高润霖-冠心病介入治疗的热点-2008.ppt

冠心病介入治疗的热点-2008 中国医学科学院阜外心血管病医院 高润霖 DES的安全性和长期疗效  新一代DES ARC Proposed Standard Definitions Definite/Confirmed Acute coronary syndrome AND [Angiographic confirmation of thrombus or occlusion OR Pathologic confirmation of acute thrombosis] Probable Unexplained death within 30 days Target vessel MI without angiographic confirmation of thrombosis or other identified culprit lesion Possible Unexplained death after 30 days Stent Thrombosis: FDA Advisory Panel, 8RCT RCT荟萃分析显示,死亡、MI,不论on-label或off-label应用,在DES与BMS组均无显著差别;TVR则不论on-label或off-label应用 DES均明显低于BMS 30 项研究 174,302患者真实世界注册研究则显示,全因死亡、MI在DES组均明显低于BMS DES的长期安全性及有效性已得到临床试验及真实世界研究证实 Discontinuation of Anti-platelet Therapy and Risk for ST 不适宜长期双重抗血小板治疗的情况 计划中的非心脏手术 支架血栓形成的高危患者 出血并发症风险增加 高龄，贫血，肾功能衰竭，消化道出血后， 低体重 需长期服口服抗凝剂者 房颤、肺栓塞、机械瓣置换术后 不愿意或不能长期按医嘱服药者 Summary Long-term efficacy of DES is persistent and the safety of DES is confirmed by meta-analysis based on patients level Late stent thrombosis after DES implantation has emerged as a concerning entity Indication for DES stenting Proper dual antiplatelet therapy, at least 1year Technical improvement of DES and new type of DES are emerging and promising Acute Myocardial Infarction Emerging role of aspiration thrombectomy in a large trial from Europe TAPAS Primary endpoint Myocardial blush grade TAPAS: Mortality at 1 year TAPAS: Mortality or non-fatal ReMI at 1 year Take Home Message Unlike earlier studies with aggressive rheolytic thrombecomy, the mild aspiration thrombectomy had significant angiographic and clinical benefit in patients with STEMI having PCI 在稳定性CAD患者中，哪些患者更能从PCI获益 COURAGE: Study design COURAGE: Treatment effect on primary outcome COURAGE: Treatment effects COURAGE: Treatment effect on hospitalization for ACS COURAGE: Treatment effect on angina Treatment effect in CV and diabetes subgroups Need for Subsequent Revascularization At a median 4.6 year follow-up, 21