復(fù)雜的亞組患者中的血運(yùn)重建術(shù)葛均波英文

復(fù)雜的亞組患者中的血運(yùn)重建術(shù)葛均波英文第1頁/共44頁RevascularizationinComplexPatientSubsetsTheveryelderly(C.Grines)ComplexCADanddiabetes(V.Fuster)Chronickidneydisease(N.Lepor)PoorLVfunction(J.Bax)Vascularcomplicationsandwomen(B.Ahmed)第2頁/共44頁Revascularization

InTheVeryElderlyCindyL.Grines,M.D.,F.A.C.C.WilliamBeaumontHospitalRoyalOak,Michigan,U.S.A.第3頁/共44頁In-HospitalComplicationsAfterPCI:

EffectofAgeBachelor,JACC2000;36:723第4頁/共44頁Complications*AfterElectivePCI

inOctogenariansDeathMIQ-waveStrokeDeath/MI/CVARenalfailureVascularcomplicationsBachelor.JACC2000;36:723*p<.001forallcomplications******第5頁/共44頁

SafetyConcernsinACSCare:

TheElderlyBleedMoreYangetalJAmCollCardiol2005;46:1490-505101520<5555-6465-74≥75Agegroup(years)BloodTransfusion(%)<5555-6465-74≥75Agegroup(years)#ofAnti-platelet/coagulantsUsed*1AgentUsed2AgentsUsed≥3AgentsUsed*Aspirin,Clopidogrel,UFH,LMWH,GPIIb/IIIaInhibitor第6頁/共44頁AcuteCoronarySyndromeRegistriesElderlypatientsVaguesymptomsMoreco-morbiditiesLesslikelytoreceivemedicaltreatmentsofprovenbenefitLesslikelytoreceivecathorrevascularizationWorseoutcomesPRAIS-UK,AgeandAging2005;34:61-66CRUSADE,JAMA2004;292:2096-104GRACE,AmHeartJ2005;149:67-73第7頁/共44頁TACTICS-TIMI18:ElderlyACSPatientsBenefittheMostFromEarlyInvasiveStrategyAnnInternMed2004;141:186-195第8頁/共44頁AMIintheElderlyAdvancedagestrongestdeterminantofearlyandlatemortality80%ofalldeathsareinpatients>60yearsoldriskofintracranialbleedingMinorityreceivelytictherapy(10%ofpatients>65yearsold)第9頁/共44頁<75yrs(n=2580)75yrs(n=452)p<.001p=.01p<.001p<.001p<.001p<.001DeGeare.AJC2000;86:30PCIrestoredTIMI3flowin92%ofyoung,85%ofelderly(p=.001)OutcomeofPAMIPatientsBasedonAge第10頁/共44頁SeniorPAMI:30-DayOutcome

BasedonAgeStratifiedRandomizationPCI LyticDeathDeath/CVAD/CVA/reMIDeathDeath/CVAD/CVA/reMIAge70-80yrs(n=351)Age>80yrs(n=130)Percent(%)38%↓p=.1736%↓p=.1855%↓p=.0093p=.72p=.57p=.96第11頁/共44頁EventrateNodiabetes/CVD(+)RR=1.71(1.41–2.06)Nodiabetes/CVD(?)RR=1.00Diabetes/CVD(+)RR=2.85(2.30–3.53)Diabetes/CVD(?)RR=1.71(1.25–2.33)3691215182124Diabetes+CVD0.000.050.100.150.20MonthsNodiabetes+CVDDiabetes+noCVDNodiabetes+noCVD3)RiskofCardiovascularMortality:

OASISRegistry(n=8,013)MalmbergK,etal.Circulation.2000;102:1014-1019.第12頁/共44頁MortalityinPatientsAssignedtoCABGorPCIAccordingtoDiabetesStatus

10Trials,7812pts,Angiopl6Trials&BMS4TrialsFU6yrsMAHlatkyet.al.Lancet

2009;373:March20th第13頁/共44頁2)BARI-2D:EvaluatingTreatmentOptionsforCADandDMinType2DMInclusionCriteria

Type2DM StableCADExclusionCriteriaMandatoryCABG–UnstableCAD–CADextent–LVfunctionBARI-2Committee:K.Detre,R.Frye,T.Orchard,D.Kelley,R.Nesto,B.Sobel,S.Genuth,B.ChaitmanRevascularization

ofChoice&MedicalRxRevascularization

ofChoice&MedicalRxMedicalRxMedicalRx2x2FactorialDesign(n=2300)CATHInsulin

ProvidingInsulin

Sensitizing第14頁/共44頁CABG(n=897)DES(n=903)All-causeMIStrokeDeath/MI/Stroke

Revasc

MACCE

Interv!!CTS!!!!!!!death%

MainResultsat1-Year

2)SYNTAXTrial(TAXUSDES)3.54.33.24.82.20.67.77.6P=0.37P=0.11P=0.003P=0.98

P<0.0001P=0.00155.913.712.117.8SerruysPetal.NEJM2009;360:961-SYNTAXhighScoreFavorsCABG第15頁/共44頁2)SYNTAXTrialConclusions:

(victoryforbothcamps)

SurgicalViewpoint:

PCIwasinferiortoCABGandfailed

tomeetit’sprimaryendpoint

PCIViewpoint:

PCIwasequaltoCABGinhardendpointsofdeath&MI(eveninLM)andAnyptwilltradere-PCI(+8%)toCVA第16頁/共44頁AggressivebackgroundtherapyforCADanddiabetesContemporaryPCIwithDESn=1,000Patients:DMandmultiveselCADeligibleforPCIorCABGContemporaryCABGwithorwithoutCPBn=1,000Randomized1:13)FREEDOM(NHLBI)第17頁/共44頁3)FREEDOMRecruitment:1532patients20052006200720081408150312981532asof1/28/092009US:MountSinaiMedicalCenterCanada–VancouverHospandHealthSciencesCenterCanada–MontrealHeartInstituteSouthAmerica–InCorHeartInstituteSouthAmerica–InstituteDantePazzanese第18頁/共44頁CABGissuperiortoPCIwithregardstotheneedforrepeatrevascularization;DES-PCIisclosingthegapWell-poweredtrialsofatleast3-yearsdurationarerequiredbeforedefinitiveconclusionsontheclusterofdeath/MI/Strokecanbedrawn

TheSYNTAXScore

canhelpguidetherapy;morecomplexdiseasebenefitsfromCABGwhileothersachieveequalresultswithPCIMajoremphasisshouldbeputonintensiveCVriskfactormanagement.ItiscriticalthatbotharmsachieveoptimalcontrolofriskfactorsTAKEHOMEMESSAGE第19頁/共44頁CoronaryArteryRevascularizationinPatientswithChronicKidneyDisease.

NormanE.LeporMDFACCCedars-SinaiHeartInstituteAssociateClinicalProfessorofMedicineGeffenSchoolofMedicine-UCLAWestsideMedicalAssociatesofLosAngeles第20頁/共44頁CKDandRevascularizationPCIhigherriskowingtoincreasedincidenceofacuterenalinjury,restenosisandmortalityCABhigherriskforallcausemortalityLongerpostoperativebleedingtimesHigherpostoperativebleedingratesandtransfusionrequirementsIncreasedlengthofhospitalstaysKidneyInt.1999;55:1057-1062.第21頁/共44頁CONTRAST-INDUCEDNEPHROPATHY

IN-HOSPITALMORTALITYProfoundincreaseinin-hospitalmortalityinpatientsdevelopingacute

renalfailure(ARF),particularlyindiabeticpatients%IN-HOSPITALDEATHP<.0000001NoARFARFDialysisMcCullough,etal.AmJMed.1997:103–375.1.1%7.1%35.7%第22頁/共44頁IncidenceofAdverseOutcomes@6MonthsWithSTEMIReperfusion-GRACERegistryJAmCollCardiolIntv2009;2:26-33第23頁/共44頁IncidenceofHospitalStrokeandMajorBleedingStratifiedbyRenalFunctioninGRACERegistryJAmCollCardiolIntv2009;2:26-33第24頁/共44頁SurvivalPostPCIinEVENTRegistryJAmCollCardiolIntv2009;2:37-45第25頁/共44頁SurvivalAfterRevascularizationinCKD

AlbertaProvincialProjectforOutcomesinCHD(APPROACH)

Circulation2004;110:1890-95NondialysisCKDDialysis-CKD第26頁/共44頁SurvivalPostCABGinESRDJAmCollCardiol2004;44:1343-1353第27頁/共44頁AlgorithmForRevascularizationinCKD

ANephrologistsPerspectiveClinJAmSocNephrol2006;1:209-220第28頁/共44頁ConclusionTheCKDpatientrepresentsachallengingpatientpopulationtotreatwithrevascularizationHasuniquephysiologypredisposingbothtothedevelopmentofCADandcomplicationsofrevascularizationtherapiesNorecentrandomizedtrialexperiencetoguideselectionoftherapyDataseemstosupporttheuseofPCI(DES>BMS)inpatientswithmildtomoderateCKDSurgicalrevascularizationmaybebestinthosewithESRD第29頁/共44頁Revascularization

inpoorLVfunctionJeroenJBaxDeptCardiologyLeidenUniversityMedicalCenterTheNetherlandsACC2009,OrlandoGrants:GEhealthcare,BMSmedicalimaging,EdwardsLifesciences,Biotronik,StJudeMedical,BostonScientific,Medtronic

第30頁/共44頁IschemicLVDysfunction

Clinicalgoal: -identifypatientswithviabletissue -withpotentialtorecoverfunction -tojustifyenhancedsurgicalrisk第31頁/共44頁Howtoassessviability?Metabolism(glucose,FFA’s):FDG,BMIPPIntactcellmembrane:Tl-201Intactmitochondria:Tc-99mIntactperfusion:Tl-201,Tc-99m,MCEContractilereserve:stressecho/MRI第32頁/共44頁ConclusionsRevascularizationinlowEFhasenhancedriskAssessmentofviabilityisimportantButalso:ScarextentLVsizeandfunctionMitralregurgitation第33頁/共44頁SignificantlyImprovedVascularComplicationsAmongWomenUndergoingPCI:

FromtheNorthernNewEnglandPCIRegistryBinaAhmed*,WinthropD.Piper,DavidMalenka,PeterVerLee,JohnRobb,MerleKellet,ThomasRyan,MichaelHerne,WilliamPhillipsandHaroldL.Dauerman**UniversityofVermontCollegeofMedicine第34頁/共44頁VascularComplicationsDecreasingAfterPCI:

IsThisTrueforBothWomenandMen?

第35頁/共44頁Dartmouth-HitchcockMedicalCenterFletcherAllenHealthCareEasternMaineMedicalCenterCatholicMedicalCenterMaineMedicalCenterPortsmouthRegionalHospital-AffiliatesYorkHospitalandWentworthDouglassHospitalConcordHospitalCentralMaineMedicalCenterNorthernNewEnglandCardiovascularDisease

StudyGroupMethods第36頁/共44頁VascularComplicationsAmongWomenareLinearlyRelatedtoAge第37頁/共44頁VascularComplicationsinWomenHaveDecreasedDramatically第38頁/共44頁RevascularizationinComplexPatientSubsetsTheveryelderly(C.Grines)ComplexCADanddiabetes(V.Fuster)Chronickidneydisease(N.Lepor)PoorLVfunction(J.Bax)Vas