE-ACS) provides the greatest clinical benefit.     

Temporal trends in the use of invasive cardiac procedures for non-ST segment elevation acute coronary syndromes according to initial risk stratification

BACKGROUND:

Current guidelines support an early invasive strategy in the management of high-risk non-ST elevation acute coronary syndromes (NSTE-ACS). Although studies in the 1990s suggested that high-risk patients received less aggressive treatment, there are limited data on the contemporary management patterns of NSTE-ACS in Canada.

OBJECTIVE:

To examine the in-hospital use of coronary angiography and revascularization in relation to risk among less selected patients with NSTE-ACS.

METHODS:

Data from the prospective, multicentre Global Registry of Acute Coronary Events (main GRACE and expanded GRACE²) were used. Between June 1999 and September 2007, 7131 patients from across Canada with a final diagnosis of NSTE-ACS were included the study. The study population was stratified into low-, intermediate- and high-risk groups, based on their calculated GRACE risk score (a validated predictor of in-hospital mortality) and according to time of enrollment.

RESULTS:

While rates of in-hospital death and reinfarction were significantly (P<0.001) greater in higher-risk patients, the in-hospital use of cardiac catheterization in low- (64.7%), intermediate- (60.3%) and high-risk (42.3%) patients showed an inverse relationship (P<0.001). This trend persisted despite the increase in the overall rates of cardiac catheterization over time (47.9% in 1999 to 2003 versus 51.6% in 2004 to 2005 versus 63.8% in 2006 to 2007; P<0.001). After adjusting for confounders, intermediate-risk (adjusted OR 0.80 [95% CI 0.70 to 0.92], P=0.002) and high-risk (adjusted OR 0.38 [95% CI 0.29 to 0.48], P<0.001) patients remained less likely to undergo in-hospital cardiac catheterization.

CONCLUSION:

Despite the temporal increase in the use of invasive cardiac procedures, they remain paradoxically targeted toward low-risk patients with NSTE-ACS in contemporary practice. This treatment-risk paradox needs to be further addressed to maximize the benefits of invasive therapies in Canada.     

Percutaneous coronary intervention in diabetic patients with non-ST-segment elevation acute coronary syndromes.

Key pathophysiologic mechanisms of diabetes-related coronary disease include inflammation and a prothrombotic state. In the setting of non-ST-segment elevation acute coronary syndromes diabetic patients are at high risk for subsequent cardiovascular events. At the same time, they derive greater benefit than non-diabetic counterparts from aggressive antithrombotic therapy, early coronary angiography, and stent-based percutaneous coronary intervention. The mainstays of antithrombotic therapy for diabetic patients undergoing percutaneous revascularization include aspirin, clopidogrel, platelet glycoprotein IIb/IIIa receptor antagonists, and heparin or low-molecular-weight heparin. Despite dramatic reduction in restenosis conferred by drug-eluting stents, diabetic patients remain at increased risk for repeat revascularization. More efforts are needed both in terms of local drug elution as well as systemic pharmacologic therapies to further contain the excessive neointimal proliferation that characterizes the diabetic response to vascular injury.     

The use of risk scores for stratification of non-ST elevation acute coronary syndrome patients

OBJECTIVE:

To review the methods available for the risk stratification of non-ST elevation (NSTE) acute coronary syndrome (ACS) patients and to evaluate the use of risk scores for their initial risk assessment.

DATA SOURCES:

The data of the present review were identified by searching PUBMED and other databases (1996 to 2008) using the key terms “risk stratification”, “risk scores”, “NSTEMI”, “UA” and “acute coronary syndrome”.

STUDY SELECTION:

Mainly original articles, guidelines and critical reviews written by major pioneer researchers in this field were selected.

RESULT:

After evaluation of several risk predictors and risk scores, it was found that estimating risk based on clinical characteristics is challenging and imprecise. Risk predictors, whether used alone or in simple binary combination, lacked sufficient precision because they have high specificity but low sensitivity. Risk scores are more accurate at stratifying NSTE ACS patients into low-, intermediate- or high-risk groups. The Global Registry of Acute Cardiac Events risk score was found to have superior predictive accuracy compared with other risk scores in ACS population. Treatments based according to specific clinical and risk grouping show that certain benefits may be predominantly or exclusively restricted to higher risk patients.

CONCLUSION:

Based on the trials in the literature, the Global Registry of Acute Cardiac Events risk score is more advantageous and easier to use than other risk scores. It can categorize a patient’s risk of death and/or ischemic events, which can help tailor therapy to match the intensity of the patient’s NSTE ACS.     

急性冠状动脉综合征的抗血小板治疗

急性冠状动脉综合征 (ACS)发生的成因主要由冠状动脉内不稳定的斑块形成及破损。在此基础上 ,血小板发生活化并介导血栓形成 ,因此抗血小板药物在 ACS的治疗中有着重要的地位。本文就抗血小板药物应用进展作一综述     

Rates and causes of death from non-ST elevation acute coronary syndromes: Ten year follow-up of the PRAIS-UK registry

Background

Long term nationally representative mortality rates following acute coronary syndrome (ACS) admissions are lacking beyond 5 years. We report rates and causes of mortality at approximately 10 years from PRAIS-UK.

Methods

PRAIS-UK was a prospective registry of 1046 non-ST-elevation ACS admissions to 56 UK hospitals between 1998 and 1999. 493 patients surviving to 6 months were consented to long term follow-up. We identified deaths and causes (ICD codes) via the UK central death register and examined the influence of baseline characteristics and early revascularisation procedures. A modified GRACE risk score was constructed to determine the association of baseline score with long term risk of death.

Results

The mean age was 66 years and 40% were women. After a median follow-up of 11.6 years (IQR 6.3–11.9), 46% (225) of patients had died with 55% being classified as cardiovascular. In a multivariate analysis, the following variables were associated with higher mortality (hazard ratio [HR] and 95% confidence intervals [CI]): age (10 years increase) 2.14 (1.87 to 2.45), ST depression or bundle branch block (compared to normal ECG) 1.68 (1.06 to 2.67), and history of heart failure (compared to no HF) 1.81 (1.28 to 2.56). The HR for risk of death in patients who received a revascularisation procedure (versus those who did not) in the first 6 months was 0.41 (0.24 to 0.69). The mean adapted GRACE score was 99.3 ± 26.4, associated with approximately 50% mortality at 10 years.

Conclusions

Non-ST elevation ACS is associated with about 50% mortality over 10 years that may be improved by early revascularisation. Well designed long-term registries can provide key data to determine prognosis and burden of disease.     

Electrocardiographic diagnosis of non-ST-segment elevation acute coronary syndromes: current concepts for the physician

With several myocardial infarction (MI) registries reporting a decline in the incidence of ST-elevation MI (STEMI) and an increase in non-ST-elevation MI (NSTEMI) and unstable angina (UA), it is important that future healthcare resources are directed towards this increased volume of patients, ECG technology, core to the early diagnosis of these patients, has lagged behind relative to other techniques and little progress has been as far as acute coronary syndrome triage is concerned beyond ST-segment deviation. We present a review of the literature on current electrocardiographic changes which will allow admitting physicians to better risk stratify those patients with “non-diagnostic ECGs.” These ECGs may become diagnostic with careful evaluation, use of serial ECGs and when additional lead sets are used.     

盐酸替罗非班对急性冠脉综合征并冠脉内血栓的疗效观察

目的探讨冠状动脉内注射盐酸替罗非班治疗急性冠脉综合征并冠脉内血栓的疗效。方法对2005年12月至2006年9月首都医科大学附属北京友谊医院心血管中心经冠状动脉造影证实为急性冠脉综合征并冠脉血栓病变患者38例,随机分为替罗非班组19例和对照组19例。替罗非班组在经皮腔内冠脉成形术(PT-CA)和(或)支架置入治疗前(后)行冠状动脉内注射盐酸替罗非班10~30mL,之后进行支架置入,术后静脉滴注盐酸替罗非班0.15μg/(kg.min)持续24~48h。对照组采用常规经皮冠状动脉介入治疗(PCI)。观察两组PCI术前、术后心肌梗死血栓溶解(TIMI)积分、TIMI血流、无复流或慢血流、校正的TIMI帧计数(cTFC)、心肌灌注分级(MBG),术后左心室射血分数(LVEF)及住院期间出血并发症与包括死亡、再发心肌梗死、再次血运重建等的主要心血管不良事件(MACE)发生情况。结果盐酸替罗非班组与对照组相比治疗后TIMI血栓积分明显下降(0.90±0.14对1.53±0.54,P<0.01),最后TIMI血流改善[(2.78±0.32)%对(2.14±0.23)%,P<0.01],cT-FC降低[(17.9±5.1)%对(25.3±13.2)%,P<0.01],MBG改善[(2.70±0.54)%对(2.06±0.38)%,P<0.01];盐酸替罗非班组左室射血分数显著高于对照组[(57.1±12.6)%对(51.0±13.9)%,P<0.01];两组住院期间出血并发症与MACE比较差异无显著性意义。结论盐酸替罗非班可改善合并冠脉血栓病变的急性冠状动脉综合征的血栓负荷、冠状动脉血流、心肌灌注和左室收缩功能,且不增加患者住院期间主要并发症的发生。     

Determinants of use and outcomes of invasive coronary procedures in acute coronary syndromes: results from ENACT.

AIMS: To explore the variations in the use of invasive coronary procedures after acute coronary syndromes. METHODS AND RESULTS: In the ENACT registry, use of invasive procedures was analyzed as a function of hospital type, country and patient characteristics among 2768 patients with acute coronary syndromes (731 with ST-segment elevation myocardial infarction (STEMI) within 12h of symptom onset, and 2037 with other acute coronary syndromes). Percutaneous coronary intervention (PCI) was more likely to be performed in teaching than in community hospitals, and in hospitals with, rather than without, catheterization facilities. There were marked country-to-country variations in the use of PCI during the index hospital stay, ranging from 8 to 67% after STEMI (p<0.001) and from 9 to 44% after other acute coronary syndromes (p<0.001). The main independent predictors of the performance of PCI were the country rate of use of PCI and the hospital availability of PCI. For patients with other acute coronary syndromes, the risk of adverse events, assessed by the simplified TIMI-risk score, was not associated with PCI. Logistic regression analysis showed that lack of PCI was an independent predictor of in-hospital mortality (odds ratio (OR): 3.75, p<0.029) after other acute coronary syndromes, but not after STEMI. CONCLUSIONS: The use of PCI after acute coronary syndromes appears related more to local practice and hospital characteristics than to patients' characteristics or risk.     

急性冠状动脉综合征介入并用替罗非班的近期疗效

目的评价急性冠状动脉综合征病人接受经皮冠状动脉介入术治疗中,使用国产血小板糖蛋白Ⅱb/Ⅲa(GPⅡb/Ⅲa)受体阻断药替罗非班(tirofiban)的近期疗效及安全性。方法急性冠状动脉综合征行介入治疗病人90例,分成替罗非班组及安慰剂组,替罗非班组剂量10μg/kg,在3min内静脉注入,然后以每分钟0.1μg/kg维持24～72h,随访30d,观察亚急性血栓形成、死亡、心肌梗死和紧急靶血管血运重建、出血等临床终点事件。结果两组临床、冠状动脉造影及介入治疗基线特征差异无统计学意义,替罗非班组及安慰剂组死亡、心肌梗死和紧急靶血管血运重建联合终点事件发生率,分别为2%和15%,差异有统计学意义(P<0.05)。两组病人主要、次要及轻微出血事件发生率差异无统计学意义。结论替罗非班可改善急性冠状动脉综合征行介入治疗病人的近期疗效,安全性相似,病人耐受性好。