冠状动脉血运重建的适宜标准于洪泉PPT.ppt

接受PCI治疗适宜标准 无论有无糖尿病或LVEF下降合并下列情况： 二支冠脉病变，累及前降支近段 无论有无糖尿病或LVEF下降合并下列情况： 左主干狭窄合并其他冠脉病变 孤立左主干病变 PCI治疗非适应证 标准的作用 做为临床医生决定治疗方案的依据 作为临床医生的教育工具 作为医生和患者讨论治疗方案的依据 作为医师推荐需要再血管化患者的依据 作为保险支付单位预付的依据（支付，附加说明） 作为质量控制的依据 确保患者接受必须的，有益的，价效相当的治疗，而不是其它目的（rather than other purposes) Stent use in CHINA 2007 2002-2005 1997-2001 1996 DES use 90% ,partially 100% 胡大一教授指出 加强CABG力度-因为为患者带来长期存活的益处 规范PCI应用-尽管创伤较小，但不适当使用没有给患者带来益处。 COURAGE Study Boden WE et al. Am Heart J. 2006;151:1173-9. Boden WE et al. N Engl J Med. 2007;356:1503-16. Optimal medical therapy* + PCI (n = 1149) Optimal medical therapy(n = 1138) AHA/ACC Class I/II indications for PCI, suitable coronary artery anatomy + ≥70% stenosis in ≥1 proximal epicardial vessel + objective evidence of ischemia (or ≥80% stenosis + CCS class III angina without provocation testing) Primary outcomes: All-cause mortality, nonfatal MI Follow-up: Median 4.6 years Randomized *Intensive pharmacologic therapy + lifestyle interventionCCS = Canadian Cardiovascular Society Secondary outcomes: Death, MI, stroke; ACS hospitalization Number at Risk Medical Therapy 1138 1017 959 834 638 408 192 30 PCI 1149 1013 952 833 637 417 200 35 Years 0 1 2 3 4 5 6 0.0 0.5 0.6 0.7 0.8 0.9 1.0 PCI + OMT Optimal Medical Therapy (OMT) Hazard ratio: 1.05 95% CI (0.87-1.27) P = 0.62 7 Survival Free from Death and MI(median FU 4.6 yrs) Boden WE et al. NEJM 2007;356:1503-16 Freedom from Death or MI (%) Death/MI at 4.6 yrs 19.0% 18.5% COURAGE: Treatment effect on angina Boden WE et al. N Engl J Med. 2007;356:1503-16. P 0.001 P = 0.02 NS Angina-free(%) NS OAT 主要复合终点 (HR=1.16, p=0.20) 死亡、MI NYHA IV 级 Hochman JS, et al. NEJM 2006, 355:2395-407 ) 0 6 12 20 40 0 Months Since Allocation Cumulative Event Rate (%) TAXUS (N=118) CABG (N=103) P=0.19* 7.7% 13.0% Event rate ± 1.5 SE, *Fisher exact test Calculated b