1. Levine GN, Keaney JF Jr, Vita JA. Cholesterol reduction in cardiovascular disease: clinical benefits and possible mechanisms. N
Engl J Med.. 1995;332:512-521.
% of the Patients
<50%
50-70%
>70%
% of Diameter Stenosis
Bar graph shows severity of coronary artery stenosis before AMI (n=195, 4 studies)
68% patients had stenosis less than 50% at baseline
Many sided strategic changes
n 诊断进步：由以CAG为主导，到重视斑块检测技术的发展如IVUS、OCT； n 基础研究方向：逐渐以稳定易损斑块以及减少斑块破裂后血栓形成为方
向； n 二级预防重点：也将由治疗冠脉狭窄转为易损斑块的干预。
Lesion < 60 micron Cap
1. Kullo IJ, Edwards WD, Schwartz RS. Vulnerable plaque: pathobiology and clinical implications. Ann Intern Med 1998; 129(12):1050-60.
2. Ozer K, Cilingiroglu M. Vulnerable plaque: definition, detection, treatment, and future implications. Curr Atheroscler Rep. 2005; 7(2):121-6
2. Philbin EF, Pearson TA. How does lipid-lowering therapy rapidly reduce ischemic events? J Myocard Ischemia.. 1994;6:13-18.
3. Pitt B, Mancini GBJ, Ellis SG, Rosman HS, Park J-S, McGovern ME, for the PLAC I investigators. Pravastatin limitation of
冠心病治疗策略的演变
COURAGE –研究设计
Study design of COURAGE trial
2287例稳定型心绞痛患者
( 他汀类, 抗血小板, ACEI/ARB, β-受体阻滞剂)
随机化
加PCI 组
不加PCI组
随访 2.5-7 Y
死亡率/ MACE/ACS
冠心病治疗策略的演变
两组主要终点比较
冠心病治疗策略的演变
冠脉介入治疗的短处
Limitations of PCI
n Although PCI could relieve severe stenosis of coronary artery, it wouldn’t change the biologic course of AS, thus the problem of “unstable” is still
Coronary Artery Stenosis And Cardiac Events
冠脉狭窄与心脏事件 n Plaque volume or severity of coronary
artery stenosis may not be the key factor for inducing cardiac events.
冠心病治疗策略的演变
两组总生存率
Overall Survival
PCI + OMT
1.0
0.9
OMT
0.8
0.7
Hazard ratio: 0.87
95% CI (0.65-1.16)
0.6
P = 0.38
0.5
0.0
0
1
2
3
4
5
6
7
Years
Number at Risk
Medical Therapy 1138
Characteristic CLINICAL Angina free – no.
Baseline 1 Yr 3 Yr 5 Yr
PCI + OMT
12% 66% 72% 74%
OMT
13% 58% 67% 72%
The comparison between the PCI group and the medical-therapy group was significant at 1 year ( P<0.001) and 3 years (P=0.02) but not at baseline or 5 years.
unresolved. 尚未能解决斑块不稳定问题
冠心病治疗策略的演变
COURAGE临床试验
n Boden WE, et al. Optimal Medical Therapy with or without PCI for Stable coronary Disease (NEJM.356:1503-1516;April 12,2007)
n 提示:冠脉狭窄并非心血管事件关键原因
冠心病治疗策略的演变
Concept of Vulnerable Plaque
易损斑块概念的提出
n In 1989, Muller and colleagues first used “vulnerable plaques” to describe rupture-prone plaques as the underlying cause of most clinical coronary events. 首倡易损斑块破裂观念
Trial Cholesterol Decrease, %
FATS
23
STARS
14
STARS
23
SCRIP
16
PLAC 1
19
Cardiac Event Decrease, % 80 69 89 39 74
Change in Stenosis, % -1.1 ±3.7 -0.5±3.6 -1.5 ±4.0 0.3±2.5 0.69
冠心病治疗策略的演变
心脏事件的发生
Progression of Cardiac Events
CHD Plaque formation Atherosclerosis Dyslipidemia
ACS AMI
LVபைடு நூலகம்dysfunction LV reconstruction
Heart failure
CHD develops in 20~30 years 冠心病慢性病程 Plaque rupture occurs in 2~3 hrs 斑块破裂快过程
▪ Standardized treatment to individualized therapy 从注重规范化治疗到个体化治疗
冠心病治疗策略的演变
冠心病治疗观念改变之一
First Change in Concept of CHD Treatment
Luminal Stenosis 管腔狭窄
Vulnerable Plaque 易损斑块
冠心病治疗策略的演变
2020/11/7
冠心病治疗策略的演变
冠心病治疗观念的改变
Novel Changes in Concept of Elderly CHDTreatment
▪ Luminal stenosis to vulnerable plaque formation 从重视管腔狭窄到易损斑块
n A vulnerable plaque often has a large lipid pool, a thin cap, and macrophage-dense inflammation on or beneath its surface. 特征
n Vulnerable plaque rupture or disruption causes bleeding into the plaque, luminal thrombosis, and/or vasospasm that may cause sudden flow obstruction and ischemic injury. 破裂致血栓形成
1073
1029
917
717
468
302
38
PCI
1149
1094
1051
929
733
488
312
44
冠心病治疗策略的演变
稳定易损斑块的重要作用
Stabilization of Vulnerable Plaques
n The vascular pathophysiological research has focused on stabilizing the vulnerable plaque and inhibiting thrombosis after plaque rupture.
冠心病治疗策略的演变
震撼全球心血管病学界
Grobal impact on cardiological field
n 慢性稳定性冠心病/临界狭窄病变者:现 代药物治疗效果理想/病人依从性好
COURAGE trial:
n 医生应该有信心面对这些病人 n 保护病人效果和利益的最大化 n 在病人身上做有证据的治疗 n 中西医结合应受理解和提倡
The comparison of endpoints with two groups