陈纪言

广东省人民医院

从最新欧洲指南看 ACS诊疗进展

ESC Guidelines for the management of NSTEMI

• Management strategy

• Step one: initial evaluation

• Step two: diagnosis validation and risk assessment

• Step three: invasive strategy

ESC Guidelines for the management of NSTEMI

• Treatment

– Anti-ischaemic agents

– Antiplatelet agents

– Anticoagulants

– Coronary revascularization

– Special populations and conditions

– Long-term management

ESC Guidelines for the management of NSTEMI

• Anti-ischaemic agents

– decrease myocardial oxygen demand

– increase myocardial oxygen supply

b-Blockers

Nitrates

Calcium channel blockers

ESC Guidelines for the management of NSTEMI

• Antiplatelet agents

– Aspirin

– Clopidogrel\Prasugrel

– glycoprotein IIb/IIIa receptor inhibitors

P2y12拮抗剂的建议

ESC Guidelines for the management of NSTEMI

clopidogrel treatment was recommended to be

withheld for 5 days and ticagrelor for 1–3 days

before CABG （ PLATO trial)

Withdrawal of clopidogrel in high risk cohorts such

as those with ongoing ischaemia in the presence of

high risk anatomy (e.g. left main or severe proximal

multivessel disease) is not recommended

The optimal timing of restarting medication

following CABG surgery remains uncertain.

ESC Guidelines for the management of NSTEMI

• Upstream vs procedural initiation of

glycoprotein IIb/IIIa receptor inhibitors

– ACUITY Timing trial\EARLY-ACS trial

– no advantage with a routine upstream use

• may be considered if there is active

ongoing ischaemia among high risk

patients or DAPT is not feasible

ESC Guidelines for the management of NSTEMI

• Coronary revascularization

– Invasive versus conservative approach

– Timing of angiography and intervention

– Percutaneous coronary intervention

versus coronary artery bypass surgery

– Risk stratification should be performed

as early as possible

ESC Guidelines for the management of NSTEMI

• Urgent invasive strategy (<120 min after first medical contact)– Refractory angina (indicating evolving MI

without ST abnormalities)– Recurrent angina despite intense

antianginal treatment, associated with ST depression (2 mm) or deep negative T waves.

– Clinical symptoms of heart failure or haemodynamic instability (‘shock’).

– Life-threatening arrhythmias (ventricular fibrillation or ventricular tachycardia).

ESC Guidelines for the management of NSTEMI

• Early invasive strategy (<24 h after first

medical contact)

– High risk patients as identified by a GRACE

risk score >140 and/or the presence of at

least one primary high risk criterion (Table 9)

should undergo invasive evaluation within 24

h.

ESC Guidelines for the management of NSTEMI

• Invasive strategy (<72 h after first medical contact)– less acute risk, GRACE risk score <140

• Conservative strategy (no or elective angiography)– No recurrence of chest pain.– No signs of heart failure.– No abnormalities in the initial ECG or a

second ECG (at 6–9 h).– No rise in troponin level (at arrival and at

6–9 h).– No inducible ischaemia.

特殊人群的治疗

ESC Guidelines for the management of NSTEMI

Special populations and conditions- The elderly: >75 years

one of the most important predictors of riskat higher risk of side effects from medical

treatment: bleeding• SYNERGY trial: enoxaparin>UFH• OASIS-5 trial: enoxaparin>fondaparinux

(TACTICS)\TIMI 18 trial: patients>75 years

with NSTE-ACS derived the largest benefit

from PCI

ESC Guidelines for the management of NSTEMI

• Gender issues– older than men– higher bleeding risk than men– Contradictory results have been published

ESC Guidelines for the management of NSTEMI

• Diabetes mellitus

• independent predictor of mortality:two-fold

ESC Guidelines for the management of NSTEMI

• Chronic kidney disease

– independent predictor of mortality and of

major bleeding

– dose adjustment

– hydration and low- or iso-osmolar contrast

– medium at low volume (<4 mL/kg) are

recommended

ESC Guidelines for the management of NSTEMI

• heart failure

• independent predictors of mortality

ESC Guidelines for the management of NSTEMI

• Step five: hospital discharge and post-discharge management

ESC Guidelines for the management of NSTEMI

谢 谢谢 谢