冠心病的治疗策略-这些病例我们可以“不做”演示文稿.pptVIP

武汉亚洲心脏病医院 朱国英 冠 心 病 药物治疗 介入治疗 外科手术 冠心病的治疗策略 危险因素 血运重建 Balloon Angioplasty Stents Drug Eluting Stents 1977-1989 1990-2000 2001- CRF DES Evidence-based Medicine Guidelines Summary 2007 Ⅰ Ⅱa Ⅱb Ⅲ A ISR of BMS B CTO Bifurcation ( DES main branch, side branch PTCA w/provisional DES ) Multivessal disease ( Vs. CABG ) (Pts. with mostly non complex lesion ) ISR with branchytherapy failure Bifurcation ( planned 2 stent – either routine T-stent of crush ( with final kiss ) or SKS ( V-stent ) Multivessal disease ( Vs. CABG ) (Pts. With multiple complex lesion, diffuse disease, especially diabetics ) Unprotected LM AMI C DES for ISR of DES ( ? same or different DES ) OAT Trial - Study Design Primary Endpoints: Death, MI, or NYHA class IV heart failure PCI with stenting n=1082 Medical Therapy n=1084 2166 patients with angiography on day 3-28 post-MI revealing total occlusion of the infarct-related artery with TIMI flow grade 0 or 1; and meeting a criterion for increased risk, defined as EF 50%, proximal occlusion of a major epicardial vessel with a large risk region, or both Exclusions: NYHA class III or IV heart failure, shock , serum creatinine concentration 2.5 mg/dl, angiographically significant left main or three-vessel coronary artery disease, angina at rest, or severe ischemia on stress testing. Randomized. 22% female, mean age 59 years, mean follow-up 3 years, mean EF 48% at baseline Concomitant medications: Aspirin, anticoagulation if indicated, ACE inhibitors, beta-blockers, and lipid-lowering therapy, unless contraindicated Presented at AHA 2006 COURAGE : Study design 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 wi