非ST段抬高急性冠脉综合征.ppt

非ST段抬高急性冠脉综合征
Million Hospital
Discharges
AHA. Heart Disease and Stroke
Statistics—2019 Update
ACS
STEMI

Death/(re)-MI
ISAR-COOLPrimary Endpoint
CP1107655-2
30-day
event rate
(%)
Death & MI
Death
Neumann FJ et al JAMA 2019
P=
P=
P=
P=
Any nonfatal MI
Nonfatal Q-wave MI
RR (-)
Cooling off (n=207)
Early intervention (n=203)
ISAR-COOLFrequency of Events Before, After Catheterization
CP1107655-3
Death and MI (%)
Before
During and After
Neumann FJ et al JAMA 2019
P=
P=
Cooling off (n=207)
Early intervention (n=203)
Catheterization
Timing of an Invasive Strategy in Non-ST Elevation ACS
ISAR-REACT was a small, single center study
Other analyses also indicate that cath within 24 hours is better than later cath
Ought to use intensive antiplatelet therapy with a very early invasive strategy
What medical therapy ought to be used in ACS?
Antithrombotic Trialists’ Collaboration. BMJ. 2019;324:71–86.
OR*




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
Aspirin Dose and Events in High-Risk PtsFrequency of CV Death, MI, Stroke
P=
CURE
CP999547-2
Yusuf S et al NEJM 2019;16:494-502
Non-ST elevation ACS
12,562 patients
ASA 75 to 325 mg po qd
placebo
n=6,303
3-12 month follow-up
(average 9 mo)
ASA + clopidogrel
(300 mg load, 75 mg qd)
n=6,259
CURE: Aspirin Dose and Outcome
%
(N = 1,927)
(N = 7,428)
(N = 3,201)
ASA/Clopidogrel ASA/Placebo
CV Death, MI, Stroke
Major Bleeding
Aspirin in ACS
More bleeding with higher doses, especially when combined with clopidogrel, coumadin
Possibly greater efficacy with lower doses (not sure)
I recommend: <165 mg once daily
Guidelines: still recommend 81-365 mg aspirin
CURECV Death/MI/Stroke, 1 Year
CP999