β受体阻滞剂在PCI中的应用

1、受体阻滞剂在受体阻滞剂在PCI术的应用术的应用提提 纲纲受体阻滞剂药理受体阻滞剂药理心率心率增快增加冠心病患者的临床事件增快增加冠心病患者的临床事件受体阻滞剂在受体阻滞剂在PCI围手术期的应用围手术期的应用药理学及作用机制药理学及作用机制 主要机制：对抗儿茶酚胺类肾上腺素能递质毒性尤其是通过1受体介导的心脏毒性，是此类药物发挥心血管保护作用。 其他机制： 1.抗高血压作用 2.抗心肌缺血作用 3.阻断肾小球旁细胞1受体，抑制肾素-AngII-醛固酮系统。 4.改善心脏功能增加LVEF: 5.抗心律失常作用 6.其他：抑制肾上腺素能通路介导的心肌细胞凋亡、抑制血小板聚集、减少对粥样硬化斑块的机械

2、应激、防止斑块破裂等。心率增快增加冠心病患者的风险！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.Impact of Left Ventricular Ejection Fraction on Clinical OutcomesOver Five Years After Infar

3、ct-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 infarction, irrespective of the basel

4、ine 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)包括倍他乐克在内的最佳药物治疗仍然是冠心病治疗的基石！阻滞剂在急性心肌梗死的应用阻滞剂在急性心肌梗死的应用Setting/indicationClassLeveli.v. admi

5、nistrationFor relief of ischaemic painTo control hypertension, sinus tachycardiaPrimary prevention of sudden cardiac deathSustained ventricular tachycardiaSupraventricular tachyarrhythmiasTo limit infarct sizeAll patients without contraindicationsOral administrationAll patients without contraindicat

6、ionsIIIIIIIaIIbIBBBCCAAA阻滞剂在慢性稳定性心绞痛的应用阻滞剂在慢性稳定性心绞痛的应用Expert consensus document on -adrenergic receptor blockers. European Heart Journal .2004, 25: 13411362.Setting/indicationClassLevelPrevious infarctionTo improve survivalTo reduce reinfarctionTo prevent/control ischaemiaNo previous infarctionTo im

7、prove survivalTo reduce reinfarctionTo prevent/control ischaemiaIIIIIIAAACBAHeart Rate as an Independent Prognostic Risk Factor in Patients with Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary InterventionCONCLUSION: In patients with acute myocardial infarction undergoing primar

8、y 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.急性心肌梗死患者即使行PCI，心率增快的患者发生院内死亡的风险明显增高！阻滞剂在心肌梗塞后二级预防的应用阻滞剂在心肌梗塞后二级预防的应用Setting/indicationClassLevelAll patien

9、ts without contraindications, indefinitelyTo improve survivalTo prevent reinfarctionPrimary prevention of sudden cardiac deathTo prevent/treat late ventricular arrhythmiasIIIIIIaAAAAB阻滞剂在非阻滞剂在非ST段抬高段抬高ACS的应用的应用Setting/indicationClassLevelEarly benefit, reduction of ischaemiaEarly benefit, prevention

10、 MILong-term secondary preventionIIIBBB实践与指南的差距：实践与指南的差距：阻滞剂在中国冠心病患者中使阻滞剂在中国冠心病患者中使用现状用现状中华医学会心血管病学分会中华心血管病杂志编辑委员会.肾上腺素能受体阻滞剂在心血管疾病应用专家共识. 使用率低使用率低使用时间滞后使用时间滞后剂量较低剂量较低获益渐少获益渐少 受体阻滞剂在受体阻滞剂在PCI围手术期的应用围手术期的应用受体阻断剂在非心脏手术期间的使用一直受到重视!但是在PCI围手术期间的使用？2009 Focused Updates: ACC/AHA Guidelines for the Manageme

11、nt of Patients With 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 受体阻断剂在受体阻断剂在PCI围手术期间

12、的使用围手术期间的使用 术前术前 术中术中 术后术后PCI术前使用术前使用阻滞剂渐少术后阻滞剂渐少术后CK-MB的上升的上升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术前使用术前使用阻滞剂与未使用组术后阻滞剂

13、与未使用组术后CK-MBCK-MB增高的发生率及增高程度比较增高的发生率及增高程度比较术前使用术前使用阻滞剂对阻滞剂对AMI PCI术后临床预后的影响术后临床预后的影响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术前使用BB与未使用两组术后并发症、

14、住院期间及一年随访临床预后的比较AMI PCI术前静注术前静注阻滞剂提高术后生存率阻滞剂提高术后生存率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 Cardiol, 2004; 43:1780-17

15、87 . 术前静脉注射BB与未注射组随访三个月及一年生存率的比较RABBIT II 研究研究 PCI术中冠状动脉内注射术中冠状动脉内注射阻滞剂渐少术后不良事件发生率阻滞剂渐少术后不良事件发生率Barry F Uretsky; Ernst R Schwarz; Abdulfatah Osman ,et al.Intracoronary Beta Blockade (BB) During Percutaneous Coronary Intervention (PCI): 30 Day Results of the Randomized Angioplasty Beta Blocker Intrac

16、oronary Trial II (RABBIT II). Circulation. 2006;114:II_547 急性心肌梗塞急性心肌梗塞PCI术后使用术后使用阻滞剂对临床预后的影响阻滞剂对临床预后的影响Steven J. Kernis, Kishore J. Harjai, Gregg W. Stone, et.al. Does beta-blocker therapy improve clinical outcomes of acute myocardial infarction after successful primary angioplasty?JACC,43（10）:1773

17、 - 1779.术后使用术后使用BB组较未使用组显著降低死亡率及主要心脏不良事件率组较未使用组显著降低死亡率及主要心脏不良事件率急性心肌梗塞急性心肌梗塞PCI术后使用术后使用阻滞剂对临床预后的影响阻滞剂对临床预后的影响AMI PCI术后使用术后使用阻滞剂显著渐少六个月死亡风险阻滞剂显著渐少六个月死亡风险PCI术后使用术后使用阻滞剂渐少一年死亡率阻滞剂渐少一年死亡率 PCI术后使用术后使用BB与未使用组随访一年生存率的比较与未使用组随访一年生存率的比较.P=0.0014.Albert W. Chan, Martin J. Quinn, Deepak L. Bhatt, et.al, Mortal

18、ity Benefit of Beta-Blockade After Successful Elective Percutaneous Coronary Intervention. Journal of the American College of Cardiology.2002,40(4)670-675.Am Heart J 2003;145:875-81Conclusions -Adrenergic receptor blockers prescribed after PCI reduced the risk of clinical restenosis, target lesion r

19、estenosis, 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术后长期使用受体阻断剂可以明显减少再狭窄及临床事件！围围PCI期间使用期间使用受体阻断剂基于以下几个方面受体阻断剂基于以下几个方面 抗炎与稳定斑块抗炎与稳定斑块 心肌保护心肌保护 预防再狭窄！预防再狭窄！These

20、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 shear stress to physiological shear stress around plaque may play an important role.Conclusions: The intravenous administration of metoprolol before coronary reperfusion results in larger myocardial salvage than its oral administration initiated early after reperfusion. If confirmed