急性心肌梗死直接CI

ACCF/AHA/SCAI关于AMI直接PCI指南解析YidaTang,MD,PhDDept.ofCardiology,FuwaiHospitalChineseAcademyofMedicalSciencesNationalCenterforCardiovascularDisease2010ESCcoronaryrevascularizationguideline2011ACCAHAPCIguideline

2012ACCAHANSTEMIguideline2012ESCDefinitionofMIGuideline2012ESCNSTEMIGuideline2013ACCAHAdefinitionofMI

2013ACCAHASTEMIguideline2013ESCSTEMIGuidelineClassofRecommendation(COR)CORBenefit/RiskKeyWords(Theprocedureortreatment…)ClassIBenefit>>>RiskShouldbeperformed/administeredIsrecommendedIsindicatedIsuseful/effective/beneficialClassIIaBenefit>>RiskIsreasonableCanbeuseful/effective/beneficialIsprobablyrecommendedorindicatedClassIIbBenefit≥RiskMay/mightbeconsideredorbereasonableUsefulness/effectivenessisunknown/unclear/uncertainornotwellestablishedClassIII–NoBenefitNothelpfulNoprovenbenefitIsnotrecommended/indicatedShouldnotbeperformed/administeredIsnotuseful/beneficial/effectiveClassIII–HarmHarmfulExcesscostwithoutbenefitorharmfulPotentiallyharmfulCausesharmShouldnotbeperformed/administeredGNL2011LevelofEvidence(LOE)LOECriteriaAMultiplepopulationsevaluatedDataderivedfrommultiplerandomizedclinicaltrialsormeta-analysesBLimitedpopulationsevaluatedDataderivedfromasinglerandomizedtrialornonrandomizedstudiesCVerylimitedpopulationsevaluatedOnlyconsensusopinionofexperts,casestudies,orstandardofcareGNL2011STEMI急诊PCI方式直接(primary,direct)PCI：不溶栓直接行PCI补救(rescue,salvage)PCI：溶栓失败后行PCI即刻(immediate)PCI：溶栓成功对严重残余狭窄行PCI延迟(delayed,deferred)PCI：溶栓后1-7天行PCIPCIinSTEMI*IndicationsCORLOEPrimaryPCI*STEMIsymptomswithin12hIASevereheartfailureorcardio-genicshockIBContraindicationstofibrinolytictherapywithischemicsymptoms<12hIBClinicaland/orECGevidenceofongoingischemiabetween12and24haftersymptomonsetIIaBAsymptomaticpatientpresentingbetween12and24haftersymptomonsetandhigherriskIIbCNoninfarctarteryPCIatthetimeofprimaryPCIinpatientswithouthemodynamiccompromiseIII:HarmBDelayedorElectivePCIinPatientswithSTEMI(i.e.Non-PrimaryPCI)ClinicalevidenceforfibrinolyticfailureorinfarctarteryreocclusionIIaBPatentinfarctartery3to24hafterfibrinolytictherapyIIaBIschemiaonnoninvasivetestingIIaBHemodynamicallysignificantstenosisinapatentinfarctartery>24hoursafterSTEMIIIbBTotallyoccludedinfarctartery>24hafterSTEMIinahemodyamicallystableasymptomaticpatientwithoutevidenceofsevereischemiaIII:NoBenefitBGNL2011新版PCI指南的要点分析作为整体目标，应当在STEMI发生后12小时内并且在首次医疗接触后90分钟内实施直接PCICardiogenicShockRecommendationCORLOEImmediatecoronaryangiographyinpatientswithSTEMIwithsevereheartfailureorcardiogenicshockwhoaresuitablecandidatesforrevascularizationIBPCIforpatientswithacuteMIwhodevelopcardiogenicshockandaresuitablecandidatesIBHemodynamicsupportdeviceforpatientswithcardiogenicshockafterSTEMIwhodonotquicklystabilizewithpharmacologicaltherapyIBGNL2011IA床BP棉应用孔率：魄13匹.5姿%心源煌性休脱克或啄严重耍低血腾压状细态No螺-r裂ef灯lo冶w心肺成复苏最大串可能深保障趁IR震A开抽通新版PC勾I指南樱的要县点分父析ST裙EM普I并发插心源五性休司克者滚，若奏能耐正受，沿尽早欢行冠灿脉造托影药物它稳定题血流莲动力钩学困徐难者衣尽早斤行IA壤BP支持UA舟/N房诚ST侵EM蜡I:旁Ch祥oi薪ce工o柳f傻St预ra香te讨gy忘*RecommendationCORLOEAnearlyinvasivestrategy**inpatientswhohaverefractoryanginaorhemodynamicorelectricalinstability(withoutseriouscomorbiditiesorcontraindicationstosuchprocedures)IBAnearlyinvasivestrategy**ininitiallystabilizedpatients(withoutseriouscomorbiditiesorcontraindicationstosuchprocedures)whohaveanelevatedriskforclinicaleventsIATheselectionofPCIorCABGasthemeansofrevascularizationinthepatientwithACSshouldgenerallybebasedonthesameconsiderationsasthosewithoutACSIBAconservativestrategyrecommended(overanearlyinvasivestrategy)inwomenwithlow-riskfeaturesIBAnearlyinvasivestrategy(within12to24hoursofadmission)chosenoveradelayedinvasivestrategyforinitiallystabilizedhigh-riskpatients***IIaBAninitialconservative(i.e.,aselectivelyinvasive)strategyininitiallystabilizedpatientswhohaveanelevatedriskforclinicalevents(includingtroponinpositivepatients)***IIbCAnearlyinvasivestrategy**inpatientswithextensivecomorbiditiesinwhomtherisksofrevascularizationandcomorbidconditionsarelikelytooutweighthebenefitsofrevascularization,inpatientswithacutechestpainandalowlikelihoodofACS,orinpatientswhowillnotconsenttorevascularizationregardlessofthefindingsIII–NoBenefitCGN侄L制20取11优选介入治疗首先优选药物治疗RecurrentanginaorischemiaatrestorwithlowlevelactivitiesdespiteintensivemedicaltherapyElevatedcardiacbiomarkers(TnTorTnI)NeworpresumablynewST-depressionSignsorsymptomsofheartfailureHemodynamicinstabilityHighriskscore(e.g.,GRACE,TIMI)SustainedventriculartachycardiaPCIwithin6moPriorCABGDiabetesmellitusMildtomoderaterenaldysfunctionReducedLVfunction(LVEF<40%)Lowriskscore(e.g.,GRACE,TIMI)Absenceofhigh-riskfeaturesHighriskforcatheterization-relatedcomplicationsPatientnotarevascularizationcandidate(witheitherPCIorCABG)PatientprefersconservativetherapyGN锈L程20乱11新版PC惑I指南印要点片分析NS出TE旷MIUP状LM已P槐CI姑t疗o僻Im柜pr容ov胖e该Su释rv谨iv抓al诱(匀AC胞S)CORLOEIIaForUA/NSTEMIifnotaCABGcandidateBIIaForSTEMIwhendistalcoronaryflowis<TIMIgrade3andPCIcanbeperformedmorerapidlyandsafelythanCABGCGN记L哭20腔11新版融PC竹I指喉南的潜要点瞎分析对于比无保尤护左孝主干渐是罪导犯病面变并期且冠间脉远历端血喘流不拌足TI革MI自3级的祸急性ST金EM宁I患者术，PC悄I可以服提高盯存活热，并俭且与CA乳BG比较啄，可竞迅速怀和安职全实久施PC全IUP炸LM勤R炸ev撑as祖cu菠la妻ri类za割ti混on槽t舅o拜Im咽pr瞎ov右e休Su斜rv介iv停alRevascMethodCORLOECABGIBPCIIIaForSIHDwhenbothofthefollowingarepresent:AnatomicconditionsassociatedwithalowriskofPCIproceduralcomplicationsandahighlikelihoodofgoodlong-termoutcome(e.g.,alowSYNTAXscoreof≤22,ostialortrunkleftmainCAD)Clinicalcharacteristicsthatpredictasignificantlyincreasedriskofadversesurgicaloutcomes(e.g.,STS-predictedriskofoperativemortality≥5%)BIIaForUA/NSTEMIifnotaCABGcandidateBIIaForSTEMIwhendistalcoronaryflowis<TIMIgrade3andPCIcanbeperformedmorerapidlyandsafelythanCABGCIIbForSIHDwhenbothofthefollowingarepresent:AnatomicconditionsassociatedwithalowtointermediateriskofPCIproceduralcomplicationsandanintermediatetohighlikelihoodofgoodlong-termoutcome(e.g.,low-intermediateSYNTAXscoreof<33,bifurcationleftmainCAD)Clinicalcharacteristicsthatpredictanincreasedriskofadversesurgicaloutcomes(e.g.,moderate-severeCOPD,disabilityfrompriorstroke,orpriorcardiacsurgery;STS-predictedoperativemortality>2%)BIII:HarmForSIHDinpatients(versusperformingCABG)withunfavorableanatomyforPCIandwhoaregoodcandidatesforCABGBGN添L晓20个11PC湾I爆in竖H风os轧pi益ta递ls趣W衬it伏ho纳ut诉O开n-宰Si情te广S瘦ur佣gi抵ca容l肾Ba滤ck祥upRecommendationCORLOEPrimaryPCIinhospitalswithoutonsitecardiacsurgery(providedthatappropriateplanningforprogramdevelopmenthasbeenaccomplished)IIaBElectivePCIinhospitalswithoutonsitecardiacsurgery(providedthatappropriateplanningforprogramdevelopmenthasbeenaccomplished,andrigorousclinicalandangiographiccriteriaareusedforproperpatientselection)IIbBPrimaryorelectivePCIinhospitalswithouton-sitecardiacsurgerycapabilitieswithoutaprovenplanforrapidtransporttoacardiacsurgeryoperatingroominanearbyhospitalorwithoutappropriatehemodynamicsupportcapabilityfortransferIII–HarmCGN竭L其20晕11新版材PC妨I指适南的婶要点载分析在没赤有心遥脏外决科支搏持的纱医院子，如即果已材经有除相应龟的临洒床路统径和壶预备中措施汽，可挺以实萝施直惰接PC点ICo侦ro站na茶ry逗S务te形nt哈sRi坚sk润o穗f倚re侍st输en类os跪is浇n旺ee点ds亏t任o薯be趋w杏ei达gh南te距d宫ag谢ai潮ns秋t偿th脖e锁li概ke遥li朵ho户od套o棵f讯th乡丰e巷pa盼ti肢en木t叮to第b捆e苦ab蔬le杰t怠o窃to侵le磁ra钳te械a递nd投c巨om它pl祝y免wi伪th肝(微pr耗ol口on衰ge晚d)胃D颈AP推TRecommendationCORLOEDESasanalternativetoBMStoreducetheriskofrestenosisincasesinwhichtheriskofrestenosisisincreasedandthepatientislikelytobeabletotolerateandcomplywithprolongedDAPTIElectivePCI:AUA/NSTEMI:CSTEMI:ABeforeimplantationofaDES,interventionalcardiologistdiscussionwiththepatientregardingtheneedforanddurationofDAPTandtheabilityofthepatienttocomplywithandtolerateDAPTICUseofballoonangioplastyorBMS(insteadofDES)inpatientswithhighbleedingrisk,inabilitytocomplywith12monthsofDAPT,orwithanticipatedinvasiveorsurgicalprocedureswithinthenext12monthsduringwhichtimeDAPTmaybeIBPCIwithcoronarystentingincasesinwhichthepatientisnotlikelytobeabletotolerateandtocomplywithDAPTIII-HarmBDESimplantationincasesinwhichthepatientisnotlikelytobeabletotolerateandcomplywithprolongedDAPT,orthiscannotbedeterminedpriortostentimplantationIII-HarmBGN笼L感20拾11Cl梢in心ic拘al丝式S绝it穗ua婚ti让on死s跃As姓so牌ci危at表ed奖W往it唤h驰DE摊S址or云B声MS宜S掠el售ec垦ti党on胳P垫re盾fe此re兔nc态eDESGenerallyPreferredOverBMS(efficacyconsiderations)BMSPreferredOverDES(safetyconsiderations)LeftmaindiseaseSmallvesselsIn-stentrestenosisBifurcationlesionsLonglesionsMultiplelesionsSaphenousveingraftlesionsDiabeticpatientsPatientsunabletotolerateorcomplywithprolonged

DAPTAnticipatedsurgeryrequiringdiscontinuationofDAPTwithin12monthsHighriskofbleedingGN身L暮20阴11ST嫂EM弓I患发者中完DE肉S优然于B务MSTh碑e盘EX康AM桨IN妹AT榨IO爹N凝(a墓c帖li牢ni刘ca崇l磨Ev敌al全ua组ti似on县o说f醒Xi剩en驶ce葬-V服s密te井nt旅i反n毕Ac络ut抗e河My字oc男ar顽di宜al设I弱Nf祸Ar云cT勤IO勤N)侮t核ri膊al新版PC焦I指南确：DE全S如果牲再狭脂窄风贱险增设高并筛且患更者可验以耐层受和旋依从拆长期DA狠PT，可销应用DE芝S替代BM柄S，减及少再陈狭窄叫风险Va惑sc钻ul袜ar钓A蹦cc陈es浓sRecommendationCORLOERadialarteryaccesstodecreaseaccesssitecomplicationsIIaAGN代L肠20饲11ST版EM众I患映者桡协动脉六路径丙较股胳动脉运路径酱安全RI慈FL遮E择ST谱EA均CS：对侮比分曾析S饭TE杀MI劝桡股仿动脉升穿刺马路径穿刺秧部位桃出血配并发栋症减暴少4谎7%舟，M动AC贝CE兰无差麦异新版奔CA泽BG验指南某的要壶点分荐析急诊CA显BG的指伞征：-直接PC屡I失败跳或不条能实揪施-冠脉冶解剖张适合CA零BG-静息盘时有府大面详积心齿肌持烛续缺趣血和融（或泻）血赔流动梢力学挽障碍暮对非摇手术奖治疗絮无效血栓嗽抽吸索术不阅能减然少1着年时煌MI卷面积MU碍ST垫EL扁A:揪A狠Pr住os冷pe蛇ct扯iv弄e,鼻R句an血do赖mi典ze汽d桨Tr惹ia耳l熔of刮T烧hr元om萝be招ct纤om棵y救vs博.弯no蜓T病hr尤om糠be惹ct采om孙y朴in微P任at湿ie层nt堵s存wi洒th贪S升TEM盯Ian逃d尸Th摸ro件mb吩us洞-R菠ic很h早Le脊si扑on告s前瞻度随机溪入选阅了20兴8例患若者，论分为足抽吸遭和非她抽吸猛组，土抽吸巷组患身者再侍分为搂机械跟和手遍动抽流吸方逮式所有誓患者抓均为ST驶ME袄I血栓同负荷龟较重茄（TI才MI血栓涨≥3级）MU劲ST花EL幼A结治果血栓酿抽吸予组术拳后TI巩MI筛3级血筑流高息达90棚.4均%，对疯照组81展.7透%（P=延.0胖7），60够mi括n时ST棍R饮>7奴0%以上豆抽吸双组57角.4折%，对位照组37显.3辉%（P=猴.0足04）3个月MR表明禁血栓玻抽吸共组延弦迟增攻强面缩慧积为20胀.4堵%，对北照组话为19理.3庭%（P=估.5畅4）1年时咐无MA阁CE生存兵率分涉别为92碌.3题%和93毁.9提%（P=乱.5摧7）亚组破分析辽显示阁使用仪机械湿抽吸段患者袜（54例）槽相比毕手动子抽吸贩的（50例）怀造影填成功高率更较高（P=棍.0哨2）整体哨成功兼率分喊别为94笛.4毕%和78叶.0俘%衔(P故=.枪02沫)但3个月旬时MR排I却发陆现两雪组梗次死面贯积无围显著撕差异手动畅抽吸障装置使成功顿输送吗率为98症%，机笑械抽存吸装售置为10恶0%AM射I冠霸脉内购阿昔咱单抗涛并不蔬优于肃静脉辜应用AI妇DA羡S颠TE圈MI君(魔Ab栋ci呼xi址ma狮b停In吊tr个ac周or占on硬ar盛y塑ve右rs改us块i鬼nt栽ra德ve要no冲us扩D罩ru祸g窃Ap缘瑞pl晃ic忙at烈io茫n考in某S本T-塌El嫌ev脾at购io甲n够My丢oc选ar有di些al盏I象nf任ar鄙ct抬io跳n)试验入选27家医趋院20鼓65例ST汗EM圾I患者银，随疮机分少为在多直接PC驻I中冠悟脉内间（0.娇25鸟m臣g/兴kg）组掏（10垫32例）墓或静尊推阿旗昔单景抗组侄（10丈33例）也，2组患博者在围随后12起h内均誉以0.臣12夺5µ旨g/屠kg谊/m罪in输注均服卵用50线0m谊gA界SA谊+6液00析mg氯吡虑格雷朵或60迟mg普拉牵格雷90讲天临戴床终粗点事勺件ICIVOR(95%CI)P主要终点7.0%7.6%0.91(0.91-1.28)0.58死亡4.5%3.6%1.24(0.78-1.97)0.36再次MI1.8%1.8%1.00(0.51-1.96)0.99新发充血性心衰2.4%4.1%0.57(0.33-0.97)0.04ICIVP院内脑卒中0.5%0.76%0.70支架内血栓形成1.7%2.0%0.65出血、致命或严重出血2.6%1.8%0.63推注时血液动力学改变0.1%0.6%0.06PCI时致死性心律失常1.7%2.1%0.22安全塞性终渐点AI淡DA胀S荣TE牢MI肚试验直接PC症I冠脉件内应莫用阿病昔单辉抗并摘不比市常规渠静脉高内应织用更搏有益在新李发心牲力衰吉竭方秒面的乔优势杏可能肯是偶贼发事济件建议