急性心肌梗死的药物溶栓及介入治疗课件

1、急性心肌梗死的药物溶栓及介入治疗急性心肌梗死的药物溶栓及介入治疗急性心肌梗死的药物溶栓及介入治疗时间就是心肌，就是生命时间对再灌注抢救的意义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22021/1/12急性心肌梗死的药物溶栓及介入治疗急性心肌梗死的药物溶栓及介入时间就是心肌，就是生命时间对再灌注抢救的意义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

2、, 但有IRA开通的益处2021/1/122时间就是心肌，就是生命时间对再灌注抢救的意义0 - 0.5 90年代中已证明溶栓治疗的益处与安慰剂对比2021/1/12390年代中已证明溶栓治疗的益处与安慰剂对比2021/1/12003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2021/1/1242003年，心梗治疗-溶栓与介入对比-We know是溶栓与介入的比较2021/1/125溶栓与介入的比较2021/1/125NRMI-2: 死亡率与时间的关系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: 死亡率与时间的关系Door-to-Ballo2004ACC/AHAAMI指南的选择的推荐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熟练的队伍且有外科保障(Door-balloon

4、)-(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2021/1/1272004ACC/AHAAMI指南的选择的推荐下列情形下溶我们已经知道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查显示，D2B时间达标比例低如何选择溶栓与介入？ 溶栓后还可以介入？2021/1/128我们已经知道PCI优于溶栓北京的调查显示，D2B时间达标比例溶栓与PCI选择之考虑至少有部分病人，溶栓可能优于PCIWho? When? Where? What? Which?

5、2021/1/129溶栓与PCI选择之考虑至少有部分病人，溶栓可能优于PCI20 Sx Door Needle Balloon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 PPCI is 90min give lytic within 30min2021/1/1210 Sx 选择依据1-起病长短2021/1/1211选择依据1-起病长短2021/1/1211选择依据2-拖

6、延时间起病早3h到院者PCI/溶栓的衡量P = 0.006020406080100PCI相关的时间延误 (入院-球囊扩张时间入院-溶栓时间)死亡的绝对危险差异 (%)-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=1.082021/1/1212选择依据2-拖延时间起病早 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如果已经准备PCI,不要乱给药了，不给更好2021/1/1244Key trials for facilitate PCI如FINESSEPCI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Ab无益处202

8、1/1/1245FINESSEPCI前常规abciximab或PCI时嘱情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转运是安全的2021/1/1250转运是安全的2021/1/1250易化，立即，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?180min110minD2B2021/1/1251易化，立即，转运的综合问题：那些无法在90min内PCI的患转运与立即PCI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 Eng

10、l J Med 2009; 360:2705-2718. 32.5h2.8h2021/1/1252转运与立即PCI的结合Tenecteplase溶栓后的病人何转运与立即PCI的结合:Sx2hTNKBohmer E etal:JACC2010;55:102-1103d2.7h2021/1/1253转运与立即PCI的结合:Sx2hTNKBohmer E 溶栓后PCI Meta20102021/1/1254溶栓后PCI Meta20102021/1/1254溶栓后PCI获益2021/1/1255溶栓后PCI获益2021/1/1255溶栓后PCI Meta-201130d 复合终点2021/1/125

11、6溶栓后PCI Meta-201130d 复合终点202溶栓后PCI Meta-201130d缺血终点30d出血终点30d死亡率2021/1/1257溶栓后PCI Meta-201130d缺血终点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治疗急性STEMI 疗效及安全性评价2021/1/1260rt-PA半量溶栓后早期PCI治疗急性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