急性心肌梗死的再灌注治疗——商德亚.ppt

急性心肌梗死的再灌注治疗的方法与选择,山东省立医院急救中心,STEMI治疗原则,挽救濒死的心肌，防止梗死扩大及时处理严重心律失常、泵衰竭和各种并发症保护和维持心脏功能,治疗方法,STEMI,一般治疗,再灌注治疗,再灌注疗法：药物-介入-手术,药物溶栓PTCA+支架术(PCI):直接/补救/择期CABG其他：激光、基因工程？,溶栓治疗仍是目前首选,欧洲20年来心梗溶栓试验荟萃中国医学论坛报网络版总第902期,时间就是心肌，就是生命,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,TimelineofAMITreatment,SxDoorNeedleBalloon,“拖”多久可以接受？,NRMI-2:死亡率与时间的关系,P=0.01,P=0.0007,P=0.0003,Door-to-BalloonTime(minutes),起病早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,STEMI：直接PCI对院内溶栓治疗,STEMI:就地溶栓与转运PCI,STEMI再灌注治疗：重要的时间段,STEMI:再灌注治疗的获益与时间延迟相关,ACC/AHASTEMIGuidelines2007Update,再灌注治疗：直接PCI,再灌注治疗：溶栓,指南区分3h界限的根据,*有PCI条件：具备24小时进行PCI的条件及有经验的团队，并且D2B时间在90分钟内。*高危：发病时合并有心源性休克、重度充血性心力衰竭和(或)肺水肿、恶性心律失常、中度或大面积心肌梗死(前壁心梗、合并右室心梗或心前区ST段压低的下壁心梗)。*高龄：年龄75岁。,STEMI患者处理流程图,2010ESC介入指南,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,直接PCI的可接受延搁时间取决于患者病情,Z=0.59X-0.033Y-0.0003W-1.3,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,指南对高危患者更倾向PCI的根据DANAMI-2发现转运PCI有益于高危者,越是高危，PPCI越经“拖”,共识之背景-给患者最合适的措施,PCI之于AMI最有效AMI也以PCI最有效但：时间各地发展不平衡（经济，社会，认识）美国年初AMI新指南近年许多观念变化,北京的调查显示，D2B时间达标比例低,ShouldPCIbeperformedaftersuccessfulthrombolysis?,ImmediatePCI？80-90sdatasuggestharmful,lyticactivatedplatelet,morethrombogenicPronetohemorragicinintracoronarylesionMorevascularcomplicationsAspirinnotgivenwiththrombolysisLowdoseheparine,noACTmonitorGPIIb/IIIaantagonist360:2705-2718.,32.5h,2.8h,转运与立即PCI的结合:Sx2hTNK,BohmerEetal:JACC2010;55:102-110,3d,2.7h,PPCI介入时间的变化,TemporalDynamicsofPrimaryPCI,Timeismuscle,timeislifePatientswithSTEMIwhopresentearlyachievegreatermyocardialsalvagefromprimaryPCIthanthosepresentingmorethan12hoursaftersymptomonset.STEMIpatientspresentingtoahospitalwithPCIcapabilityshouldbetreatedwithprimaryPCIwithin90minutesoffirstmedicalcontactasasystemsgoal.,ACC/AHASTEMIGuidelines2007Update,TimeMatters,butShouldNOTPrecludePCI,CouldprimaryPCIstillbeneficiallaterthan12hoursafterSTEMI?ApaperpublishedonlineApril8,2009ofEuropeanHeartJournalsupportthatlatepresentersstillachievesubstantialreductionsinfinalinfarctsize(FIS)fromintervention.,Atotalof396outof619screenedpatientswhounderwentprimaryPCIforSTEMIweredividedinto2groups:earlypresenters(n=341),whoweretreated12hoursaftersymptomonset,andlatepresenters(n=55),whoreceivedPCIbetween12and72hours.MyocardialperfusionimagingwithTc-99mSPECTwasperformedatthetimeofenrollmenttomeasureareaatrisk(AAR)andat30dayspost-PCItomeasurefinalinfarctsize(FIS,percentoftheLVmyocardium),salvageindex(percentofnon-infarctedAAR),LVEF,end-diastolicvolume(EDV),andend-systolicvolume(ESV).,EuropeanHeartJournalAdvanceAccesspublishedonlineonApril8,2009,Infarctsizeandmyocardialsalvageafterprimaryangioplastyinpatientspresentingwithsymptomsfor12h)thanearlypresentersafterprimaryangioplastyforSTEMI.However,substantialmyocardialsalvagecanbeobtainedbeyondthe12hlimit,evenwhentheinfarct-relatedarteryistotallyoccluded.,OutcomesofEarlyvs.LatePresenters,EuropeanHeartJournalAdvanceAccesspublishedonlineonApril8,2009,SupporttingsoflengtheningthetreatmentwindowforSTEMIpatients,BRAVE-2,arandomizedstudypublishedin2005thatshowedstentingreducedinfarctsizemorethanconservativetherapyinstableSTEMIpatientswhopresentedbetween12and48hours.InFebruary2009,theBRAVE-2researchersreportedinaresearchletterpublishedintheJournaloftheAmericanMedicalAssociationthatPCIinlatepresentersmayalsoreduce4-yearmortality.,Transfer-AMI-Design,High-riskpatientstreatedwithfibrinolytictherapywererandomizedto:-immediatetransferforPCl(pharmaco-invasivestrategy)or:-standardtreatment(includingrescuePClforongoingchestpainandlessthan50%resolutionofST-elevationat60-90minorhemodynamicinstability),Cantoretal.NEngJMed2009;360:26.,2009UpdatedGuidelines,.reasonabletotransferpatientswhoreceivefibrinolytictherapytoaPCI-capablefacilityassoonaspossiblewhereeitherPCIcanbeperformedwhenneededorasapharmac