AMI再灌注治疗院前我们能做什么PPT课件

.,1,AMI再灌注治疗，院前我们能做什么,.,2,DOOR,NEEDLE,BALLOON,.,3,时间就是心肌！,.,4,缩短时间,.,5,.,6,.,7,.,8,D2BTimesSurpassNationalCampaignsGoal,ElizabethH.Bradley,PhD.YaleSchoolofPublicHealth.Friday,December04,2009TheAmericanCollegeofCardiology(ACC)Door-to-Balloon(D2B)联盟目标：STEMI病人D2B90minutes达到75%.从2005年4月到2008年3月，614医院参加NCDR登记研究并加入D2B联盟3年中82,610住院患者D2B时间显著缩短,.,9,.,10,Impressive3-YearIncrease,62.8%ofUSpatientshadaD2Btimewithin90minin2006By2008,thepercentagehadincreasedto76.4%,slightlybetterthantheinitialgoalof75%setatthestartofthecampaigncontinuedtoimprovebeyondtheendofthestudyperiod(March31,2008).81.7%ofeligiblepatientshadD2Btimes90minutesfromJune30,2009TheaverageD2Btimefromanaverageof121minutesattheendof2005,toanaverageof80minutesasofJune30,2009,.,11,StillRoomforImprovement,Directtransportationtocatheterizationlaboratorybyemergencyteamsreducesdoor-to-balloontimeExtendaccomplishmentoutintothecommunitysothatpatientspresentingtosmallerhospitalsandcanhavefastertimesfromfirstcontactwiththehealthcaresystemuntilreperfusion,我们还有巨大差距！,.,12,策略上的争论,.,13,易化PCI,易化PCI是指发病12h内拟行PCI的患者于PCI前使用血栓溶解药物，以期缩短开通IRA时间，使药物治疗和PCI更有机结合以ASSENT4为代表的临床研究结果表明，易化PCI结果劣于直接PCI。目前已完全否定了应用全量溶栓剂后立即行易化PCI的策略然对出血风险很低的轻、高危的STEMI患者90min不能立即PCI时可考虑应用,经皮冠状动脉介入治疗指南(2009)-中华医学会心血管病学分会,.,14,.,15,荟萃分析：Keeley等对比较直接PCI和易化PCI疗效的17项随机对照临床试验进行了，所纳入STEMI患者数分别为2267例和2237例最终冠脉血流达到TIMI3级者的比例相似(89%vs88%)：易化PCI组冠脉血流在术后立即达到TIMI3级者多于直接PCI组(37%vs15%)易化PCI组死亡率较高(5%vs3%)：非致死性MI率较高(3%vs2%)，靶血管的紧急血运重建率较高(4%vs1%)，大出血率也较高(7%vs5%)易化PCI组不良反应发生率的增高主要原因：溶栓药易化PCI亚组出血性脑卒中和总的脑卒中发生率均显著增高(分别为0.7%vs0.1%和1.1%vs0.3%)。,.,16,产生机理,可能是早期激活血小板的副作用，无有效的抗血小板作用动脉粥样硬化斑块出血,可能溶栓到PCI时间短缺乏良好的抗血小板治疗,.,17,可能原因,ItispossiblethatthetimebetweenfibrinolysisandPCI(median,90to104minutes)wastooshortinthesetrials,withtheresultthatpersistentfibrinolyticactivityledtoincreasedbleedingcomplicationsThelackofadequateantiplatelettherapyinthesetrialsmayhavealsoconferredapredispositiontothromboticcomplications.Fibrinolysisisfollowedbyincreasedplateletactivationandaggregation,andstentimplantationearlyafterfibrinolysiswithoutadequateantiplatelettherapymaybeassociatedwithincreasedratesofacutestentthrombosis,.,18,TRANSFER-AMITrial,.,19,Background,PatientswithSTEMIinthehospitalsthatdonothavethecapabilityofPCIoftencannotundergotimelyprimaryPCIandthereforereceivefibrinolysisTheroleandoptimaltimingofroutinePCIafterfibrinolysishavenotbeenestablished.,.,20,Methods,Randomized;nonblindedtrial;52sitesinthreeprovincesinCanada1059high-riskpatientswithSTEMIandwhowerereceivingfibrinolytictherapyatcentersthatdidnothavethecapabilityofperformingPCIAllpatientsreceivedaspirin,tenecteplase,andheparinorenoxaparin;concomitantclopidogrelwasrecommendedTheprimaryendpointwasthecompositeofdeath,reinfarction,recurrentischemia,neworworseningcongestiveheartfailure,orcardiogenicshockwithin30days,.,21,.,22,Results,88.7%ofthepatientsassignedtostandardtreatmentamedianof32.5hoursafterrandomizationandin98.5%ofthepatientsassignedtoroutineearlyPCIamedianof2.8hoursafterrandomizationAt30days,theprimaryendpointoccurredin11.0%ofthepatientswhowereassignedtoroutineearlyPCIandin17.2%ofthepatientsassignedtostandardtreatment(P=0.004)Therewerenosignificantdifferencesbetweenthegroupsintheincidenceofmajorbleeding,.,23,Conclusions,Amonghigh-riskpatientswhohadamyocardialinfarctionwithST-segmentelevationandwhoweretreatedwithfibrinolysis,transferforPCIwithin6hoursafterfibrinolysiswasassociatedwithsignificantlyfewerischemiccomplicationsthanwasstandardtreatment.,.,24,院前溶栓与院内溶栓的比较,六项涉及6434例急性心肌梗死患者随机临床试验的汇总分析显示，与院内溶栓比较，院前溶栓明显降低住院总死亡率17。院前溶栓平均节省时间约1个小时法国全国急诊室注册登记入选1922例ST段抬高心肌梗死患者，其中的180例（9）接受了院前静脉溶栓治疗，住院死亡率在院前溶栓、院内溶栓和直接PCI组分别为3.3、8.0和6.7，1年生存率三组分别为94、89和89，与其他再灌注方式比较，死亡率降低更为显著,.,25,院前溶栓与直接PCI的比较,CAPTIM试验比较院前溶栓和直接PCI，从出现症状到治疗开始的时间院前溶栓组为130分钟，比直接PCI早了1个小时，两组30日主要复合终点（死亡、非致命心肌梗死和非致命脑卒中）分别为8.2和6.2，P0.29，死亡分别为3.8和4.8，P0.61。独立分析症状开始2小时以内和2小时后随机分组患者，2小时以内随机分组患者院前溶栓和直接PCI30日死亡分别为2.2和5.7，P=0.058，心源性休克分别为1.3和5.3，P=0.032两组三重复合终点（死亡、再梗死和致残性脑卒中）没有显著性差别（7.4比6.6，P=0.86）在2小时分组的患者，两组30日死亡率分别为5.9和3.7，P=0.47，直接PCI组偏低，心源性休克两组没有显著性差别,.,26,院前用药的变化,.,27,是否需要增加氯吡格雷的负荷量,.,28,氯吡格雷600mg可以更迅速地抑制血小板聚集,抑制血小板聚集(%),103名非ST段抬高的ACS患者随机分配接受300、600或900mg氯吡格雷,0,Montalescotetal.JACC2006;48:931-8,0,50,10,20,30,40,1,2,3,4,5,6,时间(小时),5mol/LADP,*p0.05与300mg相比,900mg,600mg,300mg,600mg,300mg,*,900mg,*,600mgLD2小时的抑制水平与300mgLD6小时相当,.,29,高负荷剂量未显著增加出血,*按GUSTO分级定义,.,30,ARMYDA-2:600mg负荷剂量显著降低主要终点事件,p=0.041,4%,12%,0%,2%,4%,6%,8%,10%,12%,14%,600mg,300mg,死亡、心梗及靶血管血运重建%,PattiG.etal,Circulation.2005;111:2099-2106,.,31,600mg的波立维负荷剂量可降低血栓事件的发生率,292名连续接受300或600mg氯吡格雷负荷剂量支架植入的NSTEACS患者,Cuissetetal.JAmCollCardiol2006;48:133945,无心血管事件生存(%),100,80,90,95,p0.0024,300mg,600mg,事件率(%),心血管事件,0,12.5,2.5,7.5,10.0,脑卒中,300mg,600mg,30,20,10,0,85,时间(天),ACS事件,ST*,心血管死亡,5.0,ST*=支架血栓形成,.,32,GPb/a受体拮抗剂在STEMI的临床应用,.,33,A,B,B,B,UA/NSTEMI行PCI的患者，如未服用氯吡格雷，应给予一种血小板糖蛋白IIb/IIIa受体拮抗剂。,在实施诊断性CAG前或PCI术前即可给药均可。,STEMI行PCI的患者，可尽早应用血小板糖蛋白IIb/IIIa受体拮抗剂。,接受择期PCI并置入支架的高危患者或高危病变（如ACS、近期MI、桥血管狭窄、冠状动脉慢性闭塞病变及CAG可见的血栓病变等），可应用血小板糖蛋白IIb/IIIa受体拮抗剂，但应充分权衡出血与获益风险。,33,2009中国经皮冠状动脉介入治疗指南PCI术的药物治疗,UA/NSTEMI行PCI的患者，如已服用氯吡格雷，可同时给予一种血小板糖蛋白IIb/IIIa受体拮抗剂。,B,.,34,FINESSETrial,.,35,.,36,Results,Atotalof2452patientswererandomlyassignedtoatreatmentgroupSignificantlymorepatientshadearlyST-segmentresolutionwithcombination-facilitatedPCI(43.9%)thanwithabciximab-facilitatedPCI(33.1%)orprimaryPCI(P=0.01andP=0.003,respectively).Theprimaryendpointoccurredin9.8%,10.5%,and10.7%of(P=0.55)90-daymortalityrateswere5.2%,5.5%,and4.5%,respectively(P=0.49).,.,37,Conclusions,NeitherfacilitationofPCIwithreteplaseplusabciximabnorfacilitationwithabciximabalonesignificantlyimprovedtheclinicaloutcomes,ascomparedwithabciximabgivenatthetimeofPCI,inpatientswithST-segmentelevationmyocardialinfarction.,.,38,ON-TIMEStudies,ON-TIME1:NosignificantbenefitforlowbolusdoseTirofibaninAMI低负荷剂量、不提前使用替罗非班在急性心梗中的应用无显著获益ON-TIME2RegistryStudy:注册研究OpenlabelTirofiban,highbolusdose开放标签，高剂量替罗非班(N=416,Zwolle+Nieuwegein)ON-TIME2RandomizedStudy:随机研究Tirofibanhighbolusdosedouble-blind高负荷剂量替罗非班,PrehospitalTirofibaninAMI在急性心梗患者给予院前应用替罗非班,HammCWetal.Abstract413-5.PresentedApril1,2008,attheAmericanCollegeofCardiology57thAnnualMeetinginChicago,IL.,.,39,在救护车或转诊中心被确诊为急性心梗(STEMI)ASA+600mgClopidogrel+UFH,冠脉造影,替罗非班,安慰剂,PCI手术室,冠脉造影,必要时使用替罗非班,持续使用替罗非班*,ON-TIME-2,N=9846/2006-11/2007,PCI,*Bolus:25g/kg&0.15g/kg/mininfusion,HammCWetal.Abstract413-5.PresentedApril1,2008,attheAmericanCollegeofCardiology57thAnnualMeetinginChicago,IL.,转运,.,40,Event-freeSurvival无事件生存率,OngoingTirofibanInMyocardialInfarctionEvaluation,P=0.012,HammCWetal.Abstract413-5.PresentedApril1,2008,attheAmericanCollegeofCardiology57thAnnualMeetinginChicago,IL.,66.7%,74.0%,.,41,1年全因死亡率,ACC2009,RR:0.78(95%CI:0.53-1.14,p=0.157),RR:0.77(95%CI:0.46