ACCAHA不稳定型心绞痛和非ST段抬高心肌梗死治疗指南修订版

ACC/AHA非ST段抬高型急性冠脉综合征管理指南解读美国心脏病学会（ACC）和美国心脏协会（AHA）发布了2014 版非ST 段抬高型急性冠脉综合征（NSTE-ACS）患者管理指南（2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the Am erican College of Cardiology/American Heart Association Task For ce on Practice Guidelines）。

该指南是对2007 年ACC/AHA 不稳定性心绞痛和非ST段抬高型心肌梗死管理指南和后续更新的首次完整修订，新指南同时在线发表于《Journal of the American College of Cardiology》和《Circulation》杂志。

和上一版指南相比，新版指南在内容上有较多更新，在理念、术语及处理策略都有新的内容，反映了近年来在NSTE-ACS领域的诸多进展，现就新版指南涉及的相关内容做一简述。

一、理念及术语的更新1.NSTE-ACS 替代不稳定型心绞痛和NSTEMI新指南采用了新的名称和术语，用NSTE-ACS 替代了不稳定型心绞痛和非ST 段抬高型心肌梗死（NSTEMI），反映了目前临床上对这种频发而且紧急的心脏疾病的思考方式。

事实上，新版指南是对2007 版ACC/AHA 不稳定型心绞痛和非ST 段抬高型心肌梗死管理指南及其后续更新的首次完整修订。

2.“缺血指导策略”取代“初始保守管理”另一个重大变化是用“缺血指导策略”（ischemia guided strategy）这一术语代替了“初始保守管理”（initial conservative management），更清楚地表达了这种方法的生理学基本原理。

2007 ACC/AHA不稳定型心绞痛/非ST抬高心肌梗死指南解读-------治疗策略选择美国心脏病学会（ACC）、美国心脏协会（AHA）于2007年8月8日发布了新版不稳定型心绞痛/非ST段抬高心肌梗死诊疗指南，该版指南结合领域内5年来新的临床试验结果，对2002年版指南作出调整，本文将就新旧指南中关于治疗策略的变化进行探讨。

??? 指南采用了惯用的推荐分类：I类推荐指所用的措施或治疗有证据和（或）有共识，对患者有效、有用、有益；Ⅱ类推荐指所用的措施或治疗效益其证据有矛盾和（或）观点有分歧；II a类的证据或观点偏向于有益；Ⅱb类的证据或观点尚难确定获益或获益较小；Ⅲ类推荐指所用措施或治疗的证据或共识为无效，甚至有害。

证据水平分为：A级证据，资料来自多中心临床试验或荟萃分析；B级证据，资料来自个别的随机或非随机试验；C级证据，资料来自专家共识观点、病例研究或规范治疗。

??? 一、?早期侵入治疗与早期保守治疗??? 指南将早期侵入性策略定义为在进行无创性缺血评估或药物治疗失败之前行侵入性评估(诊断性造影并拟行血管重建术)；早期保守策略则仅在强化药物治疗下无效或无创方法证实有缺血证据的基础上考虑侵入性评估手段。

??? (一)推荐水平：??? Ⅰ类：??? 1. 存在顽固性心绞痛或血流动力学及电生理学不稳定, 同时无严重合并症及侵入性手术禁忌症的患者, 采取早期侵入性策略(证据水平: B级);????2. 初始稳定但有临床事件高风险, 同时无严重合并症及侵入性手术禁忌症的患者, 采取早期侵入性策略(证据水平: A级);??? Ⅱb类:??? 1. 初始稳定但有升高的临床事件发生危险性(包括肌钙蛋白阳性), 同时无严重合并症及侵入性手术禁忌症的患者, 早期保守策略可作为一种选择予以考虑, 应综合医生及患者的意见而定(证据水平: C级);??? 2．对于合并慢性肾功能不全的患者，选择早期侵入性策略是合理的(证据水平: C级);??? Ⅲ类:???? 1. 对于有严重合并症如肝、肺功能衰竭者, 因血管重建的手术风险以及因合并症的存在而从血管重建中获益较小,不推荐采取早期侵入性策略(证据水平: C级);??? 2. 不推荐对急性胸痛,但急性冠脉综合征的可能性较小的患者采取早期侵入性策略(证据水平: C级);?????? 3. 无论临床证据如何, 对不愿考虑血管重建的患者, 不推荐行早期侵入性策略(证据水平: C级);??? (二)总则??? 近年来对于早期侵入性还是早期保守的策略之争论一直没有停止，甚至越来越激烈，FRISC II、ISAR-COOL， TACTICS-TIMI 18等研究的结果显示早期侵入性治疗优于早期保守治疗，而早期的VANQUISH试验及2006年公布的ICT US试验则显示和早期保守治疗相比，早期侵入性治疗在主要终点事件方面并无差异。

不稳定型心绞痛和非ST段抬高心肌梗死药物治疗指南推荐医脉通2013-11-11分享刘梅林在第二十四届长城国际心脏病学会议上，北京大学第一医院刘梅林教授介绍了《2012ACCF/AHA 不稳定心绞痛、非ST段抬高心肌梗死患者管理指南》对不稳定型心绞痛和非ST段抬高心肌梗死（UA/NSTEMI）抗心肌缺血和抗血小板治疗的推荐要点。

抗心肌缺血治疗☆UA/NSTEMI患者缺血症状发作，舌下含服硝酸甘油（NTG）0.4mg，每5min重复3次，之后评估是否静注（ⅠC）；☆持续缺血、心衰或高血压患者，前48h应静注NTG；但不应影响降低死亡率的β受体阻滞剂或ACEI使用（ⅠB）；☆24h内口服β受体阻滞剂治疗，但需除外：心力衰竭；低心排状态；心源性休克风险（＞70岁，SBP＜120mmHg，HR＞110 or＜60BPM，出现UA/NSTEMI症状时间长）增加；β受体阻滞剂相对禁忌证（PR＞0.24s，Ⅱ、Ⅲ°AVB，活动性）（ⅠB）；☆UA/NSTEMI缺血症状持续或反复发作，β受体阻滞剂禁忌时，如无LV功能异常或其他禁忌，非二氢吡啶类CCB可作为初始治疗（ⅠB）；☆UA/NSTEMI肺淤血或LVEF≤40%，如无低血压（SBP＜100mmHg或平时收缩压30mmHg）或其他禁忌，前24h应口服ACEI（ⅠA）；☆临床或影像有HF征象或LVEF≤40%，ACEI不耐受应使用ARB（ⅠA）；☆β受体阻滞剂、硝酸酯类充分使用后，缺血仍反复发作者，如无禁忌，可口服长效非二氢吡啶类（ⅡaC）；☆无肺淤血或LVEF≤40%，如无低血压（SBP＜100mmHg或平时收缩压30mmHg）或其他禁忌，前24h应口服ACEI（ⅡaB）；抗血小板治疗☆患者如能耐受，尽快启动阿司匹林治疗（ⅠA）；阿司匹林不能耐受者，负荷剂量后使用氯吡格雷、普拉格雷（PCI）或替卡格雷；☆药物保守治疗患者（如：非介入），尽快阿司匹林+氯吡格雷或替卡格雷（负荷剂量后每日维持）及抗凝治疗，双联抗血小板维持治疗12月；ⅠB☆Abciximab 不应用于非PCI，缺血事件低危患者（TIMI risk score≤2）或高出血风险和已服用阿司匹林及氯吡格雷，不推荐使用GPⅡb/Ⅲa抑制剂；☆拟行介入治疗的高危、非出血高危患者：如TNI高、糖尿病或明显ST压低，在阿司匹林和一种P2Y12抑制剂基础上，可使用GPⅡb/Ⅲa抑制剂；☆保守治疗患者，依诺肝素或肝素或优选磺达肝葵钠；出血风险增加的保守治疗患者，优选磺达肝葵钠；除非24h行CABG，依诺肝素或磺达肝葵钠优于肝素；☆支架术后（BMS/DES）继续阿司匹林，P2Y12受体抑制剂：a.氯吡格雷75mg/d，普拉格雷10mg/d，或替卡格雷90mg bid，DES至少12月，BMS最好12月；b.出血风险超过获益可提前停用P2Y12受体抑制剂；☆有抗凝指征者，继续阿司匹林，华法林INR2.0-3.0（最好2.0-2.5），机械瓣膜至少2.5；DES后继续P2Y12受体抑制剂12月；不推荐双嘧达膜；表三种不同P2Y12受体抑制剂的比较ACS长期抗血小板治疗☆ACS患者终生服用阿司匹林，75-150mg/天；☆氯吡格雷75mg/天，或替卡格雷、普拉格雷，最好使用1年；☆高危患者考虑长期双联抗血小板治疗；☆持续评估患者缺血症状和出血危险；阿司匹林治疗建议☆服用阿司匹林后出血或有出血风险，选择低剂量75-100mg/日；☆不能耐受或禁忌使用阿司匹林，可长期使用氯吡格雷75mg/日代替；☆因胃肠内道出血用氯吡格雷替代阿司匹林时，给予质子泵抑制剂；老年人的抗血小板治疗☆治疗决策需个体化；☆65岁以上老年人亚组分析：老年人同样从阿司匹林和氯吡格雷中获益，并且其绝对和相对获益比65岁以下人群更显著；☆阿司匹林长期剂量建议不超过100mg，急性期抗血小板药物负荷剂量应酌情减少或不用。

不稳定性心绞痛和非ST段抬高心肌梗死诊断与治疗指南不稳定性心绞痛（unstable angina）和非ST段抬高心肌梗死（non-ST elevation myocardial infarction，NSTEMI）是急性冠脉综合征（acute coronary syndrome，ACS）的两种常见类型。

这两种疾病在病理生理和临床表现上有许多相似之处，因此，在诊断和治疗方面有着一些共同的指南。

本文将重点介绍不稳定性心绞痛和非ST段抬高心肌梗死的诊断和治疗指南。

不稳定性心绞痛和非ST段抬高心肌梗死是由冠状动脉狭窄或阻塞导致的心肌缺血所引起的。

两者主要的临床表现是胸痛或胸闷，伴有心电图改变和心肌标志物的升高。

不稳定性心绞痛主要是冠脉斑块的不稳定破裂引起的，而非ST段抬高心肌梗死是冠脉斑块的完全闭塞所致。

对于不稳定性心绞痛和非ST段抬高心肌梗死的诊断，主要依据临床表现、心电图和心肌标志物的改变。

不稳定性心绞痛的特征是胸痛在近期或休息时发作或变得更加严重，而非ST段抬高心肌梗死则是胸痛持续时间较长，并伴有心电图ST段的压低或倒置，以及心肌标志物的升高。

对于疑似的不稳定性心绞痛和非ST段抬高心肌梗死患者，需要进行进一步的评估，包括血压、心率、心肌标志物的测定、心电图检查等。

治疗上，不稳定性心绞痛和非ST段抬高心肌梗死的目的是减轻心肌缺血和改善患者的症状。

根据指南，治疗包括药物治疗和介入治疗两方面。

药物治疗方面，主要包括抗血小板药物（如阿司匹林、氯吡格雷）、抗凝药物（如肝素、低分子肝素或直接凝血酶抑制剂）、硝酸酯类药物、β受体阻滞剂和他汀类药物等。

抗血小板药物和抗凝药物的使用可减少血栓的形成，从而减轻心肌缺血和改善预后。

硝酸酯类药物可扩张冠状动脉并减轻心肌缺血症状。

β受体阻滞剂的使用可降低心率和血压，减轻心肌负荷，从而减轻心肌缺血和改善预后。

他汀类药物的使用可降低血脂水平，减少动脉粥样硬化的形成。

介入治疗方面，对于不稳定性心绞痛和非ST段抬高心肌梗死患者，存在冠脉严重狭窄或闭塞的情况时，需要进行冠状动脉血运重建治疗。

ACC/AHA最新ST段抬高心肌梗死治疗指南（全文）美国心脏病学会（ACC）和美国心脏协会（AHA）早在1990年推出“急性心肌梗死病人早期治疗指南”，后经修改并加入新内容，于1999年再版“急性心肌梗死治疗指南”。

5年来，新的临床试验结果不断发表，新的循证医学证据大量公布，ACC / AHA 总汇新的研究成果，并采用急性冠状动脉综合征（ACS）最新分类方法，于2004年再次重点推出“ST段抬高心肌梗死（ST elevation myocardial infarction,STEMI）治疗指南”。

本章将对该指南的重点内容，特别是集中介绍新指南关于STEMI诊断和治疗进展方面并加以解读。

第一节STEMI的流行病学ACS最新分类方法，将ACS分为两大类：①ST 段不抬高ACS；和②ST 段抬高ACS即STEMI。

STEMI一直是发达国家的重要公众健康问题，但近年来也正迅速危及发展中国家。

虽然STEMI的准确发生率很难确定，但美国有资料分析首次和第二次出院记录显示，仅2001年就有168万人是因为ACS出院。

据美国NRMI-4注册资料的保守估计，30％的ACS患者为STEMI，可以推测美国每年约有50万例STEMI发生。

第二节对有STEMI发病危险的患者教育一、早期控制危险因素新指南强调早期预防与干预危险因素的重要性：1．家庭医生或基层医生应对冠心病患者进行STEMI的危险性评估，定期规律地（大约每3至5年）评价就诊者的主要危险因素以及其控制情况。

2．对所有那些有2个或多个主要危险因素的患者，应估算其发展为有症状冠心病的10年危险性（NCEP-global risk），确定一级预防策略的必要性。

3．确定有冠心病的患者应进行二级预防，有冠心病等危因素（例如糖尿病、慢性肾脏疾病或高于Framingham公式计算20％的10年危险性）的患者应与那些临床明显冠心病的患者，接受相同的强化危险因素干预措施。

二、早期接受教育和急救治疗新指南同时强调对STEMI患者进行早期相关知识教育和早期认知STEMI 的重要性：1．有STEMI症状的病人（胸部不适伴有或不伴有向手臂、后背、颈部、下颌或上腹的放射，气短，无力，腹泻，呕吐和头晕等）应当用急救车而不是被亲人或朋友送到医院。

不稳定型心绞痛和非ST段抬高心肌梗死治疗指南解读不稳定型心绞痛（unstable angina）和非ST段抬高心肌梗死（non-ST elevation myocardial infarction，NSTEMI）是心血管疾病中常见的急性冠状动脉综合征，其临床表现类似但具体病变机制不同。

不稳定型心绞痛指的是心绞痛的频次、持续时间和疼痛程度增加，以及新发生的心绞痛，包括休息时心绞痛及初次发作心绞痛；而非ST段抬高心肌梗死则是心肌缺血引起的心肌细胞坏死，但心电图上未出现ST段抬高。

治疗不稳定型心绞痛和非ST段抬高心肌梗死的主要目标是缓解症状、减少心肌梗死的危险和改善预后。

以下是对两种疾病治疗指南的解读：1.早期评估和诊断：采集详细的病史、实施全面的体格检查和相关实验室检查，包括心电图、血液生化指标（如肌钙蛋白、心肌酶谱）、心脏超声等。

这有助于确定患者的病情严重程度和选择合适的治疗策略。

2.不药物治疗策略：包括监护、维持血液供应、心脏监护以及饮食和运动等生活方式干预。

对于非ST段抬高心肌梗死患者，早期选择冠状动脉介入治疗（包括球囊扩张术、支架置入）可显著改善预后。

3.药物治疗策略：药物治疗的目标是缓解症状、控制心肌缺血、改善预后。

通常首选的药物包括抗血小板药物（如阿司匹林、氯吡格雷）、抗凝血药物（如肝素、低分子肝素）、硝酸酯类药物、β受体阻滞剂和他汀类药物。

药物选择和剂量会根据个体情况和病情严重程度进行调整。

4.高危患者的进一步处理：对于高危患者，特别是存在心血管事件危险的患者，需要提供更加积极的治疗。

这可以包括介入治疗（如紧急血管成形术、支架置入），以及其他治疗措施，如近期内行动脉搭桥手术。

总之，治疗不稳定型心绞痛和非ST段抬高心肌梗死的治疗指南强调了早期评估和诊断，并提供了以药物为主的治疗策略，重点是缓解症状、控制心肌缺血、改善预后。

针对高危患者的处理则更加积极，可能需要介入治疗。

这些指南的目的是为了提供最佳的治疗选择和改善患者的预后，但具体的治疗策略还应根据患者个体情况进行调整和决策。

2011年ACCF/AHA不稳定型心绞痛/非ST段抬高心肌梗死治疗指南（2007年指南的焦点更新）J Am Coll Cardiol, doi:10.1016/j.jacc.2011.02.009 (Published online 28 March 2011)/cgi/content/full/j.jacc.2011.02.009v13. 早期院内治疗3.2 可能或者确定诊断为UA/NSTEMI病人的抗血小板/抗凝治疗的推荐3.2.1 抗血小板治疗的推荐（表2）表2：抗血小板治疗的推荐3.2.3抗血小板和抗凝之外的治疗推荐3.3.起初保守治疗还是起初侵入性治疗策略（参见表4）表4 最初侵入性治疗策略与保守性治疗策略的推荐5.住院后期护理，出院和出院后护理5.2. 长期的药物治疗和二级预防5.2.1. 抗血小板治疗的推荐（表5）表 5 抗血小板治疗推荐5.2.6. 华法令抗凝治疗的推荐表6 华法令抗凝治疗的推荐6.5 慢性肾脏疾病（CKD）推荐表8慢性肾脏疾病（CKD）推荐在使用造影剂之前的至少12小时内进行水化，以达到扩容的目的，并同时抑制肾素系统。

造影剂使用完毕后水化要持续12-20小时（Nephrol Dial Transplant 1999;14:1064-1066.）。

水化的基本原则是单独使用等张或者半浓度的生理盐水（0.45%），这是传统的金标准。

最近，正在试验使用碳酸氢钠作为水化溶液。

一些研究认为在预防造影剂诱发的肾病（CIN）上碳酸氢钠优于生理盐水。

最新的研究显示造影剂体积与肌酐清除率的比值>3.7是血清肌酐浓度异常升高的显著性的、独立的预测因子。

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不稳定性心绞痛和非ST段抬高心肌梗死诊疗指南引言本文档旨在提供不稳定性心绞痛和非ST段抬高心肌梗死（NSTEMI）的诊疗指南。

针对这两种心血管疾病，我们将介绍诊断标准、急性处理措施以及长期治疗建议。

不稳定性心绞痛的诊疗指南诊断标准不稳定性心绞痛通常表现为胸痛或不适感，伴随心电图改变，但没有持续性ST段抬高。

以下是诊断不稳定性心绞痛的标准：1. 典型胸痛症状：剧烈或重压感的胸痛，持续数分钟到数十分钟。

2. 心电图改变：至少出现T波倒置、ST段压低或借鉴性ST段抬高。

3. 临床特征：中年以上，有冠心病危险因素（如高血压、高血脂、糖尿病等）。

急性处理措施一旦诊断为不稳定性心绞痛，应立即采取以下急性处理措施：1. 给予硝酸甘油：可通过扩张冠状动脉来缓解症状。

2. 口服阿司匹林：抗血小板治疗，减少进一步血栓形成的风险。

3. 如有持续胸痛或血流动力学不稳定，考虑转至心内科或急诊科。

长期治疗建议长期治疗旨在预防病情恶化和心血管事件的发生。

以下是不稳定性心绞痛的长期治疗建议：1. 药物治疗：包括β受体阻断剂、ACE抑制剂、他汀类药物等。

2. 生活方式干预：戒烟、控制体重、规律锻炼等。

3. 心脏康复：参加心脏康复方案，改善心血管健康。

4. 紧急情况计划：向患者提供紧急情况处理计划，以应对可能的再发胸痛。

非ST段抬高心肌梗死的诊疗指南诊断标准非ST段抬高心肌梗死（NSTEMI）是一种心肌缺血性病变，常常没有持续性ST段抬高，但存在其他心电图异常。

以下是诊断NSTEMI的标准：1. 典型胸痛症状：剧烈或重压感的胸痛，持续数分钟到数十分钟。

2. 心电图改变：T波倒置、ST段压低或借鉴性ST段抬高等。

3. 血清心肌酶标志物升高：例如肌钙蛋白、肌酸激酶等。

急性处理措施一旦诊断为NSTEMI，应立即采取以下急性处理措施：1. 给予硝酸甘油：可通过扩张冠状动脉来缓解症状。

2. 口服阿司匹林：抗血小板治疗，减少进一步血栓形成的风险。