病例讨论_acs.ppt

病例讨论－ACS 浙江大学医学院附属第一医院心内科 邱原刚 病例介绍 患者，男，62岁； 因反复自发性胸痛半月，剧烈胸痛持续一小时入急诊科； 有高血压史五年，控制在110/70mmHg左右；无糖尿病史； 入院BP 140/87mmHg,R17次/分,T 36.3℃; EKG EKG 辅助检查 血常规：WBC 5.2*109/L,N 40%,Hb 155g/L, plt 216*109/L,Cr 63umol/L,Bun 4.03 mmol/L; SCr 71mmol/L,按照MDRD公式估算eGFR为104ml/min/1.73m2; UCG: LVIDd 4.75,AO 3.49, LA 3.54, LVEF 69%，二尖瓣少量返流，左室舒张功能下降； 心肌酶谱 诊断 冠状动脉性心脏病 急性非ST段抬高型心肌梗死（TIMI危险度评分：3分） 高血压病3级（极高危） 治疗 阿司匹林片 300mg,立即嚼服，其后300mg, qd, po; 波力维片 300mg,立即口服，其后75mg, qd, po; 克赛针 0.4 ml，ih, st+q12h; 倍它乐克片 25mg, po, bid; 开搏通片 12.5mg, po,tid; 立普妥片 20mg，qd; 欣维宁针 12ml, iv, st; 继以 11ml/h静脉微泵维持； 讨论 Selection of Strategy: Invasive vs. Conservative Strategy TIMI risk score Age 65 years or older; At least 3 risk factors for CAD; Prior coronary stenosis of 50% or more; ST-segment deviation on ECG presentation; At least 2 anginal events in prior 24 hours; Use of aspirin in prior 7 days; Elevated serum cardiac biomarkers Preferred Invasive Strategy Recurrent angina/ischemia at rest or low-level activities Elevated cardiac biomarkers New/presumably new ST-segment depression Signs or symptoms of HF or new/worsening mitral regurgitation High-risk findings from noninvasive testing Hemodynamic instability Sustained ventricular tachycardia PCI within 6 months Prior CABG High risk score (e.g. TIMI,GRACE) LVEF less than 0.40 Preferred Conservative Strategy Low-risk score (e.g. TIMI,GRACE) Patient or physician preference in absence of high-risk features Initial Invasive Strategy: Antiplatelet, Anticoagulant Therapy Initiate anticoagulant therapy as soon as possible after presentation (I, A) Enoxaparin or UFH (I, A) Or Bivalirudin or fondaparinux (I, B) Prior to angiography, initiate one (I, A) or both (IIa, B) Clopidogrel IV GP IIb/IIIa inhibitor Use both if: Delay to angiography High risk features Early recurrent ischemic symptoms Initial Conservative Strategy: Early Hospital Care (1) ASA; clopidogrel if intolerant (I, A) Anticoagulant therapy should be added to antiplatelet therapy as soon as possible