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TheManagementofAcuteMyocardialInfarction北京协和医院急诊科朱华栋EarlyRepolarizationBrugadaSyndromeAnteriorAMIPrinzmetalAnginaPericarditisAcuteInf.AMISTSegmentElevation(Transmuralischemia)Non-infarctSTElevationSTSegmentDepression(Non-transmuralischemia)STDepressionNSTEMITwaveinversionNSTEMINSTEACS:KeyThemesNSTEACS:KeyThemesNSTEACS:KeyThemesNSTEACS:KeyThemes•NSTEACS:ahighriskpopulation•patientriskbenefitfromtreatmentwithmedications,aninvasivestrategy•Interactionbetweeninvasivestrategyandpharmacologictx•Antithromboticscornerstoneoftreatment•Anticoagulants:heparin,LMWH,directthrombininhibitors•Antiplateletagents:aspirin,IIb/IIIa,ADPinhibitors•NSTEACS:ahighriskpopulation•patientriskbenefitfromtreatmentwithmedications,aninvasivestrategy•Interactionbetweeninvasivestrategyandpharmacologictx•Antithromboticscornerstoneoftreatment•Anticoagulants:heparin,LMWH,directthrombininhibitors•Antiplateletagents:aspirin,IIb/IIIa,ADPinhibitorsAntmanEMetalNEnglJMed1996;335:1342-9Invasivevs.ConservativeStrategyforACSInvasivevs.ConservativeStrategyforACSDeathor(re)-MIDeathor(re)-MIInvasivevs.ConservativeStrategyforACSInvasivevs.ConservativeStrategyforACSDeathor(re)-MIDeathor(re)-MITrialNPCIConsTrialNPCIConsRITA318107.68.3RITA318107.68.3VINO1316.322.4VINO1316.322.4TACTICS22207.39.5TACTICS22207.39.5TRUCS1487.616.7TRUCS1487.616.7FRISCII245110.414.1FRISCII245110.414.1MATE2019.96.7MATE2019.96.7VANQUISH92024.012.2VANQUISH92024.012.2Overall7876Overall7876TrialNPCIConsTrialNPCIConsRITA318107.68.3RITA318107.68.3VINO1316.322.4VINO1316.322.4TACTICS22207.39.5TACTICS22207.39.5TRUCS1487.616.7TRUCS1487.616.7FRISCII245110.414.1FRISCII245110.414.1MATE2019.96.7MATE2019.96.7VANQUISH92024.012.2VANQUISH92024.012.2Overall7876Overall7876Fox,Lancet360:743‘03Fox,Lancet360:743‘03Death/(re)InfarctionRR=0.88,p=0.05RR=0.88,p=0.05InterventionbetterInterventionbetter0.10.20.30.50.71.01.52.00.10.20.30.50.71.01.52.0RR=0.88,p=0.05RR=0.88,p=0.05InterventionbetterInterventionbetter0.10.20.30.50.71.01.52.00.10.20.30.50.71.01.52.0Death/(re)-MIDeath/(re)-MICP971744-4514.524.216.914.3051015202530TnT-TnT+%ConsConsInvInvTACTICS–TIMI18TACTICS–TIMI18TnTcutpoint=0.01ng/mL(54%ofptTnT+)TroponinT:Death,MI,RehospACS,6MonthsTroponinT:Death,MI,RehospACS,6MonthsOR=0.52OR=0.52*P<0.001*P<0.001InteractionInteractionP<0.001P<0.001P=NSP=NS**n=414n=396n=463n=495BenefitsofanInvasiveStrategyinNon-BenefitsofanInvasiveStrategyinNon-STElevationACSSTElevationACSBenefitsofanInvasiveStrategyinNon-BenefitsofanInvasiveStrategyinNon-STElevationACSSTElevationACS•OnlyshowntoreducedeathandMIinOnlyshowntoreducedeathandMIinhighriskptshighriskpts•Reducesre-hospitalization,anginainReducesre-hospitalization,anginainmanyothersmanyothers•Shortenshospitalization,maybecostShortenshospitalization,maybecosteffectiveeffective•WhatabouttheoptimaltimingofanWhatabouttheoptimaltimingofaninvasivestrategy?invasivestrategy?•OnlyshowntoreducedeathandMIinOnlyshowntoreducedeathandMIinhighriskptshighriskpts•Reducesre-hospitalization,anginainReducesre-hospitalization,anginainmanyothersmanyothers•Shortenshospitalization,maybecostShortenshospitalization,maybecosteffectiveeffective•WhatabouttheoptimaltimingofanWhatabouttheoptimaltimingofaninvasivestrategy?invasivestrategy?MedicalTxfor72-170hrThen,cathlabn=207MedicalTxfor72-170hrThen,cathlabn=207Cathlab6hr...