急性心肌梗死的药物溶栓及介入治疗.ppt

心肌梗死的药物/介入策略,时间就是心肌，就是生命,时间对再灌注抢救的意义,0-0.5hrs预防梗死0.52hrs大量挽救心肌+IRA开通的益处26hrs心肌挽救降低,IRA开通的益处6hrs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,2019年，心梗治疗-溶栓与介入对比-Weknow,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,Door-to-BalloonTime(minutes),校正了的死亡率,P=0.01,P=0.0007,P=0.0003,n=2,230,5,734,6,616,4,461,2,627,5,412,“拖”多久可以接受？,2019ACC/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)1hMedicalcontact-balloontime1.5h,下列情形下介入更好熟练的队伍且有外科保障(Door-balloon)-(Door-needle)3h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,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？,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?,SxDoorNeedleBalloon,策略的变化,2019GregStone(Lancet):PPCIregardnessofnearestcathsuite3floorsor3hrsaway2019JACCACCAHAguidelineLyticifanticipatedPPCIis90mingivelyticwithin30min,选择依据1-起病长短,选择依据2-拖延时间起病早ASA+Heparin5000U;pre-hospitaltPAvsprimaryPCI,p=0.29,p=0.61,p=0.13,p=0.12,p=0.06,30deventsrate,Bonnefoy,Lancet2019；360:825-29,KeytrialsforfacilitatePCI,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Ab无益处,MetaanalysisforF-PCIprePCITIMIflownottransfertogoodoutcome,MetaanalysisforF-PCI,FacilitatePCI2019guideline,Pharmacoinvasive概念的提出,转运是安全的,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?,180min,110min,D2B,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3hNEnglJMed2009;360:2705-2718.,32.5h,2.8h,转运与立即PCI的结合:Sx2hTNK,BohmerEetal:JACC2019;55:102-110,3d,2.7h,溶栓后PCIMeta2019,溶栓后PCI获益,溶栓后PCIMeta-2019,30d复合终点,溶栓后PCIMeta-2019,30d缺血终点,30d出血终点,30d死亡率,LatestGuideline,Whatsnew?,TriageandtransferforPCI,espinhighrisk,butnoemphasizesurgicalbackupAbandonthemanytermsofPPCI,immediate,rescueLyticthenPCIsafePtbedividedintosenttocapabilityofPCIinstituteornotEmphasizePPCIASAP,2019ESC介入指南,rt-PA半量溶栓后早期PCI治疗急性STEMI疗效及安全性评价,Timeintervals,lysis,2.0h1.1h0.5h1.5h6.8h,MedianD-to-Ntime:1.6hMedianD-to-Btime:8.4h,symptomonset,hospitalization,consentsignature,ballooninfllation,2withnolesions50%diameterstenosisand1withunsuitableanatomydidnotundergoPCI,6hadTIMI0-1,34hadTIMI2-3,50enrolledandacceptedhalf-dosert-PA,40(81.6%)Achievedclinicalcriteriaofreperfusion,1wasunwillingtoundergoangiography,9(18.4%)underwentrescuePCI,4hadTIMI2-3,5hadTIMI0-1,EarlyPCI75.5%,FinalflowofIRA,FinalflowofIRA,8hadTIMI2-3,1hadTIMI0-1,36hadTIMI2-3,1hadTIMI0-1,Proceduralcharacteristics(n=46),GlycoproteinIIb/IIIause,-no.(%)7(15.2%)Thrombectomy,-no.(%)0(0%)Coronary-arterybypassgrafting,-no.(%)0(0%)Distalprotectiondevice,-no.(%)0(0%)Coronarystents,-no.(%)45(97.8%)Complications-no.(%)Minordissection1(2.2%)Noreflow2(4.3%),(PPCI5-25%),ImprovedTIMIgradeflow,48.532.1,37.925.6,p0.01,ImprovedCTFC,ImprovedMBG,OptimaltimeofearlyPCI(Pilot),137.557.3,110.851.3,116.752.5,157.044.8,n=12,n=8,n=4,n=14,OptimaltimeofearlyPCI(Pilot),Clinicaloutcomesat30daysaftersymptomonset(n=47),1.5%8.1%,Borgia1etal.,1.0%-4.9%,1.2%-5.8%,