心梗指南

2013 ACCF/AHA心梗指南,2012年12月17日ACCF、AHA联合发布ST段抬高急性心肌梗死治疗指南2013年1月在JACC、Circulation发表,2013 ACCF/AHA 指南,MI新定义(ESC/ACC/AHA/WHF),存在下列任何一项时，均可诊断心肌梗死,心肌梗死临床分类,心肌梗死临床分类,总缺血时间,总缺血时间,出现症状,急救系统,医院,患者相关延迟,快速启动EMS人员在初次接触患者后做12导联ECG直接将患者转运至可行PCI医院，FMC-器械目标时间90分钟快速将患者从不能行PCI医院转运至可行PCI医院，FMC-器械目标时间120分钟，30分钟内给予溶栓药物（推荐I, 证据级别B）,再灌注失败或再闭塞患者紧急转运至可行PCI医院(推荐IIa, 证据级别B),3-24小时内转运行冠脉造影和再血管化治疗(推荐IIa, 证据级别B),冠脉造影诊断,药物治疗,PCI,CABG,STEMI患者直接PCI指征,直接PCI是优选再灌注治疗措施,非梗死血管行PCI,A total of 18 studies enrolled 48398 patients with STEMI and muti-vessel CAD and reported outcomes after MVI （muti-vessel intervention) or CVI (culprit-vessel intervention)-only at the time of primary PCI Neither MVI nor CVI emerges as a preferred strategy in an analysis that accounts mortality differences Catheter Cardiovasc Interv 2015,Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study,1071 Patients with ST-elevation myocardial infarction assigned to either thrombus aspiration or conventional treatment,Vlaar, PJ, et al.Lancet, 2008; 371:1915-20,直接PCI时人工血栓抽吸治疗是合理的a B,溶栓治疗指征,预计从首次医疗接触到直接PCI时间120分钟，符合以下情况可行溶栓治疗,Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomized trials,Keeley EC, et al. Lancet,2003;361:13,7739 patients with ST-segment elevation AMI in primary PCI (n=387) or thrombolytic therapy (n=3867),溶栓获益,获益大小主要取决于治疗时间和达到的TIMI（thrombolysis in myocardial infarction)血流3h内行溶栓治疗，其临床疗效与直接PCI相当3-12h内行溶栓治疗，其疗效不如直接PCI，但仍能获益12-24h内，如果仍有持续或间断的缺血症状和持续ST段抬高，溶栓治疗仍然有效(IIa，B),生存获益可维持长达5年左束支传导阻滞、大面积梗死患者，溶栓获益最大,DANAMI-2（Danish Acute Myocardial Infarction-2 )Study,Nielsen PH,et al.Am J Cardiol. 2011;108:776 781.,溶栓后再灌注评估,相对突然和完全缓解的胸痛加上ST回落70% ，高度提示恢复正常心肌血流量治疗后2小时，ST段回落50%和无再灌注心律失常预测梗塞动脉TIMI血流3, 敏感性81%，特异性88%60到90分钟，最差导联ST段回落50%,应考虑立即行冠脉造影和补救性PCI,溶栓后或未接受再灌注治疗患者，梗死相关动脉的PCI指征,*临床稳定定义为无心脏低排量、低血压、持续心动过速、明显的休克、高位室性或症状性室上性心动过速和自发缺血症状,Rescue angioplasty after Failed Thrombolytic Therapy for Acute Myocardial infarction,Jershlick A,et al. N EJ M 2005;353:2758-68,427 patients in whom reperfusion failed to occur (less than 50% ST-segment resolution) within 90 minutes after thrombolytic treatment,Which Early ST-Elevation Myocardial Infarction Therapy (WEST) trial,Group A : received tenecteplase (TNK) followed by the usual standard of care Group B: received TNK but underwent invasive management within 24 h including rescue PCI (from fibrinolysis to PCI :4.5h)Group C: underwent primary PCI with a clopidogrel 300 mg loading dose (from medical contact to PCI: 104 minutes)A vs. C (13% vs. 4%, P=0.021) B vs. C (6.7% vs. 4%, P=0.378),Armstrong PW, et al. Eur Heart J 2006;27:1530-8,timely primary PCI is superior to fibrinolysisfibrinolysis followed by adjunctive PCI may achieve a similar outcome to primary PCI,直接PCI置入支架,行直接PCI患者抗血小板治疗：P2Y12受体阻滞剂,*与替格瑞洛联用时，阿司匹林推荐剂量为 81 mg/d,行直接PCI患者抗血小板治疗：GPIIb/IIIa受体拮抗剂,抗凝治疗,对于合并有心房颤动、CHADS2* 评分2分、机械性心脏瓣膜、静脉血栓栓塞或高凝血障碍的STEMI患者，应加用维生素K拮抗剂溶栓后可考虑三联药物治疗14天，后一种维生素K拮抗剂加一种抗血小板药物治疗,*非风湿性房颤卒中风险评估,急诊CABG指征,Both patients with and without diabetes with 3-vessel and/or left main disease, CABG compared with PCI was associated with better 5-year outcomes,Marui A, et al. Am J Cardi0l 2015;115:1063-72,Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With End-Stage Renal Disease Requiring Dialysis (5-Year Outcomes of the CREDO-Kyoto PCI/CABG Registry Cohort-2),Myocardial Infarction,coronary revascularization,Years after revascularization,Years after revascularization,Cumulative Incidence,Cumulative Incidence,CI,PCI,CABG,P=0.01,PCI,CABG,P0.01,In patients with multi-vessel and/or left main disease undergoing dialysis, 5-year outcomes revealed that CABG relative to PCI reduced the risk of myocardial infarction and any revascularization,Marui A,et al. Am J Cardiol,2014;114:555-561,STEMI并发心源性休克的治疗,STEMI并发心源性休克的治疗,目前证据未明显支持IABP可以显著改善预后，但可使患者更加安全地接受血运治疗应用IABP的前提条件是药物治疗无法迅速稳定改善心功能，IABP只是STEMI合并心源性休克等高风险患者的辅助治疗措施,IABP-SHOCK II期试验,Thiele H et al. N Engl J Med2012;367:1287-1296.,Eur Heart J, 2009,30: 459-468,抗血小板治疗部分的重要更新替格瑞洛,替格瑞洛是为可逆性、非噻吩吡啶类P2Y12 受体拮抗剂,环戊基三唑嘧啶类(CPTP),替格瑞洛本身为活性药物，不需代谢转化,替格瑞洛不影响ADP受体结合位点，选择性与P2Y12 受体可逆性结合,推荐用于行直接PCI的STEMI患者的一线抗血小板药物,ONSET/OFFSET 研究,* P0.0001 P0.005 P0.05,时间 (小时),Circulation. 2009;120:25772585.,Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes,Cumulative incidence of end point(%),9.8,11.7,clopidogrel,ticagrelor,HR =0.84 P 0.001,Wallentin L,et al. New Engl J Med 2009;361;10451057.,primary end point - a composite of death, myocardial infarction, or stroke,ticagrelor (180-mg loading dose, 90 mg twice daily) clopidogrel (300-to-600-mg loading dose, 75 mg daily),风险分层与影像检查,急性期，诊断不明确，超声心动图检查可提供帮助急性期后，所有患者均应行超声心动图检查，评估梗死面积和静息左心室功能，如不可行，可行MRI多支病变或考虑对其他血管实施血运重建治疗，有指征行负荷试验或影像检查，评价缺血和存活心肌,CSCs could derive from a noncardiac source or reside in the heart itself. Various populations of CSCs have been identified based on stem cell surface markers,CSCs （Cardiac stem cell） origination and classification,Cardiac stem cell,C-kit + stem cells isolated from right atrial appendages and cardiosphere derived cells (CDCs) grown from right ventricular cardiac muscleTwo major types of autologus cardiac stem cells have been investigated in the SCIPIO and CADUCEUS clinical trials,C-kit + stem cells,SCIPIO trial C-kit + stem cells were isolated during coronary artery bypass surgery from right atrial appendages of patients with LVEF40% A maximum of one million cardiac stem cells were injected into coronary arteries supplying infarcted myocardiumAt 2 years, LEVF increased in 12 patients by 1