急性心肌梗死药物溶栓与介入治疗

1、急性心肌梗死药物溶栓与介入治疗时间就是心肌，就是生命0 - 0.5 hrs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90年代中已证明溶栓治疗的益处与安慰剂对比2003年，心梗治疗-溶栓与介入对比-We know是否意味着都做PCI? PCI时间肯定要比直接注射药物长，不是所有医疗机构都具有PCI条件。所以一系列问题需要研究溶栓与介入的比较NRMI-2: 死亡率与时间的关系“拖拖” 多久可以接受？多久可以接受？2004ACC/AHAAMI指南的选择的推荐指南的选择的推荐下列情形下溶

2、栓更好下列情形下溶栓更好到院很早（3h）介入可能延迟介入不可选 导管室没空 血管入路有困难 没有熟练的医生介入延迟(Door-balloon)-(Door-needle)1hMedical contact-balloon time1.5h下列情形下介入更好下列情形下介入更好熟练的队伍且有外科保障(Door-balloon)-(Door-needle)1hMedical contact-balloon time3h诊断STEMI有疑问如果3小时之内到院，没有特别情况，两种方案均可我们已经知道我们已经知道 PCI优于溶栓 但是PCI慢于溶栓，慢可用疗效弥补，但有个度 这个“度”的把握很重要北京的调

3、查显示，D2B时间达标比例低如何选择溶栓与介入？如何选择溶栓与介入？ 溶栓后还可以介入？溶栓后还可以介入？溶栓与溶栓与PCIPCI选择之考虑选择之考虑至少有部分病人，溶栓可能优于至少有部分病人，溶栓可能优于PCIWho? When? Where? What? Which? Sx Door Needle Balloon策略的变化策略的变化2003 Greg Stone(Lancet): PPCI regardness of nearest cath suite 3 floors or 3 hrs away2007JACC ACCAHA guidelineLytic if anticipated

4、PPCI is 90min give lytic within 30min选择依据1-起病长短选择依据2-拖延时间P = 0.006020406080100PCI相关的时间延误 (入院-球囊扩张时间入院-溶栓时间)-5051015圆的尺寸 =单独研究的样本大小.实 线=加权meta回归. . Am J Cardiol. 2003;92:824-662 分钟获益支持PCI受损支持溶栓PCI 每延迟10分钟，与溶栓间的死亡率的差异将减少1%Sx-B每延长30min，RR=1.08选择依据2-拖延时间NRMI资料192509例患者，645个中心Circulation 2006；114：2019-25

5、114min是个坎但：所有病人一样吗？选择依据3-患者本身风险DANAMI-2发现转运PCI有益于高危者选择依据选择依据4年龄，梗死部位，就诊时间Circulation 2006；114：2019-25直接直接PCI的可接受延搁时间取决于患者病情的可接受延搁时间取决于患者病情Z=PPCI对TT的益处；X=本身死亡率；Y=PCI延误W=患者症状到就诊时间越是高危，PPCI越经“拖”直接直接PCI的可接受延搁时间取决于患者病情的可接受延搁时间取决于患者病情50yM diabetic Pt,3h Ant STEMI hemodynamically stable;TRS=3;Mortality=4.4

6、%D2B-D2N=43min74-yM Pt,3hAnt STEMI hemodynamically unstableTRS=5;Mortality=12.4%D2B-D2N=200min溶栓后还可以溶栓后还可以PCIPCI吗？吗？溶栓成功后的溶栓成功后的PCI-不行到可行的过程不行到可行的过程Immediate PCIImmediate PCI-no goodBe abandoned for many yearsImmediate PCI？80-90s data suggest harmful lytic activated platelet,more thrombogenic Prone

7、to hemorragic in intracoronary lesion More vascular complications Aspirin not given with thrombolysis Low dose heparine,noACT monitor GP IIb/IIIa antagonist & Thienopydine not used Stent not availableACC/AHA2004 AMI Guideline described early angiogram after successful lytic Routine ,Immediately

8、after lytic Tx ClassIII Following successful lytic Tx in Asx Pts without ischemia Class IIbACC/AHA2005 PCIGuideline described early angiogram after successful lyticLittle bit improved?06 ESC AMI guideline :OKKey trials for immediate PCI OKCAPITAL further support routine PCI after lysis07 further met

9、a-analysis：new evidence of PCI reasonable after lysis溶栓后立即或缺血驱动溶栓后立即或缺血驱动PCI荟萃荟萃Wijeysundera H: Am Heart J 2008;156:564-572为什么又行了？ 介入的发展：支架、IIb/IIIa 溶栓药的发展：短效溶栓药 介入的时机选对了溶栓失败后的溶栓失败后的Rescue PCI-不得不行到可行的过程不得不行到可行的过程 Rescue PCIearlyRescue PCI(GUSTO-1)GUSTO-1-不补救更好 Key trial for rescue PCIMeta analysis

10、of Rescue PCI2007易化易化PCI-与溶栓后与溶栓后PCI有区别有区别区别在哪里？区别在哪里？PACTPACTCAPTIM Trial arouse some hope 840 pts in 27 tertiary care French hospitals with mobile care units 2mm STE-MI - ASA + Heparin 5000U; pre-hospital tPA vs primary PCIp=0.29p=0.61p=0.13p=0.12p=0.06Bonnefoy, Lancet 2002 ；Key trials for facilit

11、ate PCI如果已经准备PCI,不要乱给药了，不给更好FINESSE PCI前常规abciximab或PCI时嘱情abciximab的比较 不管是否有半量瑞替普酶溶栓 结果一样且院前应用Ab出血增多 Finesse+OnTime2：PCI前前Ab无益处无益处Meta analysis for F-PCIprePCI TIMI flow not transfer to good outcomeMeta analysis for F-PCIFacilitate PCI 2007 guideline Pharmacoinvasive概念的提出概念的提出转运是安全的易化，立即，转运的综合易化，立即，

12、转运的综合问题：那些无法在90min内PCI的患者接受半量瑞替普酶+Ab 后，是该立即转运作PCI还是等到发现未再通再进行 转运补救PCI?180min110minD2B转运与立即转运与立即PCI的结合的结合Tenecteplase溶栓后的病人何时转运？1059例高危患者均在2h内溶栓提示：尽早转运做PCI有益；发现了溶栓后早期介入的时间窗可以提前到3h N Engl J Med 2009; 360:2705-2718. 32.5h2.8h转运与立即转运与立即PCI的结合的结合:Sx2hTNKBohmer E etal:JACC2010;55:102-1103d2.7h溶栓后PCI Meta2

13、010溶栓后PCI获益溶栓后PCI Meta-201130d 复合终点溶栓后PCI Meta-201130d缺血终点30d出血终点30d死亡率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, rescue Lytic then PCI safePt be divided into sent to capability of PCI institut

14、e or notEmphasize PPCI ASAP2010ESC介入指南rt-PA半量溶栓后早期半量溶栓后早期PCI治疗急性治疗急性STEMI 疗效及安全性评价疗效及安全性评价Time intervalslysis2.0h 1.1h 0.5h 1.5h 6.8hMedian D-to-N time: 1.6h Median D-to-B time: 8.4hsymptom onsethospitalizationconsent signature balloon infllation2 with no lesions 50% diameter stenosis and 1 with uns

15、uitable 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 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

16、IRA 8 had TIMI 2-31 had TIMI 0-136 had TIMI 2-31 had TIMI 0-1Procedural characteristics (n=46) Glycoprotein 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%)Improved TIMI grade flow 48.532.137.925.6p0.01Improved CTFC Improved MBG 59.737.