急性冠脈綜合征評(píng)估及危險(xiǎn)分層第1頁(yè)/共22頁(yè)NewTerminologyinACSACS,acutecoronarysyndrome;MI,myocardialinfarction;UA,unstableangina;NSTEMI,non–ST-segmentelevationmyocardialinfarction;STEMI,ST-segmentelevationmyocardialinfarction;PCI,percutaneouscoronaryintervention.CannonCP.JThrombThrombolysis.1995;2:205-218.AntithromboticTherapyStableAnginaUnstableAnginaNon–

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AntmanEM,etal.JAMA.2000;284:835-842.TIMIRiskScoreforUA/NSTEMI:

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Markers(CK-MBortroponin)4.78.313.219.926.240.9010203040500/123456/7D/MI/UrgRevasc(%)NumberofRiskFactorsPopulation(%):4.317.332.029.313.03.4CStatistic=0.65c2trendP<.001第7頁(yè)/共22頁(yè)P(yáng)<.001P=.004P<.001P<.001SciricaBM,etal.AmJCardiol.2002;90:303-305.(withpermission)TIMIRiskScorevsPrognosis

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(2.6-5.5)No.Studies: 13 6Neg

Pos(TropI+T)36341849737322HeidenreichPA,JAmCollCardiol.2001;38:478-485.第9頁(yè)/共22頁(yè)TIMIIIIB:TroponinILevelsPredictMortalityInUA/NSTEMI1.01.73.43.76.07.5024680to<0.40.4to<1.01.0to<2.02.0to<5.05.0to<9.0>9.08311741481346750 Risk CardiacTroponinI(ng/ml) Ratio 1.0 1.8 3.5 3.9 6.2 7.8 Mortalityat42Days(%ofPatients)AntmanEA,etal.NEnglJMed.1996;335:1342-1349.(withpermission)第10頁(yè)/共22頁(yè)LindahlB,etal.NEnglJMed.2000;343:1139-1147.(withpermission)PredictiveValueofTroponinTandhs-CRP

forMortalityfromACSinFRISCSubstudy201000612182430364248CumulativeProbabilityofDeath(%)MonthsTroponinT>0.60μg/l(n=377)TroponinT0.60-0.59μg/l(n=367)TroponinT<0.60μg/l(n=173)P=.007P=.001CRP2-10mg/l(n=294)201000612182430364248CRP>10mg/l(n=309)CRP<2mg/l(n=314)P=.001P=.29CRP TroponinMonths第11頁(yè)/共22頁(yè)RiskStratificationWithCRPandTroponinTChiSquare:P=.00079.1%4.7%0.4%012345678910RcTnTNegANDCRP<1.55RcTnT(early+)ORCRP>1.55RcTnT(early+)ANDCRP>1.5514-DayMortality(%) N=277 N=129 N=22MorrowDA,etal.JAmCollCardiol.1998;31:1460-1465.第12頁(yè)/共22頁(yè)WBCCount(x103)30-DayMortality0510152005%10%15%20%WhiteBloodCellCountvsMortalityCannonCP,etal.AmJCardiol.2001;87:636-639.(withpermission)第13頁(yè)/共22頁(yè)B-typeNatriureticPeptide(BNP)

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(n=632)Quartile2

(n=632)Quartile1

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soluble

CD40LAndreP,etal.Circulation.2002;106:896-899.(withpermission)VaroN,etal.Circulation.2003;108:1049-1052.(withpermission)ClinicalInvestigationReportsSolubleCD40L

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CoronarySyndromes3.532.521.510.50DeathMIDIMICHFDIMICHFQ1Q2Q3Q4HazardRatios(HR)***???*P<.01comparedtofirstquartile

?P<.03comparedtofirstquartile第17頁(yè)/共22頁(yè)SolubleCD-40LinACSHeeschenC,etal.NEnglJMed.2003;348:1104-1111.(withpermission)AssociationbetweensolubleCD40ligandlevelsandtherateofcardiacevents(deathornonfatalmyocardialinfarction)at24hours,72hours,30days,and6monthsamong544patientsreceivingplacebo.TimeDeathorNonfatalMyocardialInfarction(%)24hours72hours30hours6monthsP=.13P=.003P=.004P=.0011stquartile2ndquartile3rdquartile4thquartile5thquartile第18頁(yè)/共22頁(yè)Clopidogrel,butnotASA,Reduces

ADP-InducedExpressionofCD40LHermannA,etal.Platelets.2001;12:74-82.(withpermission)ADP,30MControl00.10.20.30.40.5CD40LExpression(MnX)ControlASAClopidogrelASA+ClopidogrelP<.05vs