老年冠心病治疗策略的演变

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1、老年冠心病治疗策略的演变TheStrategicChangesofElderlyCoronaryHeartDiseaseTreatment陈可冀ChenKe-ji徐浩XuHao中国中医科学院西苑医院心血管病中心卫生部中日友好医院全国中西医结合心血管病中心2008-05-23老年冠心病临床特点ClinicalFeaturesofElderlyCHD严重心绞痛多/多支血管病变多/复杂病变多/弥漫和钙化病变多/陈旧心梗多/左室功能受累多/并存病多/无症状多/合并糖尿病多/严重心律失常多/病死率高(高龄者三支

2、病变>60%---TIME/APPROACH试验)(>75岁CHD发病率:男18.6%,女6.1%)(PCI,出血并发症16.6%)治疗目的:缓解症状/改善功能/提高生活质量2冠心病治疗观念的改变NovelChangesinConceptofElderlyCHDTreatmentLuminalstenosistovulnerableplaqueformation从重视管腔狭窄到易损斑块Lipiddeposittoinflammatoryresponse从注意脂质沉积到炎症反应Vulnerableplaq

3、uetovulnerablepatient从重视易损斑块到易损病人Epicardialvesselopentomyocardialperfusion从注意心外膜冠脉开通到心肌组织水平灌注Outshineotherstotrio从一枝独秀到三驾马车SingleRFcontroltomulti-RFintervention从单一危险因素控制到多个危险因素联合干预Standardizedtreatmenttoindividualizedtherapy从注重规范化治疗到个体化治疗3LuminalStenosis

4、管腔狭窄VulnerablePlaque易损斑块冠心病治疗观念改变之一FirstChangeinConceptofCHDTreatment4DegreeofCoronaryStenosis冠脉狭窄程度RiskofCHD冠心病严重度动脉粥样硬化的传统观念TraditionalConceptofAtherosclerosis?5急性心梗前的冠脉狭窄程度CoronaryArteryStenosispre-AMI<50%50-70%>70%%ofDiameterStenosis%ofthePatientsBa

5、rgraphshowsseverityofcoronaryarterystenosisbeforeAMI(n=195,4studies)68%patientshadstenosislessthan50%atbaseline86%patientshadstenosislessthan70%atbaselineFalketal.Circulation.1995;92:657.6降脂疗法降低心脏事件但并不改变管腔狭窄Lipid-loweringTherapiesDecreaseCardiacEventsbut

6、NotStenosisTrialCholesterolDecrease,%CardiacEventDecrease,%ChangeinStenosis,%FATS2380-1.1±3.7STARS1469-0.5±3.6STARS2389-1.5±4.0SCRIP16390.3±2.5PLAC119740.69LevineGN,KeaneyJFJr,VitaJA.Cholesterolreductionincardiovasculardisease:clinicalbenefitsandpossible

7、mechanisms.NEnglJMed..1995;332:512-521.PhilbinEF,PearsonTA.Howdoeslipid-loweringtherapyrapidlyreduceischemicevents?JMyocardIschemia..1994;6:13-18.PittB,ManciniGBJ,EllisSG,RosmanHS,ParkJ-S,McGovernME,forthePLACIinvestigators.Pravastatinlimitationofatheros

8、clerosisinthecoronaryarteries(PLACI):reductioninatherosclerosisprogressionandclinicalevents.JAmCollCardiol..1995;26:1133-11397CoronaryArteryStenosisAndCardiacEvents冠脉狭窄与心脏事件Plaquevolumeorseverityofcoronaryarterystenosismay