糖尿病患者的支架选择.ppt

糖尿病患者的支架选择上海第二医科大学附属瑞金医院张大东教授糖尿病患者意味着什么迂曲病变,冠脉病变弥漫性小血管病变,管腔在造影下纤细、僵硬病变从小血管开始，逐渐向主干发展，或者同时发展血栓负荷更重糖尿病患者病变通常更复杂：内皮功能的损伤血小板功能的损伤凝血和纤维蛋白溶解的改变更多的平滑肌细胞增殖肾功能下降糖尿病患者通常有更高的事件率:糖尿病患者病变通常更复杂：迂曲，弥漫，小血管病变糖尿病患者病变通常更复杂：血栓负荷重，心功能差4 3 2 1 0 -1StoneG.etal,Circulation2001;104:642-7危险因素±95%CI(p0.05)研究显示糖尿病患者PCI术后的死亡率更高*IntheabsenceofnewQwaves7,106名PCI术后患者，平均随访1.4+0.5年肾功能衰竭糖尿病CK增加(8xULN)*桥血管既往心梗不稳定心绞痛左主干高胆固醇吸烟高龄唯一获得FDA糖尿病适应证的DESRESOLUTE糖尿病荟萃试验荟萃分析中，接近一半的患者更伴随其他危险因素无保护左主干分叉病变支架内再狭窄完全闭塞AMI(within72hrs)肾功能不全长病变(27mm)桥血管LVEF30%多支病变1处病变/血管血栓病变Withtheexceptionoflonglesions(treatablewithasingle38-mmlengthstent),ResoluteDEScurrentlyisnotspecificallyapprovedforthepatientsubsetsnotedinthiscomplexpatientdefinition.57%标准风险糖尿病43%

复杂病变糖尿病糖尿病患者N=1535RESOLUTE139RESOLUTEAC1140RESOLUTEInt2349RESOLUTEUS1402RESOLUTEJapan1005130Resolute?ZES入组患者标准风险糖尿病患者N=878Matchedcohortisallenrolleddiabeticsubjectsexcludingsubjectswithbifurcation,saphenousveingraft(SVG),ISR,AMI(≤72hours),leftventricularejectionfraction(LVEF)30%,anunprotectedleftmainlesion,≥3vessels,renalimpairment(creatinine≥140μmol/L),totallesionlengthpervessel27mm,≥2lesionspervessel,lesionwiththrombus,orlesionwithtotalocclusion.所有糖尿病患者N=1535标准风险患者FDA适应证YeungA.ACC2012RESOLUTE糖尿病荟萃研究*PerformancegoalbasedonDEStrialsmeta-analysis:DIABETES,RAVELDM,SIRIUSDM,TAXUSIV,SCORPIUS,ENDEAVORPooledDM.?RESOLUTEmatchedcohortdiabetespooledanalysis(n=878).WindeckerS.PresentedatEuroPCR.2011.Resolute获得FDA糖尿病适应证的临床证据Resolute应用于糖尿病患者，显著降低靶血管失败率（TVF）TLRisischemiadriven.Events(%)TheRESOLUTEPooledanalysiswasnotspecificallydesignedorpoweredfortheanalysisshownabove.所有糖尿病患者–24个月临床结果TVF添加标题01TLF添加标题02TLR添加标题03CardiacDeath添加标题04TVMI添加标题05ST(ARCDef/Prob)添加标题06RESOLUTEPooledanalysis,A