1、病例討論ACS浙江大學醫學院附屬第一醫院心內科邱原剛病例介紹患者，男，62歲；因反復自發性胸痛半月，劇烈胸痛持續一小時入急診科；有高血壓史五年，控制在110/70mmHg左右；無糖尿病史；入院BP 140/87mmHg,R17次/分,T 36.3;EKGEKG輔助檢查血常規：WBC 5.2*109/L,N 40%,Hb 155g/L, plt 216*109/L,Cr 63umol/L,Bun 4.03 mmol/L;SCr 71mmol/L,按照MDRD公式估算eGFR為104ml/min/1.73m2;UCG: LVIDd 4.75,AO 3.49, LA 3.54, LVEF 69%，二

2、尖瓣少量返流，左室舒張功能下降；心肌酶譜檢查時間GOTCKCKMBLDHTNI30min13023200未查3h3631634170陰性10h1621792196364陰性17h2462412257580陽性診斷冠狀動脈性心臟病急性非ST段抬高型心肌梗死（TIMI危險度評分：3分）高血壓病3級（極高危）TIMI risk scoreAge 65 years or older;At least 3 risk factors for CAD;Prior coronary stenosis of 50% or more;ST-segment deviation on ECG presentation

3、;At least 2 anginal events in prior 24 hours;Use of aspirin in prior 7 days;Elevated serum cardiac biomarkersPreferred Conservative StrategyLow-risk score (e.g. TIMI,GRACE)Patient or physician preference in absence of high-risk featuresInitial Invasive Strategy: Antiplatelet, Anticoagulant TherapyIn

4、itiate anticoagulant therapy as soon as possible after presentation (I, A)Enoxaparin or UFH (I, A)Or Bivalirudin or fondaparinux (I, B)Prior to angiography, initiate one (I, A) or both (IIa, B)ClopidogrelIV GP IIb/IIIa inhibitorUse both if:Delay to angiographyHigh risk featuresEarly recurrent ischem

5、ic symptomsInitial Conservative Strategy: Early Hospital Care (1)ASA; clopidogrel if intolerant (I, A)Anticoagulant therapy should be added to antiplatelet therapy as soon as possible after presentation (I, A)Enoxaparin or UFH (I, A)Fondaparinux (I, B)Enoxaparin or fondaparinux preferable (IIa, B)In

6、itiate clopidogrel, loading dose + maintenance dose (I, A)Consider IV eptifibatide or tirofiban (IIb, B)Initial Conservative Strategy: Early Hospital Care (1)If LVEF is 0.40, it is reasonable to perform diagnostic angiography (IIa, B)A stress test should be performed for assessment of ischemia (I, B

7、)If the patient is classified as not as low risk, diagnostic angiography should be performed (I, A)Measurement of BNP or NT-pro-BNP may be considered to supplement assessment of global risk in patients with suspected ACS (IIb, B)Initial Conservative Strategy: Early Hospital Care (2)Beta blocker ther

8、apyInitiate oral therapy within first 24 hr unless HF, low-output state, increased risk for cardiogenic shock, or relative contraindications (I, B)IV therapy for high blood pressure without contraindications (IIa, B)IV therapy may be harmful with contraindications to beta blockade, signs of HF or lo

9、w-output state, or other risk factors for cardiogenic shock (III, A)Initial Conservative Strategy: Early Hospital Care (3)Lipid managementFasting lipid profile within 24 hr (I, C)Statin (in absence of contraindications) should be given regardless of baseline LDL-C pre-discharge (I, A)ACE inhibitor (

10、oral)Within 24 hr with pulmonary congestion or LVEF 40, in absence of hypotension (systolic blood pressure 100 mmHg or 30 mmHg below baseline) or known contraindications (I, A)ARB if ACE intolerant (I, A)Can be useful without pulmonary congestion or LVEF 0.40 (IIa, B)No IV ACE-I in first 24 hr becau

11、se of increased risk of hypotension (III, B)More Aggressive Long-Term Antiplatelet TherapyMedical therapy without stentingASA 75-162 mg/d indefinitely (I, A) + clopidogrel 75 mg/d, at least 1 mo (I, A), ideally up to 1 yr (I, B)Bare metal stentASA 162-325 mg/d at least 1 mo, 75-162 mg/d indefinitely

12、 (I, A) + clopidogrel 75 mg/d, at least 1 mo (I, A), ideally up to 1 yr (I, B)Drug-eluting stentASA 162-325 mg/d at least 3 (sirolimus)-6 (paclitaxel) mo, 75-162 mg/d indefinitely (I, A) + clopidogrel 75 mg/d at least 1 yr (I, B)ACS患者的腎功能評估ACS行PCI患者腎功能狀態多中心注冊研究(中國)腎功能狀態eGFR（mL/min）例數（%）腎功能正常901339（37.4%）輕度腎功能不全60 -901778（49.5%）中度腎功能不全30 -60434（12.1%）重度腎功能不全3038（1.0%）2212例（61.6%） * (4-vMDRD) eGFR = 186.3x(血肌酐/88.4) -1.154 x年齡-0.23 x (0.72, 女性) 其中血肌酐(mol/L), 年