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23.11.2011

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~0% (
[?])

2007
Thygesen K, Alpert JS, White H.D.
on behalf of the Joint ESC / ACCF / AHA / WHF Task Force
for the Redefinition of Myocardial Infarction.
Universal definition of myocardial infarction

Eur Heart J
2007;
28: 2525

Circulation 2007;
116: 2634

2007
/
( )
,
99-

:

,
( ST
- );

Q ;

Universal definition of myocardial infarction, 2007


,

ST

FRISC-II.
ST

T I

- 20
20
5
- 2
I 1- (AxSym 1.0 g/L

I 2- (Access 0.03 g/L)

L.Wallentin, ESC Congress 03/09/2007. http://webcasts.prous.com/esc2007




50% ,
90% .

,
.

Twerenbold R,b, Reichlin T, Reiter M, Mueller C. Swiss Med Wkly. 2011;141:w13202

718

ROC


Reichlin et al. N Engl J Med 2009;361:858

ROC

.
1818

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(no.)
(no.)
I

Keller T et al. N Engl J Med 2009;361:868

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Twerenbold R, Reichlin T, Reiter M, Mueller C. Swiss Med Wkly. 2011;141:w13202


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ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. EHJ.Published Sep21,2011

0.001
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n=3593
(97.7%).
99%

(0.0133
/)
n=407
(11.1%).


(%)

(PEACE).
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1

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Omland T et al. N Engl J Med 2009;361:2538


( I).
60 . 6-9
,
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(0-3 )

()

ESC Guidelines for the management of acute coronary syndromes in patients


presenting without persistent ST-segment elevation. EHJ 2011. Published September 21, 2011

()

<
>6

>

<6


(1
>)

, GRACE <140,

: 3

ESC Guidelines for the management of acute coronary syndromes in patients presentingwithout persistent ST-segment elevation. EHJ. Published Sep 21, 2011

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,
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35
35
30
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25
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20

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Huynh T et al. Circulation 2009;119:3101

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Huynh T et al. Circulation 2009;119:3101

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2165

2155

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Huynh T et al. Circulation 2009;119:3101

(95%)

1.0

1.5

: . .
.

14451

39802

0.77 (0.65-1.12)
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Huynh T et al. Circulation 2009;119:3101

(95%)

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ST
I
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ST ( ).
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90
( ??)
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120
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Class I
1. Primary PCI should be performed in patients within 12 hours of onset of STEMI.175178 (LOE: A)
2. Primary PCI should be performed in patients with STEMI presenting to a hospital with PCI capability within 90 minutes of first medical
contact as a systems goal.188,189 (LOE: B)
3. Primary PCI should be performed in patients with STEMI presenting to a hospital without PCI capability within 120 minutes of first medical
contact as a systems goal.190192 (Level of Evidence: B)
4. Primary PCI should be performed in patients with STEMI who develop severe heart failure or cardiogenic shock and are suitable candidates
for revascularization as soon as possible, irrespective of time delay.179,180 (LOE: B)

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention.


Circulation 2011. my.americanheart.org

ST

ST ,
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30 ,


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2007 Focused Update of the ACC/AHA 2004 Guide for the Management of Patients with STEMI


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24
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IIa

The Task Force on Myocardial Revascularization of the ESC and EACTS.


Guidelines on myocardial revascularization.
Eur Heart J 2010. published online: Aug 29, 2010


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3 12
)

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( ).
Class IIa
1.
2. A strategy of coronary angiography (or transfer for coronary angiography) 3 to 24 hours after initiating fibrinolytic therapy with intent to
perform PCI is reasonable for hemodynamically stable patients with STEMI and evidence for successful fibrinolysis when angiography and
revascularization can be performed as soon as logistically feasible in this time frame. (Level of Evidence: A)

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention.


Circulation 2011. my.americanheart.org

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1, .
ESC Guidelines for the management of acute coronary syndromes in patients presenting
without persistent ST-segment elevation. EHJ 2011. Published September 21, 2011

ELEVATE
, n=335,
75 / >1,<4
2

, n=333
CYP2C19*2, 247

CYP2C19*2, 86
80 , 6

~14 ,
( VASP VerifyNow P2Y12)

Mega J et al. Increasing Clopidogrel Based on CYP2C19 Genotype in Patients with Cardiovascular Disease.
AHA Sci sessions. Nov 16, 2011. http://my.americanheart.org/

ELEVATE:

CYP2C19*2

CYP2C19*2

(/)
Mega J et al. Increasing Clopidogrel Based on CYP2C19 Genotype in Patients with Cardiovascular Disease.
AHA Sci sessions. Nov 16, 2011. http://my.americanheart.org/

PLATO
.

PLATO.

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1.06 (0.67-1.68)

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De Caterina R et al. Anticoagulants in heart disease: current status and perspectives.


ESC position paper. EHJ April 10, 2007

ATLAS - 2
: ST, ST,
1-7


( )

N=5,176
+ , n=4,821
, n=355

+ 75
- 100 /

2.5 BID

5.0 BID

n=5,174

N=5,176

+ , n=4,825
, n=349

+ , n=4,827
, n=349

:
: , , * ( + )
: TIMI
1,002 15,342 **
Gibson , Mega J, Braunwald E. on behalf of the ATLAS ACS 2 TIMI 51 Investigators

ATLAS-2. ,
+

/ / *
0.85

12%

mITT
p=0.039

(%)

5%

0.62

5%

mITT
p<0.001

10.4%

4.2%

0.64

mITT
p<0.001

4.5%

9.0%

ITT
p=0.011

ITT
p<0.001

ITT
p<0.001
2.7%

2.5%

2.5 2/
12

2.5 2/

2.5 2/

NNT = 56

NNT = 59

NNT = 71
0

24

12

24

12

Gibson , Mega J, Braunwald E. on behalf of the ATLAS ACS 2 TIMI 51 Investigators


AHA Sci Sessions Nov 2011

24


(1)

23 FDA
( ) ,
FDA


,
, .
At its May 23 meeting, the panel voted six to four (with one abstention) against recommending that the FDA
approve rivaroxaban for reducing the risk of thrombotic cardiovascular events in patients with acute coronary
syndrome or unstable angina in combination with aspirin, aspirin plus clopidogrel, or ticlopidine.

www.theheart.org/
11.06.2012

ATLAS


(good follow-up)



(bad follow-up)

85%
4%

2.5
85%
3%

5
84%
4%

89%

88%

87%

8%
0.3%
3%

9%
0.2%
3%

9%
0.3%
4%

11%

12%

13%

T.A. Marciniak, Food & Drug Administration. http://www.fda.gov


, ATLAS
() .
The missing data and quality problems preclude ATLAS from providing substantial evidence of effectiveness.

T.A. Marciniak, Food & Drug Administration


May 23, 2012. http://www.fda.gov

11.06.2012

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n= ~15,500; 1,500
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n= ~11,500; 1500
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SNAPSHOT ( ,
).
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(%)
(%)

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(n=1861)

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31

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20

32

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(n=503)
(n=139)
(n=135)
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(%)

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14,8

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ST

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. ST,

()


n=254
n=296

61,611,9

66,411,3

<0,0001

75 (%)

13,4%

32,1%

<0,0001

(%)

33,5%

50,0%

0,0003


(%)

20,1%

52,4%

<0,0001

- (%)

19,3%

27,4%

0,026

Killip II (%)

7,9%

21,6%

<0,0001


GRACE (%)

10,2%

19,3%

0,003


(3) (%)

2,4%

7,1%

0,01

, . . 2010, 7

. ST,
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,

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(n=82) (n=172)

58,18,4

63,612,7

0,002

75 (%)

6,1%

16,9

0,02

(%)

42,7%

29,1

0,03

(%)

12,2%

23,8

0,03

KillipII (%)

2,4%

10,5%

0,025


(>3%), GRACE (%)

6,1%

12,2%

0,13


(3)
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3,5%

, . . 2010, 7

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