1、Is early invasive the answer for ACS,Dr. Ben He MD/PhD/FSCAI/FAPSIC Director of Cardiology Department Renji Hospital Affiliated to Shanghai Jiaotong university,Pathophysiology of Acute Coronary Syndrome,ACS is an Important Manifestation of Atherothrombosis1,1. Cannon CP. J Thromb Thrombolysis 2019;

2、2: 205218.,Antithrombotic,therapy,Stable,angina,UA,Non-Q-wave MI,Thrombolysis primary PCI,Q-wave,MI,Minutes hours,Days weeks,STEMI,UA/NSTEMI,Atherothrombosis,New term,Old term,Plaquerupture,Relation of TIMI risk score and MACE rate,Hot topic in ACS,Is early invasive superior to conservative strategy

3、 in ACS? Should invasive be deferred for cooling off? What is the optimal time for invasive?,Optimal Strategy for UA/NSTEMI,TIMI IIIB,2019,Conservative,Invasive,VANQWISH,FRISC II,TACTICS-TIMI 18,RITA-3,FRICS-II: high risk get more,TIMI-18: high risk get more,RITA-3: 1369:827-835,However, most of sel

4、ective pts were performed PCI So, the long-term f/u results do not inflect Inv/Cons strategy,4 yrs ICTUS Lancet 2019;369:827-835,ICTUSs criticism,Liberty definition of MI (only 1*ULN) causing the early MI increase in early invasive group 3yrs revascularization rate was equal in 2 group(81%PCI) 1year

5、 mortality rate in ACS in both arm are very low(2.5%),Is it a real high risk?,Even put ICTUS into pool, Inv Cons,Inv vs Cons/All cause death,High risk?,2019 ESC Guideline,Urgent Coronary angiography is recommended in Pts with refractory or recurrent angina associated with dynamic ST deviation, heart

6、 failure, life threatening arrhythmias, or haemodynamic instability (I-C) Early(72h) angiography followed by revascularization (PCI or CABG) in patients with intermediate to high risk features is recommended (I-A),2,ISAR-COOL Trial,ISAR-COOL Antithrombotic Regimen,ISAR-COOL,What is the optimal time

7、for PCI?,Methods for Optimal trial,Results of Optimal trial,Conclusion from Optimal trial,Whats the difference between ISAR-Cool Yuliya Lokhnygina, PhD; Lisa G. Berdan, PA-C, MHS; Steven R. Steinhubl, MD; Dietrich C. Gulba, MD; Harvey D. White, MD; Neal S. Kleiman, MD; Philip E. Aylward, MD; Anatoly

8、 Langer, MD; Robert M. Califf, MD; James J. Ferguson, MD; Elliott M. Antman, MD; L. Kristin Newby, MD, MHS; Robert A. Harrington, MD; Shaun G. Goodman, MD; Kenneth W. Mahaffey, MD,Division of Cardiology, Duke Clinical Research Institute, Durham, NC,Background,2019 ACC/AHA Guidelines for NSTE ACS rec

9、ommend the use of an early invasive strategy for high-risk patients Randomized clinical trials on early vs. conservative strategy used different timing of cardiac catheterization Optimal timing of cardiac catheterization in NSTE ACS not yet established (expedited vs. deferred) Expedited catheterizat

10、ion increasingly adopted in the US,Study Objective,To evaluate the association between time from hospital admission to cardiac catheterization and adverse outcomes among high-risk patients with NSTE ACS treated with an early invasive strategy (cardiac catheterization 48h of hospital admission),Study

11、 Population,Patients randomized in the SYNERGY trial Ischemic symptoms 60 years ST-segment depression or transient elevation Positive troponin and/or CK-MB Use of coronary angiography in SYNERGY 10,027 pts randomized in the SYNERGY trial 9,188 pts underwent cardiac catheterization 6,352 pts underwen

12、t cardiac catheterization 48h,Adjusted Estimates of 30-day Death/MI Rates (with 95% CI),Landmark Analysis: Adjusted OR of 30-day Death/MI (with 95% CI),Adjusted Estimates of In-hospital Transfusion Rates (with 95% CI),Study Limitations,Non-randomized observational analysis Propensity-based models us

13、ed to deal with lack of randomization Time to cath is a post-baseline and “dynamic” variable Statistical methodologies attempted to address these issues Events from hospital admission to randomization not available Events unlikely prior to randomization Myocardial infarction in the first hours follo

14、wing the hospitalization is more difficult to adjudicate,Conclusions from Synergy- 1,Observational analysis among high-risk NSTE ACS patients enrolled in the SYNERGY trial treated with an early invasive strategy Reduced time to cardiac catheterization was associated with decreased probability of 30-

15、day death/MI and no changes in bleeding No signals suggesting benefits of delaying the cardiac catheterization were observed,Conclusions from Synergy- 2,Randomized clinical trials to establish optimal timing of catheterization in NSTE ACS are needed but challenging Delaying cath is problematic for h

16、ospital adopting expedited cath strategy Lag from hospitalization to randomization may confound actual time to catheterization intervals Early re-MI adjudication complex Well-designed observational studies may be of value in the debate on optimal timing of cardiac catheterization among NSTE ACS patients,Conclusion & Prospective,ACS, early invasive is superior to early conservative in most Pts especially high risk Immediate invasive strategy is recommended in very high risk (instability of hemodynamic or electricity) In high risk pt