β受體阻滯劑在PCI中的應用實用教案

1、提 綱 受體阻滯劑藥理 心率增快增加冠心病患者的臨床(ln chun)事件 受體阻滯劑在PCI圍手術期的應用第1頁/共34頁第一頁，共35頁。藥理學及作用(zuyng)機制 主要機制：對抗兒茶酚胺類腎上腺素能遞質毒性尤其是通過1受體介導的心臟毒性，是此類藥物發(fā)揮心血管保護作用。 其他機制： 1.抗高血壓作用 2.抗心肌缺血作用 3.阻斷腎小球旁細胞1受體，抑制腎素-AngII-醛固酮系統(tǒng)(xtng)。 4.改善心臟功能增加LVEF: 5.抗心律失常作用 6.其他：抑制腎上腺素能通路介導的心肌細胞凋亡、抑制血小板聚集、減少對粥樣硬化斑塊的機械應激、防止斑塊破裂等。第2頁/共34頁第二頁，共35頁

2、。心率增快增加冠心病患者(hunzh)的風險！第3頁/共34頁第三頁，共35頁。The effect of heart rate on local haemodynamic forces on the endothelium.Mechanisms whereby an elevated heart rate leads to adverse outcomes in patients with coronary artery disease.第4頁/共34頁第四頁，共35頁。Impact of Left Ventricular Ejection Fraction on Clinical Outc

3、omesOver Five Years After Infarct-Related Coronary ArteryRecanalization (from the Occluded Artery Trial OAT)In conclusion, optimal medical therapy remains the overall treatment of choice for stable patients with a persistent total occlusion of the infarct-related artery after acute myocardial infarc

4、tion, irrespective of the baseline EF. In patients with normal or moderately impaired left ventricular contractility, PCI reduced the need for subsequent revascularization but did not otherwise improve outcomes. (Am J Cardiol 2010;105:10 16)包括美托洛爾在內的最佳藥物治療仍然是冠心病治療的基石！第5頁/共34頁第五頁，共35頁。阻滯劑在急性心肌梗死(xn j

5、 n s)的應用Setting/indicationClassLeveli.v. administrationFor relief of ischaemic painTo control hypertension, sinus tachycardiaPrimary prevention of sudden cardiac deathSustained ventricular tachycardiaSupraventricular tachyarrhythmiasTo limit infarct sizeAll patients without contraindicationsOral adm

6、inistrationAll patients without contraindicationsIIIIIIIaIIbIBBBCCAAA第6頁/共34頁第六頁，共35頁。阻滯劑在慢性(mn xng)穩(wěn)定性心絞痛的應用Expert consensus document on -adrenergic receptor blockers. European Heart Journal .2004, 25: 13411362.Setting/indicationClassLevelPrevious infarctionTo improve survivalTo reduce reinfarction

7、To prevent/control ischaemiaNo previous infarctionTo improve survivalTo reduce reinfarctionTo prevent/control ischaemiaIIIIIIAAACBA第7頁/共34頁第七頁，共35頁。Heart Rate as an Independent Prognostic Risk Factor in Patients with Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary InterventionCO

8、NCLUSION: In patients with acute myocardial infarction undergoing primary PCI, elevatedheart rate (80 bpm or greater) identifies those at increased risk of death. It is unknown whether heart rate reduction will result in improved outcome in this setting of patients.急性(jxng)心肌梗死患者急診行PCI，心率增快的患者發(fā)生院內死亡

9、的風險明顯增高！第8頁/共34頁第八頁，共35頁。阻滯劑在心肌梗塞(xn j n s)后二級預防的應用Setting/indicationClassLevelAll patients without contraindications, indefinitelyTo improve survivalTo prevent reinfarctionPrimary prevention of sudden cardiac deathTo prevent/treat late ventricular arrhythmiasIIIIIIaAAAAB第9頁/共34頁第九頁，共35頁。阻滯劑在非ST段抬高(

10、ti o)ACS的應用Setting/indicationClassLevelEarly benefit, reduction of ischaemiaEarly benefit, prevention MILong-term secondary preventionIIIBBB第10頁/共34頁第十頁，共35頁。PURE研究：我國社區(qū)(sh q)冠心病患者的受體阻滯劑使用率低于中低收入國家平均水平Yusuf S, et al. Lancet. 2011;378:1231-1233.中國(zhn u)屬于中低收入國家第11頁/共34頁第十一頁，共35頁。實踐與指南的差距(chj)：阻滯劑在中國

11、冠心病患者中使用現狀中華醫(yī)學會心血管病學分會中華心血管病雜志(zzh)編輯委員會.腎上腺素能受體阻滯劑在心血管疾病應用專家共識. 使用率低使用時間(shjin)滯后劑量較低獲益漸少第12頁/共34頁第十二頁，共35頁。 受體阻滯劑在PCI圍手術(shush)期的應用第13頁/共34頁第十三頁，共35頁。受體阻斷劑在非心臟手術期間的使用(shyng)一直受到重視!第14頁/共34頁第十四頁，共35頁。但是在PCI圍手術(shush)期間的使用？2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With

12、ST-Elevation Myocardial Infarction.2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention.Antithrombotic： 1. UH, LMWH 2. GP IIb/IIIa Inhibitors 3. Bivalirudin-block？ statin ？Antiplatelet： 1. Aspirin 2. clopidogrel 第15頁/共34頁第十五頁，共35頁。受體阻斷劑在PCI圍手術(shush)期間

13、的使用術前術中術后第16頁/共34頁第十六頁，共35頁。PCI術前使用(shyng)阻滯劑減少術后CK-MB的上升Samin K. Sharma, Annapoorna Kini, Jonathan D. Marmur,et al. Cardioprotective Effect of Prior -Blocker Therapy in Reducing Creatine Kinase-MB Elevation After Coronary Intervention . Circulation. 2000,102:166 -172PCIPCI術前使用阻滯劑與未使用組術后CK-MBCK-MB增高

14、(znggo)(znggo)的發(fā)生率及增高(znggo)(znggo)程度比較第17頁/共34頁第十七頁，共35頁。術前使用阻滯劑對AMI PCI術后臨床(ln chun)預后的影響Harjai KJ, Stone GW, Boura J, et al. Effects of prior beta-blocker therapy on clinical outcomes after primary coronary angioplasty for acute myocardial infarction. Am J Cardiol 2003;91:65560.AMI PCI術前使用BB與未使用兩

15、組術后并發(fā)癥、住院期間及一年隨訪臨床預后(yhu)的比較第18頁/共34頁第十八頁，共35頁。AMI PCI術前靜注阻滯劑提高(t go)術后生存率Amir Halkin , Cindy L. Grines , David A. Cox ,et.al.Impact of intravenous Beta-Blockade before primary angioplasty on survival in patients undergoing mechanical reperfusion therapy for acute myocardial infarction. J Am Coll Ca

16、rdiol, 2004; 43:1780-1787 . 術前靜脈注射BB與未注射組隨訪(su fn)30天及一年生存率的比較第19頁/共34頁第十九頁，共35頁。RABBIT II 研究(ynji) PCI術中冠狀動脈(gunzhung-dngmi)內注射阻滯劑漸少術后不良事件發(fā)生率Barry F Uretsky; Ernst R Schwarz; Abdulfatah Osman ,et al.Intracoronary Beta Blockade (BB) During Percutaneous Coronary Intervention (PCI): 30 Day Results of

17、the Randomized Angioplasty Beta Blocker Intracoronary Trial II (RABBIT II). Circulation. 2006;114:II_547 第20頁/共34頁第二十頁，共35頁。急性(jxng)心肌梗塞PCI術后使用阻滯劑對臨床預后的影響Steven J. Kernis, Kishore J. Harjai, Gregg W. Stone, et.al. Does beta-blocker therapy improve clinical outcomes of acute myocardial infarction aft

18、er successful primary angioplasty?JACC,43（10）:1773 - 1779.術后使用(shyng)BB組較未使用(shyng)組顯著降低死亡率及主要心臟不良事件率第21頁/共34頁第二十一頁，共35頁。急性心肌梗塞PCI術后使用(shyng)阻滯劑對臨床預后的影響AMI PCI術后使用阻滯劑顯著漸少六個月死亡(swng)風險第22頁/共34頁第二十二頁，共35頁。PCI術后使用(shyng)阻滯劑減少一年死亡率 PCI術后使用(shyng)BB與未使用(shyng)組隨訪一年生存率的比較.P=0.0014.Albert W. Chan, Martin J

19、. Quinn, Deepak L. Bhatt, et.al, Mortality Benefit of Beta-Blockade After Successful Elective Percutaneous Coronary Intervention. Journal of the American College of Cardiology.2002,40(4)670-675.第23頁/共34頁第二十三頁，共35頁。Am Heart J 2003;145:875-81第24頁/共34頁第二十四頁，共35頁。Conclusions -Adrenergic receptor blocker

20、s prescribed after PCI reduced the risk of clinical restenosis, target lesion restenosis, and MACE in this cohort of 4840 patients. The mechanism by which -blockers conferred a protective effectagainst restenosis remains to be determined. (Am Heart J 2003;145:875-81.)PCI術后長期使用受體阻斷劑可以明顯減少再狹窄導致(dozh)的

21、臨床事件！第25頁/共34頁第二十五頁，共35頁。圍PCI期間使用(shyng)受體阻斷劑基于以下幾個方面抗炎與穩(wěn)定(wndng)斑塊心肌保護預防再狹窄！第26頁/共34頁第二十六頁，共35頁。These findings suggest that metoprolol could inhibit the development of atherosclerosis and stabilize vulnerable plaque by regulation of lipid and reduction of inflammation, in which the change from low

22、shear stress to physiological shear stress around plaque may play an important role.第27頁/共34頁第二十七頁，共35頁。第28頁/共34頁第二十八頁，共35頁。第29頁/共34頁第二十九頁，共35頁。Conclusions: The intravenous administration of metoprolol before coronary reperfusion results in larger myocardial salvage than its oral administration initiated early after reperfusion. If confirmed in the clinicalsetting, the timing and route of -blocker initiation could be revisited.結論：術前盡早靜脈使用美托洛爾可以挽救(wnji)更多的心肌！第30頁/共34頁第三十頁，共35頁。問題是：受體阻斷劑的使用(shyng)遠遠不足！第31頁/共34頁第三十一頁，共3