急性心肌梗死的藥物溶栓及介入治療課件

1、急性心肌梗死的藥物溶栓及介入治療急性心肌梗死的藥物溶栓及介入治療急性心肌梗死的藥物溶栓及介入治療時(shí)間就是心肌，就是生命時(shí)間對(duì)再灌注搶救的意義0 - 0.5 hrs預(yù)防梗死0.5 2 hrs 大量挽救心肌 + IRA開(kāi)通的益處2 6 hrs心肌挽救降低, IRA開(kāi)通的益處 6 hrs基本不挽救心肌, 但有IRA開(kāi)通的益處22021/1/12急性心肌梗死的藥物溶栓及介入治療急性心肌梗死的藥物溶栓及介入時(shí)間就是心肌，就是生命時(shí)間對(duì)再灌注搶救的意義0 - 0.5 hrs預(yù)防梗死0.5 2 hrs 大量挽救心肌 + IRA開(kāi)通的益處2 6 hrs心肌挽救降低, IRA開(kāi)通的益處 6 hrs基本不挽救心肌

2、, 但有IRA開(kāi)通的益處2021/1/122時(shí)間就是心肌，就是生命時(shí)間對(duì)再灌注搶救的意義0 - 0.5 90年代中已證明溶栓治療的益處與安慰劑對(duì)比2021/1/12390年代中已證明溶栓治療的益處與安慰劑對(duì)比2021/1/12003年，心梗治療-溶栓與介入對(duì)比-We know是否意味著都做PCI? PCI時(shí)間肯定要比直接注射藥物長(zhǎng)，不是所有醫(yī)療機(jī)構(gòu)都具有PCI條件。所以一系列問(wèn)題需要研究2021/1/1242003年，心梗治療-溶栓與介入對(duì)比-We know是溶栓與介入的比較2021/1/125溶栓與介入的比較2021/1/125NRMI-2: 死亡率與時(shí)間的關(guān)系Door-to-Balloon

3、 Time (minutes)校正了的死亡率P=0.01P=0.0007P=0.0003n = 2,2305,7346,6164,4612,6275,412“拖” 多久可以接受？2021/1/126NRMI-2: 死亡率與時(shí)間的關(guān)系Door-to-Ballo2004ACC/AHAAMI指南的選擇的推薦下列情形下溶栓更好到院很早（3h）介入可能延遲介入不可選 導(dǎo)管室沒(méi)空 血管入路有困難 沒(méi)有熟練的醫(yī)生介入延遲(Door-balloon)-(Door-needle)1hMedical contact-balloon time1.5h下列情形下介入更好熟練的隊(duì)伍且有外科保障(Door-balloon

4、)-(Door-needle)1hMedical contact-balloon time3h診斷STEMI有疑問(wèn)如果3小時(shí)之內(nèi)到院，沒(méi)有特別情況，兩種方案均可2021/1/1272004ACC/AHAAMI指南的選擇的推薦下列情形下溶我們已經(jīng)知道PCI優(yōu)于溶栓但是PCI慢于溶栓，慢可用療效彌補(bǔ)，但有個(gè)度這個(gè)“度”的把握很重要北京的調(diào)查顯示，D2B時(shí)間達(dá)標(biāo)比例低如何選擇溶栓與介入？ 溶栓后還可以介入？2021/1/128我們已經(jīng)知道PCI優(yōu)于溶栓北京的調(diào)查顯示，D2B時(shí)間達(dá)標(biāo)比例溶栓與PCI選擇之考慮至少有部分病人，溶栓可能優(yōu)于PCIWho? When? Where? What? Which?

5、2021/1/129溶栓與PCI選擇之考慮至少有部分病人，溶栓可能優(yōu)于PCI20 Sx Door Needle Balloon策略的變化2003 Greg Stone(Lancet): PPCI regardness of nearest cath suite 3 floors or 3 hrs away2007JACC ACCAHA guidelineLytic if anticipated PPCI is 90min give lytic within 30min2021/1/1210 Sx 選擇依據(jù)1-起病長(zhǎng)短2021/1/1211選擇依據(jù)1-起病長(zhǎng)短2021/1/1211選擇依據(jù)2-拖

6、延時(shí)間起病早3h到院者PCI/溶栓的衡量P = 0.006020406080100PCI相關(guān)的時(shí)間延誤 (入院-球囊擴(kuò)張時(shí)間入院-溶栓時(shí)間)死亡的絕對(duì)危險(xiǎn)差異 (%)-5051015圓的尺寸 =單獨(dú)研究的樣本大小.實(shí) 線=加權(quán)meta回歸. . Am J Cardiol. 2003;92:824-662 分鐘獲益支持PCI受損支持溶栓PCI 每延遲10分鐘，與溶栓間的死亡率的差異將減少1%Sx-B每延長(zhǎng)30min，RR=1.082021/1/1212選擇依據(jù)2-拖延時(shí)間起病早 ASA + Heparin 5000U; pre-hospital tPA vs primary PCIp=0.29p

7、=0.61p=0.13p=0.12p=0.0630d events rateBonnefoy, Lancet 2002 ；360:825-292021/1/1243CAPTIM Trial arouse some hope Key trials for facilitate PCI如果已經(jīng)準(zhǔn)備PCI,不要亂給藥了，不給更好2021/1/1244Key trials for facilitate PCI如FINESSEPCI前常規(guī)abciximab或PCI時(shí)囑情abciximab的比較不管是否有半量瑞替普酶溶栓結(jié)果一樣且院前應(yīng)用Ab出血增多Finesse+OnTime2：PCI前Ab無(wú)益處202

8、1/1/1245FINESSEPCI前常規(guī)abciximab或PCI時(shí)囑情aMeta analysis for F-PCIprePCI TIMI flow not transfer to good outcome2021/1/1246Meta analysis for F-PCIprePCIMeta analysis for F-PCI2021/1/1247Meta analysis for F-PCI2021/1/Facilitate PCI 2007 guideline 2021/1/1248Facilitate PCI 2007 guideline Pharmacoinvasive概念的

9、提出2021/1/1249Pharmacoinvasive概念的提出2021/1/12轉(zhuǎn)運(yùn)是安全的2021/1/1250轉(zhuǎn)運(yùn)是安全的2021/1/1250易化，立即，轉(zhuǎn)運(yùn)的綜合問(wèn)題：那些無(wú)法在90min內(nèi)PCI的患者接受半量瑞替普酶+Ab 后，是該立即轉(zhuǎn)運(yùn)作PCI還是等到發(fā)現(xiàn)未再通再進(jìn)行 轉(zhuǎn)運(yùn)補(bǔ)救PCI?180min110minD2B2021/1/1251易化，立即，轉(zhuǎn)運(yùn)的綜合問(wèn)題：那些無(wú)法在90min內(nèi)PCI的患轉(zhuǎn)運(yùn)與立即PCI的結(jié)合Tenecteplase溶栓后的病人何時(shí)轉(zhuǎn)運(yùn)？1059例高?；颊呔?h內(nèi)溶栓提示：盡早轉(zhuǎn)運(yùn)做PCI有益；發(fā)現(xiàn)了溶栓后早期介入的時(shí)間窗可以提前到3h N Eng

10、l J Med 2009; 360:2705-2718. 32.5h2.8h2021/1/1252轉(zhuǎn)運(yùn)與立即PCI的結(jié)合Tenecteplase溶栓后的病人何轉(zhuǎn)運(yùn)與立即PCI的結(jié)合:Sx2hTNKBohmer E etal:JACC2010;55:102-1103d2.7h2021/1/1253轉(zhuǎn)運(yùn)與立即PCI的結(jié)合:Sx2hTNKBohmer E 溶栓后PCI Meta20102021/1/1254溶栓后PCI Meta20102021/1/1254溶栓后PCI獲益2021/1/1255溶栓后PCI獲益2021/1/1255溶栓后PCI Meta-201130d 復(fù)合終點(diǎn)2021/1/125

11、6溶栓后PCI Meta-201130d 復(fù)合終點(diǎn)202溶栓后PCI Meta-201130d缺血終點(diǎn)30d出血終點(diǎn)30d死亡率2021/1/1257溶栓后PCI Meta-201130d缺血終點(diǎn)30d出Latest Guideline, Whats new?Triage and transfer for PCI ,esp in high risk ,but no emphasize surgical backup Abandon the many terms of PPCI,immediate, rescueLytic then PCI safePt be divided into sent

12、 to capability of PCI institute or notEmphasize PPCI ASAP2021/1/1258Latest Guideline, Whats new?T2010ESC介入指南2021/1/12592010ESC介入指南2021/1/1259rt-PA半量溶栓后早期PCI治療急性STEMI 療效及安全性評(píng)價(jià)2021/1/1260rt-PA半量溶栓后早期PCI治療急性STEMI Time intervalslysis2.0h 1.1h 0.5h 1.5h 6.8hMedian D-to-N time: 1.6h Median D-to-B time: 8.

13、4hsymptom onsethospitalizationconsent signature balloon infllation2021/1/1261Time intervalslysis2.0h 2 with no lesions 50% diameter stenosis and 1 with unsuitable anatomy did not undergo PCI6 had TIMI 0-134 had TIMI 2-350 enrolled and accepted half-dose rt-PA 40(81.6%) Achieved clinical criteria of

14、reperfusion1 was unwilling to undergo angiography 9(18.4%) underwent rescue PCI 4 had TIMI 2-35 had TIMI 0-1Early PCI 75.5%Final flow of IRA Final flow of IRA 8 had TIMI 2-31 had TIMI 0-136 had TIMI 2-31 had TIMI 0-12021/1/12622 with no lesions 50% diameteProcedural characteristics (n=46) Glycoprote

15、in IIb/IIIa use, - no.(%) 7 ( 15.2 % )Thrombectomy, - no.(%) 0 ( 0 % )Coronary-artery bypass grafting, - no.(%) 0 ( 0 % )Distal protection device, - no.(%) 0 ( 0 % )Coronary stents, - no.(%) 45 ( 97.8 % )Complications - no.(%) Minor dissection 1 ( 2.2 % ) No reflow 2 ( 4.3 % ) (PPCI 5-25%)2021/1/126

16、3Procedural characteristics (n=Improved TIMI grade flow 2021/1/1264Improved TIMI grade flow 2021/48.532.137.925.6p0.01Improved CTFC 2021/1/126548.532.137.925.6p0.01ImprovImproved MBG 2021/1/1266Improved MBG 2021/1/126659.737.226.719.936.923.437.821.5n=12n=8n=15n=11Optimal time of early PCI (Pilot) 2021/1/126759.737.226.719.936.923.437.137.557.3110.851.3116.752.5157.044.8n=12n=8n=4n=14Optimal time of early PCI (Pilot) 2021/1/1268137.557.3110.851.3116.752.5Clinical outcomes at 30days after symptom onset (n=47) 1.5% 8.1% Borgia1 et al. 1.0% - 4.9% 1.2% - 5.8% 2021/1/1269Clinical o