PCI in ACS ：How early is the answer?

Dr. Ben He MD/PhD/FACCDirector of Cardiology DepartmentRenji Hospital Affiliated to Shanghai Jiaotong university

ACS is an Important Manifestation of Atherothrombosis1

1. Cannon CP. J Thromb Thrombolysis 1995; 2: 205–218.

Antithrombotictherapy

Stable angina

UA Non-Q-wave MI

Thrombolysisprimary PCI

Q-wave MI

Minutes– hours

Days–weeks

STEMIUA/NSTEMIAtherothrombosisNew term

Old term

Plaquerupture

经典的危险分层指标

危险分层预测预后

多项研究证实危险分层的意义

Hot topic in ACS

1. Is early invasive superior to conservative strategy in ACS?

2. Should invasive be deferred for cooling off? What is the optimal time for invasive?

Optimal Strategy for UA/NSTEMI

TIMI IIIBTIMI IIIB

2005Conservative Invasive

VANQWISHVANQWISH

FRISC IIFRISC II

TACTICS-TIMI 18

TACTICS-TIMI 18

RITA-3RITA-3

Inv vs Cons/Primary endpoint

Inv vs Cons/All cause death

High risk?

2007 ESC Guideline

• Urgent 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)

国内 2009 指南（早期）• 顽固性心绞痛、持续时

间长、无明显间歇或 >30min ，濒临 MI 表现

• 心脏生化标志物显著升高和心电图 ST 段压低（≥ 2mm ）持续不恢复或范围扩大

• 明显血流动力学不稳定如严重低血压、心力衰竭、心源性休克危险生命的心律失常（室颤或室性心动过速）

• 强化抗缺血治疗 24h 内反复发作心绞痛

• 心脏生化标志物升高和动态 ST 段或 T 波改变（有或无症状）（＜ 2mm ）

• 肾功能不全（ GFR<60mL/分 /1.73m2 ）

• 左室射血分数 <40%• 糖尿病 6 个月内 PCI 史既

往 CABG 史• 危险评分中到高危

紧急 Urgent<2h 早期 Early<72h

Monocyte LDL-CAdhesion molecule

Macrophage

Foam cell

OxidizedLDL-C

Plaque rupture

Smooth muscle cells

CRP

2

ISAR-COOL Trial

ISAR-COOL Antithrombotic Regimen

ISAR-COOL

What is the optimal time for PCI?

Methods for Optimal trial

Results of Optimal trial

Conclusion from Optimal trial

What’s the difference between ISAR-Cool & Optimal?

2.5 vs 84 + 0.5 vs 25 -

Time to Coronary Angiography and Outcomes Among Patients With High-Risk Non–ST-Segment–Elevation Acute Coronary

Syndromes: Results From the SYNERGY Trial

Time to Coronary Angiography and Outcomes Among Patients With High-Risk Non–ST-Segment–Elevation Acute Coronary

Syndromes: Results From the 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

Background• 2007 ACC/AHA Guidelines for NSTE ACS recommend 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 catheterization increasingly adopted in the US

Study Population• Patients randomized in the SYNERGY trial

• Ischemic symptoms <24h and at least 2 of 3 high-risk features• Age >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 underwent cardiac catheterization <48h

回顾性比较不同时间介入的疗效

TIMACS ： AHA2008• TIMACS (TIMing of Intervention in patient with Acute C

oronary Syndromes) trial • 3,031 patients with UAP or NSTEMI were randomly assi

gned to either an early or delayed invasive strategy.

• Early: <24h (mean14h)

Delayed:>36h (mean50h)• PE ： 6m death, MI, Stroke

TIMACS ： AHA2008

TIMACS ： AHA2008 (NEJM2009;360:2165)

TIMACS ： AHA2008 (NEJM2009;360:2165)

TIMACS ： AHA2008 (NEJM2009;360:2165)

TIMACS ： AHA2008 (NEJM2009;360:2165)

结论• 早期介入对高危病人肯定好• 及早的 urgent 介入只适合极高危抢救（ <

2h 甚至 0.5h ）• Cooling-off2.5h vs 84h; TIMACS14h vs 50h Synergy<6h 均提示该早介入；但不用立即• 不特别高危， 3-6h , 甚至 12h 内均可

Thank you for your attention

TIMACS ： Primary and Secondary Outcomes for Overall Cohort

EarlyN=1953

DelayN=1438

HR （ 95%CI ）

P

主要终点 9.7% 11.4% 0.85（ 0.68-1.06 ）

0.15

次要终点 9.6% 13.1% 0.72（ 0. 58-0.89 ）

0.002

次要终点 16.7% 19.7% 0.84（ 0.71-0.99 ）

0.039

TIMACS ： Primary Outcome Stratified by GRACE Risk Score

EarlyN=1953

DelayN=1438

HR （ 95%CI ）

P

低中危 7.7% 6.7% 1.14（ 0.85-1.58 ）

0.43

高危 14.1% 21.6% 0.65（ 0.48-0.88 ）

0.005