急性冠脉综合征概述

不稳定型心绞痛 (unstable angina, UA) 是一种急性冠脉综合征，无心肌损伤的生化证据。[3]Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2015 Aug 29;37(3):267-315. https://academic.oup.com/eurheartj/article/37/3/267/2466099 http://www.ncbi.nlm.nih.gov/pubmed/26320110?tool=bestpractice.com 临床特征包括休息时心绞痛持续较长（＞20 分钟）；新发严重心绞痛；心绞痛发作频率增加、持续时间延长或发作阈值降低；或心绞痛发生在近期心肌梗死发作后。典型心电图（ECG）表现为 ST 段压低和 T 波倒置，但也可为正常。[3]Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2015 Aug 29;37(3):267-315. https://academic.oup.com/eurheartj/article/37/3/267/2466099 http://www.ncbi.nlm.nih.gov/pubmed/26320110?tool=bestpractice.com 对疑似 UA 患者的早期管理重点在于根据拟诊进行初始干预和分诊。若可以测得心脏生物标志物，如果肌酸激酶同工酶 MB 或肌钙蛋白没有升高，则可以诊断为 UA。然而，随着越来越多可用敏感标志物的出现，UA 的诊断已经变得不太常见。[2]Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e344-e426. http://circ.ahajournals.org/content/130/25/e344.long http://www.ncbi.nlm.nih.gov/pubmed/25249585?tool=bestpractice.com

非 ST 段抬高型心肌梗死（NSTEMI）是一种引起心肌细胞坏死的急性缺血事件。ECG 可能显示 ST 段压低、一过性 ST 段抬高或 T 波倒置；但也可能显示正常结果或非特异性改变。与不稳定型心绞痛（unstable angina, UA）的区别在于心脏生物标志物；NSTEMI 患者在就诊时或数小时后标志物水平将升高，而 UA 患者则在连续测定中显示正常。[2]Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e344-e426. http://circ.ahajournals.org/content/130/25/e344.long http://www.ncbi.nlm.nih.gov/pubmed/25249585?tool=bestpractice.com 治疗的目的是缓解缺血、防止进一步血栓形成或栓塞以及稳定血流动力学状态，之后进行早期风险分层，以确定进一步治疗。

对于有相符临床病史且 ECG 显示两个或多个解剖上相邻的导联中 ST 段持续抬高（＞20 分钟），或新发左束支传导阻滞的患者，应怀疑 ST 段抬高型心肌梗死 （ST-elevation myocardial infarction, STEMI）。[1]Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction (2018). Eur Heart J. 2019 Jan 14;40(3):237-269. https://academic.oup.com/eurheartj/article/40/3/237/5079081 http://www.ncbi.nlm.nih.gov/pubmed/30165617?tool=bestpractice.com 此外，有心脏生物标志物水平升高。在首次发病后 90 分钟内通过经皮冠状动脉介入治疗及时进行血运重建，或者在症状出现后 12 小时内进行溶栓治疗，可以预防或减少心肌损害，并且可通过预防急性并发症来降低死亡率和并发症发生率。 [ ] How do drug-eluting stents compare with bare-metal stents for people with acute coronary syndrome?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1890/full展示答案