急性心肌梗死治疗进展霍勇.ppt

急性心肌梗死治疗进展,北京大学第一医院霍勇2007年11月23日,急性心肌梗塞治疗的进展,心肌梗塞治疗的关键：,迅速、完全、持续开通梗塞相关血管,PrimaryPTCAvsThrombolysisPAMITrial:in-hospitalmortality,P=0.01,P65,P=0.03,P=0.01,评估STEMI再灌注方式-ACC/AHA2019STEMIGuidelines,步骤1：评估时间和危险性症状发作后的时间STEMI危险分层溶栓风险转运至熟练PCI导管室所需时间,JACCAugust4,2019;44:671-719,再灌注策略危险和获益,静脉溶栓直接PCI,时间时间,评估STEMI再灌注方式-ACC/AHA2019STEMIGuidelines,步骤2：决定应首选溶栓还是PCI如果时间少于3小时，且介入治疗无耽搁，溶栓和PCI首选哪种都可以。,JACCAugust4,2019;44:671-719,评估STEMI再灌注方式-ACC/AHA2019STEMIGuidelines,溶栓首选，如果：早期就诊（症状发作在3小时内，行介入治疗有耽搁）不适合选择介入治疗导管室被占用或不能用血管入路困难缺乏熟练PCI操作相关工作人员介入治疗时间耽搁运输时间延长Door-to-balloon比door-to-needlle时间超过1小时或door-to-balloon时间超过90分钟,JACCAugust4,2019;44:671-719,评估STEMI再灌注方式-ACC/AHA2019STEMIGuidelines,PCI首选，如果：熟练PCI操作相关人员及有心外科支持Door-to-balloon时间3小时不能确定STEMI诊断,JACCAugust4,2019;44:671-719,2019年ESC的PCI指南中的AMI再灌注策略,STEMI病人中ASA+溶栓剂治疗增加的效果,ISIS-2CollaborativeGroup.Lancet1988;2:349-60,在17187例STEMI病人中进行的RCT比较:链激酶(SK)、ASA1月、SK+ASA、安慰剂治疗,安慰剂:588/4300(13.2%),0,0,血管性死亡的累积病例数,随机分组后的天数,7,14,21,28,35,100,200,300,400,500,600,Aspirin:461/4295(10.7%),Streptokinase:448/4300(10.4%),Streptokinaseaspirin:343/4292(8.0%),主要终点指标:动脉闭塞(或动脉造影/出院前发生死亡/心梗),Placebo,Clopidogrel,P=0.00000036,OddsRatio0.64(95%CI0.53-0.76),1.0,0.4,0.6,0.8,1.2,1.6,Clopidogrelbetter,Placebobetter,n=1752,n=1739,36%OddsReduction,Sabatineetal.NEJM2019;352:1179,COMMIT:主要终点死亡,0,7,14,21,28,0,1,2,3,4,5,6,7,8,9,Days(upto28days),Clopidogrel(7.5%),Placebo(8.1%),RRR=7%p=0.03,Mortality(%),ChenZMetal.Oralpresentation,ACC2019.Availableat:URL:.AccessedApril2019.,STEMI6小时符合溶栓指征,医生根据情况选择溶栓剂(TNK,TPA,rPA,SK),普通肝素60U/kg负荷剂量12U/kg/h维持48小时以上,依诺肝素75y:30mg负荷剂量皮下1.0mg/kgq12h(出院)75y:无负荷剂量皮下0.75mg/kgq12h(出院)CrCl30:1.0mg/kgq24h,双盲双模拟期,30天随访主要有效性终点：死亡或非致命性心梗主要安全性终点：TIMI严重出血事件,阿司匹林(ASA),97%在溶栓治疗开始30min内接受了研究药物治疗，中位住院时间10天,N=20,506,TNK:Tenecteplase;TPA:Tissueplasminogenactivator;rPA:Reteplase;SK:Streptokinase;UFH:Unfractionatedheparin;CrCl:Creatinineclearance,STEMI:ST-segmentelevationmyocardialinfarction;MI:Myocardialinfarction;TIMI:ThrombolysisinMyocardialInfarction,PrimaryEndPoint(ITT)DeathorNonfatalMI,PrimaryEndPoint(%),ENOX,UFH,RelativeRisk0.83(0.77to0.90)P0.0001,Days,9.9%,12.0%,Losttofollowup=3,17%RRR,在预先定义的各个亚组中，依诺肝素组显示出一致的疗效,0.5,1相对风险,2,依诺肝素更优,普通肝素更优,风险降低（）,依诺肝素,普通肝素,TheoveralltreatmenteffectofenoxaparinversusUFHisshownwiththediamondsymbol(leftandrightedgesrepresent95%confidenceinterval)andthedottedverticalline,出现终点事件的患者(%),30天结果:氯吡格雷联合依诺肝素疗效更好,事件发生率（）,12.2,11.4,绝对风险下降15,绝对风险下降24,P值,0.0005,0.0006,n=14,752(78%),n=5,727(28%),CADILLAC:MACE-6Months,0%,5%,10%,15%,20%,0,30,60,90,120,150,180,Daystoevent,15.2%,19.3%,10.8%,10.9%,StoneGR,etal.PresentedattheAHA72ndScientificSessions.2019A.II.030,TLR、TVR、MACE和TVF的发生危险分别下降：61%、62%、59%和53%.,OATTrial:StudyDesign,PrimaryEndpoints:Death,MI,orNYHAclassIVheartfailure,PCIwithstentingn=1082,MedicalTherapyn=1084,2166patientswithangiographyonday3-28post-MIrevealingtotalocclusionoftheinfarct-relatedarterywithpoororabsentantegradeflow(TIMIflowgrade0or1);andmeetingacriterionforincreasedrisk:definedasejectionfraction50%,proximalocclusionofamajorepicardialvesselwithalargeriskregion,orboth,OAT研究引起的思考,Randomized,OATTrial:PrimaryEndpoint,PrimaryEndpointofdeath,reinfarction,NYHAclassIVheartfailure(%patients)HazardRatio1.16,p=0.20,HochmanJSetal.NEnglJMed.2019;355(23):2395-407.PresentedatAHA2019,OAT研究结果质疑,入选时间过长，入选患者人数较少导致研究效力下降入选的患者仅仅占众多AMI患者的极小一部分研究长期临床随访率较低:8%Slow/No-Reflow发生率高达18：研究对象多为存活心肌较少的患者仅有8的患者使用了药物洗脱支架。,CardiacCellTherapyandSTEAMI,Randomized-controlledBOnemarrOwtransfertoenhanceST-elevationinfarctregeneration(BOOST)trial,IntracoronaryautologousBMCtransferimprovesechocardiographicparametersofdiastolicfunctioninpatientsafterAMI.,Circulation.2019Mar14;113(10):1287-94.,CardiacCellTherapyandSTEAMI,ASTAMITRIAL,NoeffectsofintracoronaryinjectionofautologousmononuclearBMCongloballeftventricularfunction.,NEnglJMed2019;355:11991209.,CardiacCellTherapyandSTEAMI,REPAIR-AMITRIAL,IntracoronaryadministrationofBMCisassociatedwithimprovedrecoveryofleftventricularcontractilefunctioninpatientswithacutemyocardialinfarction.,NEnglJMed2019;355:12101221,CardiacCellTherapyandSTEAMI,IntracoronaryinfusionofPBMNCsinpatientswithAMIisassociatedwithimprovedglobalLVcontractilefunction.,CelltherapypreferentiallyimprovesLVfunctioninpatientswithearlyreperfusion,CirculationJournalVol.71,August2019,Intracoronarytransplantationofnon-expandedperip