急性心肌梗死的藥物溶栓及介入治療課件

心肌梗死的藥物/介入策略時間就是心肌，就是生命時間對再灌注搶救的意義0-0.5hrs 預(yù)防梗死0.5–2hrs 大量挽救心肌+IRA開通的益處2–6hrs 心肌挽救降低,IRA開通的益處>6hrs 基本不挽救心肌,但有IRA開通的益處90年代中已證明溶栓治療的益處

與安慰劑對比溶栓與介入的比較NRMI-2:死亡率與時間的關(guān)系Door-to-BalloonTime(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？

2004ACC/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)管室沒空血管入路有困難沒有熟練的醫(yī)生介入延遲(Door-balloon)-(Door-needle)>1hMedicalcontact-balloontime>1.5h下列情形下介入更好熟練的隊伍且有外科保障(Door-balloon)-(Door-needle)<1hMedicalcontact-balloontime<1.5h髙?；颊?/p>

心源性休克或Killip≥3級溶栓有禁忌或可能增加出血危險到院太遲，癥狀發(fā)作>3h診斷STEMI有疑問如果3小時之內(nèi)到院，沒有特別情況，兩種方案均可溶栓與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?SxDoorNeedleBalloon策略的變化2003GregStone(Lancet):PPCIregardnessofnearestcathsuite3floorsor3hrsaway2007JACCACCAHAguidelineLyticifanticipatedPPCIis>90mingivelyticwithin30min選擇依據(jù)1---起病長短選擇依據(jù)2---拖延時間

NRMI資料192509例患者，645個中心Circulation2006；114：2019-25114min是個坎但：所有病人一樣嗎？選擇依據(jù)3---患者本身風(fēng)險

DANAMI-2發(fā)現(xiàn)轉(zhuǎn)運PCI有益于高危者選擇依據(jù)4

年齡，梗死部位，就診時間Circulation2006；114：2019-25越是高危，PPCI越經(jīng)“拖”直接PCI的可接受延擱時間取決于患者病情50yMdiabeticPt,3hAntSTEMIhemodynamicallystable;TRS=3;Mortality=4.4%D2B-D2N=43min74-yMPt,3hAntSTEMIhemodynamicallyunstableTRS=5;Mortality=12.4%D2B-D2N=200min溶栓后還可以PCI嗎？ImmediatePCIImmediatePCI---nogoodBeabandonedformanyyearsImmediatePCI？

80-90’sdatasuggestharmfullyticactivatedplatelet,morethrombogenicPronetohemorragicinintracoronarylesionMorevascularcomplicationsAspirinnotgivenwiththrombolysisLowdoseheparine,noACTmonitorGPIIb/IIIaantagonist&ThienopydinenotusedStentnotavailableACC/AHA2005PCIGuideline

describedearlyangiogramaftersuccessfullyticLittlebitimproved?06ESCAMIguideline:OK07furthermeta-analysis：

newevidenceofPCIreasonableafterlysis溶栓后立即或缺血驅(qū)動PCI薈萃WijeysunderaH:AmHeartJ2008;156:564-572為什么又行了？介入的發(fā)展：支架、IIb/IIIa溶栓藥的發(fā)展：短效溶栓藥介入的時機選對了溶栓失敗后的RescuePCI---不得不行到可行的過程RescuePCI—earlyRescuePCI(GUSTO-1)GUSTO-1---不補救更好

KeytrialforrescuePCIMetaanalysisofRescuePCI2007易化PCI---與溶栓后PCI有區(qū)別區(qū)別在哪里？PACTPACTCAPTIMTrialarousesomehope

840ptsin27tertiarycareFrenchhospitalswithmobilecareunits2mmSTE-MI->ASA+Heparin5000U;pre-hospitaltPAvsprimaryPCIp=0.29p=0.61p=0.13p=0.12p=0.0630deventsrateBonnefoy,Lancet2002；360:825-29KeytrialsforfacilitatePCI如果已經(jīng)準(zhǔn)備PCI,不要亂給藥了，不給更好FINESSEPCI前常規(guī)abciximab或PCI時囑情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無益處MetaanalysisforF-PCI

prePCITIMIflownottransfertogoodoutcomeMetaanalysisforF-PCIFacilitatePCI2007guidelinePharmacoinvasive概念的提出轉(zhuǎn)運是安全的易化，立即，轉(zhuǎn)運的綜合問題：那些無法在90min內(nèi)PCI的患者接受半量瑞替普酶+Ab

后，是該立即轉(zhuǎn)運作PCI還是等到發(fā)現(xiàn)未再通再進行轉(zhuǎn)運補救PCI?180min110minD2B轉(zhuǎn)運與立即PCI的結(jié)合Tenecteplase溶栓后的病人何時轉(zhuǎn)運？1059例高危患者均在2h內(nèi)溶栓提示：盡早轉(zhuǎn)運做PCI有益；發(fā)現(xiàn)了溶栓后早期介入的時間窗可以提前到3h

NEnglJMed2009;360:2705-2718.32.5h2.8h轉(zhuǎn)運與立即PCI的結(jié)合:

Sx<2hTNKBohmerEetal:JACC2010;55:102-1103d2.7h溶栓后PCIMeta2010溶栓后PCI獲益溶栓后PCIMeta-201130d復(fù)合終點溶栓后PCIMeta-201130d缺血終點30d出血終點30d死亡率LatestGuideline,What’snew?TriageandtransferforPCI,espinhighrisk,butnoemphasizesurgicalbackupAbandonthemanytermsofPPCI,immediate,rescueLyticthenPCIsafePtbedividedintosenttocapabilityofPCIinstituteornotEmphasizePPCIASAP2010ESC介入指南rt-PA半量溶栓后早期PCI治療急性STEMI

——療效及安全性評價Timeintervalslysis2.0h1.1h0.5h1.5h6.8hMedianD-to-Ntime:1.6hMedianD-to-Btime:8.4hsymptomonsethospitalizationconsentsignature

ballooninfllation2withnolesions≥50%diameterstenosisand1withunsuitableanatomydidnotundergoPCI6hadTIMI0-134hadTIMI2-350enrolledandacceptedhalf-dosert-PA40(81.6%)Achievedclinicalcriteriaofreperfusion1wasunwillingtoundergoangiography9(18.4%)underwentrescuePCI4hadTIMI2-35hadTIMI0-1EarlyPCI75.5%FinalflowofIRA

FinalflowofIRA

8hadTIMI2-31hadTIMI0-136hadTIMI2-31hadTIMI0-1Proceduralcharacteristics(n=46)

GlycoproteinIIb/IIIause,-no.(%)7(15.2%)Thrombectomy,-no.(%)0(0%)Coronary-arterybypassgrafting,-no.(%)0(0%)Distalprotectiondevice,-no.(%)0(0%)Coronarystents,-no.(%)45(97.8%)Complications-no.(%)

Minordissection1(2.2%)Noreflow2(4.3%)

(PPCI5-25%)ImprovedTIMIgradeflow

48.5±32.137.9±25.6p＝0.01ImprovedCTFC

ImprovedMBG

59.7±37.226.7±19.936.9±23.437.8±21.5n=12n=8n=15n=11OptimaltimeofearlyPCI(Pilot)

137.5±57.3110.8±51.3116.7±52.5157.0±44.8n=12n=8n=4n=14OptimaltimeofearlyPCI

(Pilot)

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