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Stéfanie SERRE Service de Réanimation-CHU NICE DES de cardiologie

Mehta SR et al. Stéfanie SERRE Service de Réanimation-CHU NICE DES de cardiologie 2iéme année DESC de réanimation médicale Grenoble 2006. prise en charge des syndromes coronariens aigus sans sus décalage du segment ST. - angor instable /syndrome de menace.

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Stéfanie SERRE Service de Réanimation-CHU NICE DES de cardiologie

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  1. Mehta SR et al Stéfanie SERRE Service de Réanimation-CHU NICE DES de cardiologie 2iéme année DESC de réanimation médicale Grenoble 2006

  2. prise en charge des syndromes coronariens aigus sans sus décalage du segment ST - angor instable /syndrome de menace - Idm sous endocardique/Idm non Q (NSTEMI) Stratégie invasive ou conservatrice? • Stratégie invasive: « routine invasive strategy » réalisation précoce d’une coronarographie • +/- revascularisation (angioplastie / pontage) • Stratégie conservatrice: « selective invasive strategy » traitement médical • Coronarographie +/- revascularisation envisagées que si récidive • ischémique

  3. META ANALYSE Revue de la littérature de 1970 -> juin 2004 7 études randomisées incluant 9212 patients => 4608 ROUTINE INVASIVE vs 4604 SELECTIVE INVASIVE -> mortalité -> IDM non mortels -> décès combinés/IDM -> angor -> taux de réhospitalisations

  4. les études…

  5. caractéristiques des patients

  6. Résultats

  7. RANDOMISATION SORTIE DE L’HOPITAL

  8. FIN DU SUIVIT SORTIE DE L’HOPITAL

  9. FIN DU SUIVIT RANDOMISATION

  10. Interprétationsetconclusions

  11. Stratégie invasive au cours de syndrome coronariens aigus sans sus décalage du segment ST diminue le risque combiné de décès ou de récidive d’événements ischémiques et de réhospitalisations. • Ce bénéfice émerge après la sortie de l’hôpital • Et ce… au prix d’une mortalité plus élevée durant l’hospitalisation

  12. n=201 IDM AIGU CROSS OVER++ 44% revascularisation IDM NON q Mortalté apres pontage↑ Exclusion de 247patients à haut risque) ABCIXIMAB TICLOPIDINE STENT Faible taux de CROSS OVER Mortalité moins élevée chez les pontés TICLOPIDINE

  13. les traitements utilisés n’étaient pas les mêmes …clopidogrel et antigp2b3a … • l’utilisation des stents… • évolution des techniques de cathéterisme et de chirurgies cardiaques • CROSS OVER • durées de suivit très variables

  14. Que faire ?

  15. Traitement médical «optimal»:  aspirine  clopidogrel  ß bloquant  dérivés nitrés  héparine (hbpm)  antiGp2b3a  IEC / statines

  16. STEPHEN D. WIVIOTT, M.D., and EUGENE BRAUNWALD, M.D

  17. bibliographie - Braunwald E et al. ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction Circulation. 2002;106:1893-1900. - TIMI IIIB Investigators. Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction: results of theTIMI IIIBtrial. Circulation. 1994;89:1545-1556. - Boden WE, O’Rourke RA, Crawford MH, et al;Veterans Affairs Non-Q-Wave Infarction Strategies inHospital (VANQWISH) Trial Investigators. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy.N Engl J Med. 1998;338:1785-1792. -FRagmin and Fast Revascularisation during In-Stability in Coronary artery disease (FRISC II) Investigators. Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. Lancet.1999;354:708-715.20. -Wiviott SD, Braunwald E.Unstable angina and non-ST-segment elevation myocardial infarction: part I. Initial evaluation and management, and hospital care.Am Fam Physician. 2004 Aug 1;70(3):525-32.

  18. - Cannon CP, Weintraub WS, Demopoulos LA, et al; TACTICS (Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy)—Thrombolysis in Myocardial Infarction 18 Investigators. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 2001;344:1879-1887. • - Fox KA, Poole-Wilson PA, Henderson RA, et al; Randomized Intervention Trial of unstable Angina Investigators. Interventional versus conservative treatment for patients with unstable angina or non-STelevationmyocardial infarction: the British Heart Foundation • RITA 3 randomised trial. Lancet. 2002;360:743-751 • PURSUIT Trial Investigators. Inhibition of plateletglycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. N Engl J Med. 1998;339:436-443. • - Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable • Signs and Symptoms (PRISM-PLUS) Study Investigators. Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina andnon-Q-wave myocardial infarction. • N Engl J Med.1998;338:1488-1497. • CURE Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494-502. • SYNERGY Trial Investigators. Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managedwith an intended early invasive strategy: primaryresults of the SYNERGY randomized trial.. JAMA. 2004;292:45-54.

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