《急诊PCI治疗要点》演示PPT

1、 急性心肌梗塞治疗的目标急性心肌梗塞治疗的目标: 缩小梗塞面积缩小梗塞面积 保护心功能保护心功能 防治并发症防治并发症 降低死亡率降低死亡率 无论何种血运重建无论何种血运重建 方式，都应强调：方式，都应强调： 时间就是心肌，时间就是心肌， 时间就是生命时间就是生命 症状识别症状识别呼叫急救系统呼叫急救系统急诊科急诊科 心导管室心导管室 院前处理院前处理 再灌注治疗时间延迟再灌注治疗时间延迟 心肌细胞丢失增加 延迟治疗就是否定治疗延迟治疗就是否定治疗 时间就是心肌时间就是心肌 0h 1h 2h 3h 4h 5h 6h 心心 肌肌 坏坏 死死 程程 度度 血管闭塞时间血管闭塞时间 0 0.5 hr

2、s 预防梗死 0.5 2 hrs 大量挽救心肌 + IRA开通的益处 2 6 hrs 心肌挽救降低, IRA开通的益处 6 hrs 基本不挽救心肌, 但有IRA开通的益处 时间段（分）时间段（分）平均平均 onset-door183150 door-lab7459 door-consult3.52.1 consult-consent3744 consent-lab3111 onset-balloon278159 door-balloon9858 lab-balloon2510 onset-lab257164 冠脉堵塞冠脉堵塞 再灌注再灌注 远端栓塞远端栓塞 炎症细胞聚集炎症细胞聚集 内皮损伤内

3、皮损伤 组织水肿组织水肿 血小板血小板/ /纤维素聚集纤维素聚集 氧自由基氧自由基 微血管收缩微血管收缩 血栓、粥样斑块远端微循环栓塞血栓、粥样斑块远端微循环栓塞 No-reflow OcclusionPenetrationSlow Flow Normal Flow TIMI 0TIMI 1TIMI 2 TIMI 3 % Mortality 9.3% 6.1% 3.7% p0.0001 vs TIMI 0/1 p0.0001 vs TIMI 2 P=0.003 vs TIMI 0/1 Team 2 Team 2 Team 2 German German German GUSTO 1 GUSTO

4、 1 GUSTO 1 TAM I 1-7 TAM I 1-7 TAM I 1-7 TIM I 1,4 5,10B TIM I 1,4 5,10B TIM I 1,4 5,10B CM Gibson 1998 in Acute Coronary SyndromesSample Size of Pooled Analysis: 5,498 101633344427841319 91518 2934 Restoration of “Normal” Epicardial Flow Yields Better Outcomes Unfortunately rate of agreement only 7

5、1% FZ 2008-10 Myocardial blush grade P = 0.001 TAPAS研究研究 FZ 2008-12 Myocardial blush grade P = 0.001 TAPAS研究研究 EMERALD研究：远端保护装置作用被否定研究：远端保护装置作用被否定 1071 STEMI patients randomized 535 were assigned to thrombus aspiration 33 did not undergo PCI 502 underwent primary PCI 295 underwent TA followed by dir

6、ect stenting 153 underwent TA with additional balloon dilation 54 had crossover to conventional PCI 536 were assigned to conventional PCI 33 did not undergo PCI 503 underwent primary PCI 485 underwent balloon dilation followed by stenting 12 underwent conventional PCI with additional TA 6 had crosso

7、ver to TA 530 complete follow-up at 1 year530 complete follow-up at 1 year TAPAS研究：研究： 血栓抽吸导管作用血栓抽吸导管作用 得到肯定得到肯定 Svilaas T et al. NEJM 2008;358:557 - FZ 2008-8 P 0.001 Patients (%) Thrombus aspirationConventional PCI Svilaas T et al. NEJM 2008;358-557 - FZ 2008-9 Patients (%) Thrombus aspirationConv

8、entional PCI P 0.001 NEW Recommendation Aspiration thrombectomy is reasonable for patients undergoing primary PCI I I I I I I IIaIIaIIaIIa IIaIIaIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIII I I I I I I IIaIIaIIaIIa IIaIIaIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIII I I I I I I IIaIIaIIaIIa IIaIIaIIbIIbIIbIIbIIbIIbI

9、IIIIIIIIIIIIIIIIIIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIII % IIb/IIIa受体拮抗剂受体拮抗剂 DEBATER研究 阿昔单抗组及对照组阿昔单抗组及对照组30天靶血管重建失败（天靶血管重建失败（TVF）发生率）发生率 阿昔单抗组及对照组阿昔单抗组及对照组1年年MACE发生率发生率 转运转运 PCI center N=984 6/2006-11/2007 PCI *Bolus: 25 g/kg & 0.15 g/kg/min infusion Ongoing Tirofiban In Myocardial I

10、nfarction Evaluation 14.39.1 12.19.4 5.98.1 4.86.3 14.59.1 10.99.2 4.45.3 3.34.3 0.0020.0220.028p=0.84 mm 随机时随机时造影前造影前术后术后60 分钟分钟 术后术后90 分钟分钟 Time (days) 302520151050 Event free survival 90% 80% 70% 60% 50% 40% Tirofiban Placebo P value 0,012 Ongoing Tirofiban In Myocardial Infarction Evaluation P =

11、 0.013 74.0% 66.7% P = 0.007 open label & double-blind, n = 1.155 39 It is reasonable to start treatment with glycoprotein IIb/IIIa receptor antagonists at the time of primary PCI (with or without stenting) in selected patients with STEMI: abciximab tirofiban and eptifibatide Use of Glycoprotein IIb/IIIa Receptor Antagonists in STEMI I I I IIaIIaIIa IIbIIb IIb III IIIIII I I I IIaIIaIIa IIbIIb IIb III IIIIII I I I IIaIIaIIa IIbIIb IIb III IIIIIIIIaIIaIIa IIbIIb IIb III IIIIII I I I IIaIIaIIa IIbIIb IIb III IIIIII I I I IIa