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1、病例讨论ACS,浙江大学医学院附属第一医院心内科 邱原刚,病例介绍,患者，男，62岁； 因反复自发性胸痛半月，剧烈胸痛持续一小时入急诊科； 有高血压史五年，控制在110/70mmHg左右；无糖尿病史； 入院BP 140/87mmHg,R17次/分,T 36.3;,EKG,EKG,辅助检查,血常规：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为104ml/min/1.73m2; UCG: LVIDd 4.75,AO 3.49, LA 3.5
2、4, LVEF 69%，二尖瓣少量返流，左室舒张功能下降；,心肌酶谱,诊断,冠状动脉性心脏病 急性非ST段抬高型心肌梗死（TIMI危险度评分：3分） 高血压病3级（极高危）,治疗,阿司匹林片 300mg,立即嚼服，其后300mg, qd, po; 波力维片 300mg,立即口服，其后75mg, qd, po; 克赛针 0.4 ml，ih, st+q12h; 倍它乐克片 25mg, po, bid; 开搏通片 12.5mg, po,tid; 立普妥片 20mg，qd; 欣维宁针 12ml, iv, st; 继以 11ml/h静脉微泵维持；,讨论,Selection of Strategy: In
3、vasive vs. Conservative Strategy,TIMI risk score,Age 65 years or older; At least 3 risk factors for CAD; Prior coronary stenosis of 50% or more; ST-segment deviation on ECG presentation; At least 2 anginal events in prior 24 hours; Use of aspirin in prior 7 days; Elevated serum cardiac biomarkers,Pr
4、eferred Invasive Strategy,Recurrent angina/ischemia at rest or low-level activities Elevated cardiac biomarkers New/presumably new ST-segment depression Signs or symptoms of HF or new/worsening mitral regurgitation High-risk findings from noninvasive testing Hemodynamic instability Sustained ventric
5、ular tachycardia PCI within 6 months Prior CABG High risk score (e.g. TIMI,GRACE) LVEF less than 0.40,Preferred Conservative Strategy,Low-risk score (e.g. TIMI,GRACE) Patient or physician preference in absence of high-risk features,Initial Invasive Strategy: Antiplatelet, Anticoagulant Therapy,Initi
6、ate 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) Clopidogrel IV GP IIb/IIIa inhibitor Use both if: Delay to angiography High risk features Early recurrent
7、ischemic symptoms,Initial 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 preferabl
8、e (IIa, B) Initiate 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
9、of ischemia (I, B) 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
10、(2),Beta blocker therapy Initiate 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 blo
11、ckade, signs of HF or low-output state, or other risk factors for cardiogenic shock (III, A),Initial Conservative Strategy: Early Hospital Care (3),Lipid management Fasting lipid profile within 24 hr (I, C) Statin (in absence of contraindications) should be given regardless of baseline LDL-C pre-dis
12、charge (I, A) ACE inhibitor (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)
13、 No IV ACE-I in first 24 hr because of increased risk of hypotension (III, B),More Aggressive Long-Term Antiplatelet Therapy,Medical therapy without stenting ASA 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 stent ASA 162-325 mg/d a
14、t least 1 mo, 75-162 mg/d indefinitely (I, A) + clopidogrel 75 mg/d, at least 1 mo (I, A), ideally up to 1 yr (I, B) Drug-eluting stent ASA 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患者的肾功能评估,ACS行PCI患者肾功能状态 多中心
15、注册研究(中国),2212例（61.6%）,* (4-vMDRD) eGFR = 186.3x(血肌酐/88.4) -1.154 x年龄-0.23 x (0.72, 女性) 其中血肌酐(mol/L), 年龄 (岁）,公式法计算Egfr&Ccr,GFR按MDRD公式计算 GFR（ml/min/1.73m2）=170（Scr）0.999（年龄）0.176（白蛋白）0.318（0.762女性）（1.180黑人） Ccr按 CG公式计算（Cockcroft Gault） 男性 Ccr = (140-年龄)体重 1.2/ Scr（umol/l） 女性 Ccr= 男性Ccr0.85,http:/ http:/