穩定性冠心病的治療策略2012-3現在是1頁\一共有59頁\編輯于星期三2現在是2頁\一共有59頁\編輯于星期三內容在穩定性冠心病治療中標準藥物治療的價值血管重建在那些患者可能獲益？如何選擇CABG或是PCI

單支、雙支病變

三支、左主干病變多支病變功能性完全血管重建選擇藥物洗脫支架還是裸金屬支架？3現在是3頁\一共有59頁\編輯于星期三COURAGE:StudydesignBodenWEetal.AmHeartJ.2006;151:1173-9.BodenWEetal.NEnglJMed.2007;356:1503-16.Optimalmedicaltherapy*+PCI(n=1149)Optimalmedicaltherapy

(n=1138)AHA/ACCClassI/IIindicationsforPCI,suitablecoronaryarteryanatomy+

≥70%stenosisin≥1proximalepicardialvessel+objectiveevidenceofischemia

(or≥80%stenosis+CCSclassIIIanginawithoutprovocationtesting)Primaryoutcomes:All-causemortality,nonfatalMIFollow-up:Median4.6yearsRandomized*Intensivepharmacologictherapy+lifestyleintervention

CCS=CanadianCardiovascularSocietySecondaryoutcomes:Death,MI,stroke;ACShospitalization現在是4頁\一共有59頁\編輯于星期三COURAGE:TreatmenteffectonprimaryoutcomeHR1.05(0.87-1.27)P=0.62*BodenWEetal.NEnglJMed.2007;356:1503-16.All-causedeath,MI(timetofirstevent)*UnadjustedNo.atriskMedicaltherapy 1138 1017 959 834 638 408 192 30PCI 1149 1013 952 833 637 417 200 35MedicaltherapyPCI+medicaltherapySurvivalfreeofprimaryoutcome024700.50.60.70.81.00.9Years6531現在是5頁\一共有59頁\編輯于星期三6現在是6頁\一共有59頁\編輯于星期三現在是7頁\一共有59頁\編輯于星期三現在是8頁\一共有59頁\編輯于星期三PharmacologictherapyAntiplateletAspirinClopidogrelinaccordancewithestablishedpracticestandardsDyslipidemiaSimvastatin±ezetimibe

orERniacinACEIorARBLisinoprilorlosartan-blockerERmetoprololsuccinateCalciumchannelblockerAmlodipineNitrateIsosorbide5-mononitrateBodenWEetal.AmHeartJ.2006;151:1173-9.BodenWEetal.NEnglJMed.2007;356:1503-16.現在是9頁\一共有59頁\編輯于星期三內容在穩定性冠心病治療中標準藥物治療的價值血管重建在那些患者可能獲益？如何選擇CABG或是PCI

單支、雙支病變

三支、左主干病變多支病變功能性完全血管重建選擇藥物洗脫支架還是裸金屬支架？10現在是10頁\一共有59頁\編輯于星期三11現在是11頁\一共有59頁\編輯于星期三現在是12頁\一共有59頁\編輯于星期三現在是13頁\一共有59頁\編輯于星期三14現在是14頁\一共有59頁\編輯于星期三內容在穩定性冠心病治療中標準藥物治療的價值血管重建在那些患者可能獲益？如何選擇CABG或是PCI

單支、雙支病變

三支、左主干病變多支病變功能性完全血管重建選擇藥物洗脫支架還是裸金屬支架？15現在是15頁\一共有59頁\編輯于星期三ProximalLADdisease,medicine,PTCAorCABG

（MASStrial）1724301.41.42.82.81.49.7420328298P=0.0002P=0.006NSNSP=0.019P<0.01P<0.01Eventrateatf-up(%)Huebetal.JAmCollCardiol1995;26:1600-1605SingleCenter,randomizedtrialStableangina,proximalLADsignificantlesion<12mminlength,nopriorMI,nototalocclusion,nopriorCABGorangioplasty.n=214:Medicaln=72;BAn=72;LIMAn=70現在是16頁\一共有59頁\編輯于星期三穩定性冠心病血運重建策略SilberS,TCT2010現在是17頁\一共有59頁\編輯于星期三內容在穩定性冠心病治療中標準藥物治療的價值血管重建在那些患者可能獲益？如何選擇CABG或是PCI

單支、雙支病變

三支、左主干病變

多支病變功能性完全血管重建選擇藥物洗脫支架還是裸金屬支架？18現在是18頁\一共有59頁\編輯于星期三71%enrolled

(N=3,075)AllPtswithdenovo3VDand/orLMdisease(N=4,337)Treatmentpreference(9.4%)ReferringMDorpts.refused

informedconsent(7.0%)Inclusion/exclusion(4.7%)Withdrewbeforeconsent(4.3%)Other(1.8%)Medicaltreatment(1.2%)TAXUSn=903PCIn=198CABGn=1077CABGn=897nof/un=4285yrf/un=649PCIallcapturedw/followupCABG2500750w/f/uvsTotalenrollmentN=3075Stratification:

LMandDiabetesTwoRegistryArmsRandomizedArmsn=1800TwoRegistryArmsN=1275RandomizedArmsN=1800HeartTeam(surgeon&interventionalist)PCIN=198CABGN=1077AmenableforonlyonetreatmentapproachTAXUS*N=903

CABGN=897vsAmenableforbothtreatmentoptionsStratification:

LMandDiabetesLM33.7%3VD66.3%LM34.6%3VD65.4%DM28.5%NonDM71.5%NonDM71.8%DM28.2%23USSites62EUSites+SYNTAXTrialDesign現在是19頁\一共有59頁\編輯于星期三PatientProfiling

LocalHeartteam(surgeon&interventionalcardiologist)assessedeachpatientinregardsto:Patient’soperativerisk(EuroSCORE&Parsonnetscore)Coronarylesioncomplexity(newlydevelopedSYNTAXscore)ThegoaloftheSYNTAXscoreistoprovideatooltoassistphysiciansintheirrevascularizationstrategiesforpatientswithhighrisklesionsSianosetal,EuroIntervention2005;1:219-227Valgimiglietal,AmJCardiol2007;99:1072-1081Serruysetal,EuroIntervention2007;3:450-459CoronarytreesegmentsbasedontheclassificationproposedbytheAHAandmodifiedfortheARTSstudyCirculation1975;51:31-3&SeminIntervCardiol1999;4:209-19Leamanscore,Circ1981;63:285-299LesionsclassificationACC/AHA,Circ2001;103:3019-3041Bifurcationclassification,CCI2000;49:274-283CTOclassification,JAmCollCardiol1997;30:649-656TortuosityThrombusBifurcationTotalOcclusion3VesselLeftMainDominanceCalcificationNumber&locationoflesionsSYNTAXscore現在是20頁\一共有59頁\編輯于星期三MACCEto12MonthsP=0.0015*061210200MonthsSinceAllocationCumulativeEventRate(%)ITTpopulation12.1%

17.8%EventRate±1.5SE.*Fisher’sExactTestTAXUS*

(N=903)CABG

(N=897).SerruysPW,atTCT2008現在是21頁\一共有59頁\編輯于星期三SYNTAXTrial

AdverseEventsto12Months

ITTpopulationEventRate±1.5SE,*FisherexacttestAllDeathRevascularizationCVA(Stroke)MyocardialInfarctionTAXUS*(N=903)CABG(N=897).SerruysPW,atTCT2008現在是22頁\一共有59頁\編輯于星期三現在是23頁\一共有59頁\編輯于星期三SabikJF,TCT2010現在是24頁\一共有59頁\編輯于星期三Patient1Patient1Patient2Patient2SYNTAXSCORE21SYNTAXSCORE52LCx70-90%LAD70-90%RCA270-90%RCA370-90%LM99%LCx100%LAD99%RCA100%Thereis‘3-vesseldisease’and‘3-vesseldisease’現在是25頁\一共有59頁\編輯于星期三SYNTAXTrial,MACCEto12Months

LeftMainSubsetP=0.44*061220400MonthsSinceAllocationCumulativeEventRate(%)13.6%

15.8%

TAXUS

(N=357)CABG

(N=348)Eventrate±1.5SE,*FisherexacttestITTpopulation現在是26頁\一共有59頁\編輯于星期三P=0.2026.8%22.3%0CumulativeEventRate(%)2040Before1year*13.7%vs15.8%P=0.441-2years*7.5%vs10.3%P=0.222-3years*5.2%vs5.7%P=0.780123624MonthsSinceAllocationTAXUS

(N=357)CABG

(N=348)MACCEto3Years

LMSubsetCumulativeKMEventRate±1.5SE;log-rankPvalue;*BinaryratesSerruysP,TCT2010現在是27頁\一共有59頁\編輯于星期三CABGPCIPvalueDeath6.0%2.6%0.21CVA4.1%0.9%0.12MI2.0%4.3%0.36Death,CVAorMI11.0%6.9%0.26Revasc.13.4%15.4%0.69MonthsSinceAllocationCumulativeEventRate(%)P=0.33LeftMainTAXUS

(N=118)CABG

(N=104)MACCEto3YearsbySYNTAXScoreTercileLowScores(0-22)18.0%23.0%MonthsSinceAllocationCumulativeEventRate(%)0122440020301036Site-reportedData;ITTpopulationCumulativeKMEventRate±1.5SE;log-rankPvalue>>><<現在是28頁\一共有59頁\編輯于星期三CABGPCIPvalueDeath12.4%4.9%0.06CVA2.3%1.0%0.46MI3.3%5.0%0.63Death,CVAorMI15.6%10.8%0.29Revasc.14.0%15.9%0.75P=0.90LeftMainTAXUS

(N=103)CABG

(N=92)MACCEto3YearsbySYNTAXScoreTercile

IntermediateScores(23-32)23.4%23.4%MonthsSinceAllocationCumulativeEventRate(%)0122440020301036Site-reportedData;ITTpopulationCumulativeKMEventRate±1.5SE;log-rankPvalue>>><<現在是29頁\一共有59頁\編輯于星期三P=0.003LeftMainTAXUS

(N=135)CABG

(N=149)MACCEto3YearsbySYNTAXScoreTercile

LeftMainSYNTAXScore3337.3%21.2%LeftMainMonthsSinceAllocationCumulativeEventRate(%)0122440020301036CABGPCIPvalueDeath7.6%13.4%0.10CVA4.9%1.6%0.13MI6.1%10.9%0.18Death,CVAorMI15.7%20.1%0.34Revasc.9.2%27.7%<0.001Site-reportedData;ITTpopulationCumulativeKMEventRate±1.5SE;log-rankPvalue><<<<現在是30頁\一共有59頁\編輯于星期三ESC穩定性冠心病血運重建策略(2010)SilberS,TCT2010現在是31頁\一共有59頁\編輯于星期三

血運重建策略的制定應由多學科完成32現在是32頁\一共有59頁\編輯于星期三一站式雜交手術（MIDCAB+PCI）對部分三支或左主干病變可能是一選擇ThefirstHybridOperatingRoominAsiawasbuiltatFuwaiHospitalin2007.33新技術、新理念呼喚新的治療策略現在是33頁\一共有59頁\編輯于星期三內容在穩定性冠心病治療中標準藥物治療的價值血管重建在那些患者可能獲益？如何選擇CABG或是PCI

單支、雙支病變

三支、左主干病變

多支病變功能性完全血管重建選擇藥物洗脫支架還是裸金屬支架？現在是34頁\一共有59頁\編輯于星期三Angiography-guidedPCIFFR-guidedPCIMeasureFFRinallindicatedstenosesStentallindicatedstenosesStentonlythosestenoseswithFFR≤0.80RandomizationIndicateallstenoses≥50%consideredforstentingPatientwithstenoses≥50%inatleast2ofthe3majorepicardialvessels1-yearfollow-upFLOWCHART現在是35頁\一共有59頁\編輯于星期三

FAMEstudy:ProceduralResultsANGIO-groupN=496FFR-groupN=509P-valueProceduretime(min)70±4471±430.51Contrastagentused(ml)302±127272±133<0.001Materialsusedatprocedure(US$)60075332<0.001Lengthofhospitalstay(days)3.7±3.5

3.4±3.30.05stentsperpatient2.7±1.21.9±1.3<0.001現在是36頁\一共有59頁\編輯于星期三FFR-guided30days2.9%90days3.8%180days4.9%360days5.3%Angio-guidedabsolutedifferenceinMACE-freesurvivalFAMEstudy:Event-freeSurvival現在是37頁\一共有59頁\編輯于星期三

ANGIO-groupN=496FFR-groupN=509P-valueEventsat1year,No(%)Death,MI,CABG,orrepeat-PCI91(18.4)67(13.2)0.02Death15(3.0)9(1.8)0.19Deathormyocardialinfarction55(11.1)37(7.3)0.04CABGorrepeatPCI47(9.5)33(6.5)0.08Totalno.ofMACE113760.02AdverseEventsat1year現在是38頁\一共有59頁\編輯于星期三

PCI應用的適當性（美國注冊資料），全美1091所醫院PCI500154例急癥PCI占71.1%STEMI20.6%，NSTEMI21.1%，高危UA29.3%非急癥PCI占28.9%適當性急癥PCI：適當98.6%非急癥PCI：適當50.4%，不肯定38.0%

不適當11.6%

無心絞痛53.8%

無創檢查屬低危71.6%

藥物治療不適當（≤1種藥物）95.8%

ChanP.JAMA2011；306:53現在是39頁\一共有59頁\編輯于星期三

PCIsinChina現在是40頁\一共有59頁\編輯于星