Is early invasive the answer for ACSDr. Ben He MD/PhD/FSCAI/FAPSICDirector of Cardiology DepartmentRenji Hospital Affiliated to Shanghai Jiaotong universityACS是否应该早期介入治疗Pathophysiology of Acute Coronary SyndromePathophysiology of Acute Coronary SyndromeACS是否应该早期介入治疗ACS is an Important Manifestation of ACS is an Important Manifestation of AtherothrombosisAtherothrombosis1 11. Cannon CP. J Thromb Thrombolysis 1995; 2: 205218.AntithrombotictherapyStable anginaUANon-Q-wave MIThrombolysisprimary PCIQ-wave MIMinutes hoursDaysweeksSTEMIUA/NSTEMIAtherothrombosisNew termOld termPlaqueruptureACS是否应该早期介入治疗ACS是否应该早期介入治疗Relation of TIMI risk score and MACE rateACS是否应该早期介入治疗Hot topic in ACS1.Is early invasive superior to conservative strategy in ACS?2.Should invasive be deferred for cooling off? What is the optimal time for invasive?ACS是否应该早期介入治疗ACS是否应该早期介入治疗Optimal Strategy for UA/NSTEMITIMI IIIB2005ConservativeInvasiveVANQWISHFRISC IITACTICS-TIMI 18RITA-3ACS是否应该早期介入治疗FRICS-II: high risk get moreACS是否应该早期介入治疗TIMI-18: high risk get moreACS是否应该早期介入治疗RITA-3: 1&3 yrs outcomeACS是否应该早期介入治疗RITA-3: 5yrs outcomeACS是否应该早期介入治疗ACS是否应该早期介入治疗ACS是否应该早期介入治疗ACS是否应该早期介入治疗In 2005,It seems we found answer1.In ACS, early invasive superior to early conservative2.This is particular true in high risk patientsACS是否应该早期介入治疗ESC Guideline 2005ACS是否应该早期介入治疗ACS是否应该早期介入治疗Is the problem settled?ACS是否应该早期介入治疗ICTUS DesignedACS是否应该早期介入治疗ACS是否应该早期介入治疗ACS是否应该早期介入治疗ACS是否应该早期介入治疗ACS是否应该早期介入治疗ACS是否应该早期介入治疗ACS是否应该早期介入治疗4 yrs ICTUS Lancet 2007;369:827-835However, most of selective pts were performed PCISo, the long-term f/u results do not inflect Inv/Cons strategy ACS是否应该早期介入治疗4 yrs ICTUS Lancet 2007;369:827-835ACS是否应该早期介入治疗ICTUSs criticismICTUSs criticism Liberty definition of MI (only 1*ULN) causing the early MI increase in early invasive group3yrs revascularization rate was equal in 2 group(81%PCI)1year mortality rate in ACS in both arm are very low(2.5%),Is it a real high risk?ACS是否应该早期介入治疗Even put ICTUS into pool, Inv ConsACS是否应该早期介入治疗Inv vs Cons/All cause death High risk?ACS是否应该早期介入治疗ACS是否应该早期介入治疗ACS是否应该早期介入治疗2007 ESC GuidelineUrgent Coronary angiography is recommended in Pts with refractory or recurrent angina associated with dynamic ST deviation, heart 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)ACS是否应该早期介入治疗MonocyteLDL-CAdhesion moleculeMacrophageFoam cellOxidizedLDL-CPlaque ruptureSmooth muscle cellsCRP2ACS是否应该早期介入治疗ISAR-COOL TrialACS是否应该早期介入治疗ISAR-COOL Antithrombotic RegimenACS是否应该早期介入治疗ACS是否应该早期介入治疗ISAR-COOLACS是否应该早期介入治疗ACS是否应该早期介入治疗ACS是否应该早期介入治疗ACS是否应该早期介入治疗What is the optimal time for PCI?ACS是否应该早期介入治疗ACS是否应该早期介入治疗Methods for Optimal trialACS是否应该早期介入治疗Results of Optimal trialACS是否应该早期介入治疗Conclusion from Optimal trialACS是否应该早期介入治疗Whats the difference between ISAR-Cool & Optimal?2.5 vs 84 + 0.5 vs 25 -ACS是否应该早期介入治疗Time to Coronary Angiography and Outcomes Among Patients With High-Risk Time to Coronary Angiography and Outcomes Among Patients With High-Risk NonST-SegmentElevation Acute Coronary Syndromes: Results From theNonST-SegmentElevation Acute Coronary Syndromes: Results From the SYNERGY Trial SYNERGY Trial Pierluigi Tricoci, MD, MHS, PhD; 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 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 Division of Cardiology, Duke Clinical Research Institute, Durham, NC ACS是否应该早期介入治疗Background2007 ACC/AHA Guidelines for NSTE ACS recommend the use of an early invasive strategy for high-risk patientsRandomized clinical trials on early vs. conservative strategy used different timing of cardiac catheterizationOptimal timing of cardiac catheterization in NSTE ACS not yet established (expedited vs. deferred)Expedited catheterization increasingly adopted in the USACS是否应该早期介入治疗Study ObjectiveTo 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)ACS是否应该早期介入治疗Study PopulationPatients randomized in the SYNERGY trial Ischemic symptoms 60 years ST-segment depression or transient elevation Positive troponin and/or CK-MBUse of coronary angiography in SYNERGY 10,027 pts randomized in the SYNERGY trial9,188 pts underwent cardiac catheterization6,352 pts underwent cardiac catheterization 48hACS是否应该早期介入治疗Adjusted Estimates of 30-day Death/MI Rates (with 95% CI).0.0ACS是否应该早期介入治疗Landmark Analysis: Adjusted OR of 30-day Death/MI (with 95% CI)ACS是否应该早期介入治疗Adjusted Estimates of In-hospital Transfusion Rates (with 95% CI)ACS是否应该早期介入治疗Study LimitationsNon-randomized observational analysisPropensity-based models used to deal with lack of randomizationTime to cath is a post-baseline and “dynamic” variableStatistical methodologies attempted to address these issues Events from hospital admission to randomization not availableEvents unlikely prior to randomizationMyocardial infarction in the first hours following the hospitalization is more difficult to adjudicateACS是否应该早期介入治疗Conclusions from Synergy- 1Observational analysis among high-risk NSTE ACS patients enrolled in the SYNERGY trial treated with an early invasive strategyReduced time to cardiac catheterization was associated with decreased probability of 30-day death/MI and no changes in bleedingNo signals suggesting benefits of delaying the cardiac catheterization were observedACS是否应该早期介入治疗Conclusions from Synergy- 2Randomized clinical trials to establish optimal timing of catheterization in NSTE ACS are needed but challenging Delaying cath is problematic for hospital adopting expedited cath strategyLag from hospitalization to randomization may confound actual time to catheterization intervals Early re-MI adjudication complexWell-designed observational studies may be of value in the debate on optimal timing of cardiac catheterization among NSTE ACS patientsACS是否应该早期介入治疗Conclusion & ProspectiveACS, early invasive is superior to early conservative in most Pts especially high riskImmediate invasive strategy is recommended in very high risk (instability of hemodynamic or electricity)In high risk pts, short-term(24hrs) cooling-off may be benefited (but no more than 48hs )In low risk ,esp in women, early conservative can be chosenNew antiplatelet drug may change practiceACS是否应该早期介入治疗Thank you for your attentionACS是否应该早期介入治疗