非ST段抬高急性ACS的诊断治疗NSTEACS临床指南解读.pptx

非ST段抬高急性ACS的诊断治疗------NSTEACS临床指南解读首都医科大学附属北京朝阳医院心脏中心杨新春概 况Q waveMIStableAnginaUnstableAnginaNon-Q wave MIECG – ST ? ECG - ST ? CK-MB Troponin CRP, IL-6, TNF a, PAI 1, NF-KB, CD40, COX-2急性冠脉综合征图谱Non ST Elevation ACSST Elevation MIHigh- risk featuresLow -risk features急性冠脉综合征Presumed prognosis: very high risk of in-hospitaldeathPresumed prognosis: low risk of in-hospital death, unless MI developsTreatment goal: stabilize with aspirin heparin monitor for MI developmentTreatment goal: prevent death by restoring coronary blood flow– Cardiac Enzymes+ Cardiac enzymesScheduledPCIFibrinolytictherapyDirectPCIManage medicallyST ? ACS% Cumulative mortality at 6 monthsST ? MI with fibrinolyticsT-wave inversionACSGranger CB et al. J Am Coll Cardiol. 1998; 31:79A.ACS患者6个月死亡率STEMI NSTEMI冠状动脉病变支数的比较Savonitto S, et al. J Am Med Asoc. 1999; 281:707-713.病因及病理急性冠脉综合征的病理机制易损斑块因破裂、侵蚀、钙化结节等因素引起血栓形成血栓形成可以形成阻塞性 (15%) 或非阻塞性 (85%) 的血栓阻塞状态取决于血栓形成的速度与体内自溶的平衡血小板的粘附和激活 血小板粘附于损伤的内皮表面并被激活 血小板聚集形成血栓 血流中的正常血小板 血小板血栓血小板粘附到内皮下腔血小板内皮细胞内皮下腔非ST段抬高的ACSResults from cross-linking of platelets by fibrinogen atplatelet receptors GP IIb-IIIaat site of plaque rupture冠脉被富含血小板的血栓部分堵塞UnobstructedlumenGP IIb-IIIaplateletthrombusfibrinogenRupturedplaqueArtery wallST段抬高AMIResults from stabilization of a platelet aggregate at site of plaque rupture by fibrin mesh冠脉被血栓完全堵塞plateletRBCfibrin meshGP IIb-IIIa危险分层肌钙蛋白T对预后的影响: 荟萃分析RR 3.9(2.9-5.3)RR 3.8(2.6-5.5)NegPos (Trop I + T)%32218497373634No. Studies: 13 6Heidenreich PA, J Am Coll Cardiol. 2001;38:478-485.白细胞计数和死亡率的关系20%15%30-Day Mortality10%5%005101520WBC Count (x103)Cannon CP, et al. Am J Cardiol. 2001;87:636-639. (with permission)肌钙蛋白I (TnI), C反应蛋白 (CRP), 以及脑钠肽 (BNP) 水平与30天死亡率的关系P=.014P.001671501557832490504717 Sabatine M, et al. Circulation. 2002;105:1760-1763. (with permission)10ST ? ACS8STEMI with fibrinolytics6Cumulative Mortality (%)4T-wave inversion200306090120150180Days From RandomizationGUSTO IIb: ACS患者基础ECG改变与6个月死亡率的关系GUSTO, Global Use of Strategies To Ope