Knight Charles, Timmis Adam D
Barts and the London School of Medicine and Dentistry London Chest Hospital, London, United Kingdom.
Mater Sociomed. 2011;23(3):161-70. doi: 10.5455/msm.2011.23.161-170.
This overview highlights some recent advances in the epidemiology, diagnosis, risk stratification and treatment of acute coronary syndromes. The sheer volume of new studies reflects the robust state of global cardiovascular research but the focus here is on findings that are of most interest to the practising cardiologist. Incidence and mortality rates for myocardial infarction are in decline, probably owing to a combination of lifestyle changes, particularly smoking cessation, and improved pharmacological and interventional treatment. Troponins remain central for diagnosis and new high-sensitivity assays are further lowering detection thresholds and improving outcomes. The incremental diagnostic value of other circulating biomarkers remains unclear and for risk stratification simple clinical algorithms such as the GRACE score have proved more useful. Primary PCI with minimal treatment delay is the most effective reperfusion strategy in ST elevation myocardial infarction (STEMI). Radial access is associated with less bleeding than with the femoral approach, but outcomes appear similar. Manual thrombectomy limits distal embolisation and infarct size while drug-eluting stents reduce the need for further revascularisation procedures. Non-culprit disease is best dealt with electively as a staged procedure after primary PCI has been completed. The development of antithrombotic and antiplatelet regimens for primary PCI continues to evolve, with new indications for fondaparinux and bivalirudin as well as small-molecule glycoprotein (GP)IIb/IIIa inhibitors. If timely primary PCI is unavailable, fibrinolytic treatment remains an option but a strategy of early angiographic assessment is recommended for all patients. Non-ST segment elevation myocardial infarction (NSTEMI) is now the dominant phenotype and outcomes after the acute phase are significantly worse than for STEMI. Many patients with NSTEMI remain undertreated and there is a large body of recent work seeking to define the most effective antithrombotic and antiplatelet regimens for this group of patients. The benefits of early invasive treatment for most patients are not in dispute but optimal timing remains unresolved. Cardiac rehabilitation is recommended for all patients with acute myocardial infarction but take-up rates are disappointing. Home-based programmes are effective and may be more acceptable for many patients. Evidence for the benefits of lifestyle modification and pharmacotherapy for secondary prevention continues to accumulate but the argument for omega-3 fatty acid supplements is now hard to sustain following recent negative trials. Implantable cardioverter-defibrillators for patients with severe myocardial infarction protect against sudden death but for primary prevention should be based on left ventricular ejection fraction measurements late (around 40 days) after presentation, earlier deployment showing no mortality benefit.
本综述重点介绍了急性冠状动脉综合征在流行病学、诊断、风险分层及治疗方面的一些最新进展。大量的新研究反映出全球心血管研究的蓬勃发展态势，但此处重点关注的是执业心脏病专家最感兴趣的研究结果。心肌梗死的发病率和死亡率呈下降趋势，这可能归因于生活方式的改变，尤其是戒烟，以及药物治疗和介入治疗的改善。肌钙蛋白在诊断中仍然至关重要，新型高敏检测方法进一步降低了检测阈值并改善了预后。其他循环生物标志物的增量诊断价值仍不明确，而对于风险分层，诸如全球急性冠状动脉事件注册（GRACE）评分等简单的临床算法已被证明更有用。在ST段抬高型心肌梗死（STEMI）中，以最短治疗延迟进行直接经皮冠状动脉介入治疗（PCI）是最有效的再灌注策略。桡动脉入路相较于股动脉入路出血更少，但结果似乎相似。手动血栓切除术可限制远端栓塞和梗死面积，而药物洗脱支架则减少了进一步血管重建手术的需求。非罪犯病变最好在完成直接PCI后择期作为分期手术处理。用于直接PCI的抗栓和抗血小板治疗方案不断发展，磺达肝癸钠和比伐卢定有了新的适应证，还有小分子糖蛋白（GP）IIb/IIIa抑制剂。如果无法及时进行直接PCI，溶栓治疗仍是一种选择，但建议对所有患者采用早期血管造影评估策略。非ST段抬高型心肌梗死（NSTEMI）现已成为主要类型，急性期后的预后明显比STEMI更差。许多NSTEMI患者仍未得到充分治疗，近期有大量研究致力于为这类患者确定最有效的抗栓和抗血小板治疗方案。对大多数患者而言，早期侵入性治疗的益处并无争议，但最佳时机仍未解决。建议所有急性心肌梗死患者进行心脏康复治疗，但接受率令人失望。居家项目有效，可能对许多患者更易接受。生活方式改变和药物治疗用于二级预防的益处证据不断积累，但在近期的阴性试验之后，补充ω-3脂肪酸的观点现在难以成立。对于严重心肌梗死患者，植入式心脏复律除颤器可预防猝死，但对于一级预防，应基于发病后晚期（约40天）的左心室射血分数测量结果，早期植入未显示出死亡率获益。
