ST抬高心肌梗死溶栓与抗栓治疗进展

1、1会计学ST抬高心肌梗死溶栓与抗栓治疗进展抬高心肌梗死溶栓与抗栓治疗进展Symptom RecognitionCall to Medical SystemEDCath LabPreHospitalDelay in Initiation of Reperfusion TherapyIncreasing Loss of Myocytes溶栓 vs 直接 PCI溶栓血流TIMI 3 比例60% 再梗死发生率 4%卒中总发生率 2%ICH发生率 1%任何地点(院前)任何时间所有医生无时间延迟大规模临床试验证实直接PCI血流TIMI 3 比例80-90% 再梗死发生率 1h)Circulation 20

2、07 August 10;114:671-719步骤1：评估时间和危险性Circulation 2007 August 10;114:671-719Circulation 2007 August 10;114:671-7197%7%5%9%1% (%) Events0.05%2%1% 7%3%Circulation 2007 August 10;114:671-719Circulation 2007 August 10;114:671-719急性ST段抬高心肌梗死溶栓治疗的中国专家共识(2009年更新版).P=0.01P=0.0007P=0.0003NRMI 2: Primary PCI do

3、or-to- balloon time vs mortalityn = 2,2305,734Door-to-balloon time (minutes)6,6164,4612,6275,4120-60 61-90 91-120 121-150 150-180 180Mortality(%)时间就是心肌！n非特异性非特异性纤溶酶原激活剂纤溶酶原激活剂-n 链激酶链激酶(SK) (SK) 和尿激酶（和尿激酶（UKUK）n特异性特异性纤溶酶原激活剂纤溶酶原激活剂-n 人重组组织型纤溶酶原激活剂（人重组组织型纤溶酶原激活剂（rt-PArt-PA） n 瑞替普酶瑞替普酶(r-PA)(r-PA)，兰替普酶

4、，兰替普酶(n-PA)(n-PA)，替耐普酶，替耐普酶 (TNK-tPA(TNK-tPA溶栓药物溶栓药物常规剂量常规剂量纤维蛋白纤维蛋白特异性特异性抗原性及抗原性及过敏反应过敏反应纤维蛋白纤维蛋白原消耗原消耗90分钟分钟再通率再通率(%)#TIMI 3级级血流血流(%)尿激酶60分钟,150万单位否无明显未知未知链激酶3060分钟,150万单位否有明显5032阿替普酶90分钟 100mg是无轻度8054瑞替普酶10MU2,每次2分钟是无中度8060替奈普酶3050mg根据体重*是无极小7563 2009急性ST段抬高心梗溶栓治疗的中国专家共识急性ST段抬高心肌梗死溶栓治疗的中国专家共识(200

5、9年更新版).23.0%15.0%8.0%ESC 2007, Sept 1-4ESC 2007, Sept 1-4随机5000 U IV肝素+250-500mg阿司匹林主要终点：5年随访中的死亡率Bonnefoy E et al, European Heart Journal 2009.急性ST段抬高心梗患者直接行PCI(n=421)rt-PA异化PCI (n=419)患者症状发作6小时内，rt-PA溶栓后行PCI的5年全因死亡率为 9.7% vs 12.6%Bonnefoy E et al, European Heart Journal 2009.症状发作6小时内，P=0.18HR 0.75

6、 (95% CI,0.50-1.14)死亡风险25%症状发作2小时内，p=0.04HR 0.50(95% CI,0.25-0.97)症状发作2小时内，rt-PA溶栓后行PCI的5年死亡率仅为单纯PCI组的50%Bonnefoy E et al, European Heart Journal 2009.死亡风险50%Halvorsen S: Presented in ESC 2009Bonnefoy E et al, European Heart Journal 2009.Acute STEMI 90 min21%4.5%9.8%10% (%) Events 2.2%2.3%Bonnefoy E

7、 et al, European Heart Journal 2009.ESC 2008: STEMI GuidelineESC 2008: STEMI Guideline2009STEMI溶栓治疗的中国专家共识依诺肝素显著降低主要终点事件（死亡或非致命性心梗）相对风险17(ExTRACT-TIMI 25)相对风险: 0.83 (0.770.90)p0.0001 依诺肝素普通肝素051015202530天03691215主要终点事件 (%)相对风险: 0.90(0.801.01)p=0.08 相对风险: 0.77(0.71 0.85)p0.000148 h 8 days 9.9%12.0%4.

8、7% 5.2% 7.2% 9.3% RRR17%2 8 (2006年3月ACC 上首次公布的对所有患者的分析结果)Restore coronary blood flow to ischemic myocardiumRapidly, Completely and sustainReduce area of MI Preserve LV function Preventing HF & ShockResolve the stenosis Reducing the mortalityAMI survivor with an improved outcomeYusuf S, et al. Ci

9、rculation. 1990;82(suppl II):II-117-II-134.Schrder R, et al. J Am Coll Cardiol. 1995;26:1657-1664.Time is the Myocardium！Time is the life！Symptom RecognitionCall to Medical SystemEDCath LabPreHospitalDelay in Initiation of Reperfusion TherapyIncreasing Loss of MyocytesThrombolysis vs Primary PCIThro

10、mbolysisTIMI 3 flow: 60% Re-MI rate: 4%Stroke rate: 2%ICH rate: 1%Anywhere (pre-hospital)anytimeAll doctorNo time delayRCT documentedPrimary PCITIMI 3 flow: 80-90% Re-MI rate: 1h)Circulation 2007 August 10;114:671-719Step 1：Evaluating the time and riskCirculation 2007 August 10;114:671-719Strategies

11、 for STEMI: ACC/AHA 2007 & ESC 2008 STEMI GuidelinesCirculation 2007 August 10;114:671-7197%7%5%9%1% (%) Events0.05%2%1% 7%3%Circulation 2007 August 10;114:671-719Circulation 2007 August 10;114:671-719急性ST段抬高心肌梗死溶栓治疗的中国专家共识(2009年更新版).P=0.01P=0.0007P=0.0003NRMI 2: Primary PCI door-to- balloon tim

12、e vs mortalityn = 2,2305,734Door-to-balloon time (minutes)6,6164,4612,6275,4120-60 61-90 91-120 121-150 150-180 180Mortality(%)Time is the myocardium！n非特异性非特异性纤溶酶原激活剂纤溶酶原激活剂-n 链激酶链激酶(SK) (SK) 和尿激酶（和尿激酶（UKUK）n特异性特异性纤溶酶原激活剂纤溶酶原激活剂-n 人重组组织型纤溶酶原激活剂（人重组组织型纤溶酶原激活剂（rt-PArt-PA） n 瑞替普酶瑞替普酶(r-PA)(r-PA)，兰替普酶，兰

13、替普酶(n-PA)(n-PA)，替耐普酶，替耐普酶 (TNK-tPA(TNK-tPA溶栓药物溶栓药物常规剂量常规剂量纤维蛋白纤维蛋白特异性特异性抗原性及抗原性及过敏反应过敏反应纤维蛋白纤维蛋白原消耗原消耗90分钟分钟再通率再通率(%)#TIMI 3级级血流血流(%)尿激酶60分钟,150万单位否无明显未知未知链激酶3060分钟,150万单位否有明显5032阿替普酶90分钟 100mg是无轻度8054瑞替普酶10MU2,每次2分钟是无中度8060替奈普酶3050mg根据体重*是无极小7563 2009急性ST段抬高心梗溶栓治疗的中国专家共识急性ST段抬高心肌梗死溶栓治疗的中国专家共识(2009年

14、更新版).23.0%15.0%8.0%ESC 2007, Sept 1-4ESC 2007, Sept 1-4STEMIrandomlization primary PCI(n=421)rt-PA TT-PCI (n=419)5000 U IV haprin+250-500mg ASAFirst endpoint：5-year mortalityBonnefoy E et al, European Heart Journal 2009.Bonnefoy E et al, European Heart Journal 2009.Onset 6 hours，P=0.18HR 0.75 (95% C

15、I,0.50-1.14)RR25%Onset 2hours，p=0.04HR 0.50(95% CI,0.25-0.97)Bonnefoy E et al, European Heart Journal 2009.RR50%Halvorsen S: Presented in ESC 2009Bonnefoy E et al, European Heart Journal 2009.Acute STEMI 90 min21%4.5%9.8%10% (%) Events 2.2%2.3%Bonnefoy E et al, European Heart Journal 2009.ESC 2008:

16、STEMI GuidelineESC 2008: STEMI Guideline2009STEMI溶栓治疗的中国专家共识ExTRACT-TIMI 25: Enoxaparin on AMIRR: 0.83 (0.770.90)p0.0001 enoxaparinhaprin051015202530天03691215MACE (%)RR: 0.90(0.801.01)p=0.08 RR: 0.77(0.71 0.85)p0.000148 h 8 days 9.9%12.0%4.7% 5.2% 7.2% 9.3% RRR17%2 8 Symptom RecognitionCall to Medic

17、al SystemEDCath LabPreHospitalDelay in Initiation of Reperfusion TherapyIncreasing Loss of Myocytes7%7%5%9%1% (%) Events0.05%2%1% 7%3%Circulation 2007 August 10;114:671-71921%4.5%9.8%10% (%) Events 2.2%2.3%Bonnefoy E et al, European Heart Journal 2009.Thrombolysis vs Primary PCIThrombolysisTIMI 3 flow: 60% Re-MI rate: 4%Stroke rate: 2%ICH rate: 1%Anywhere (pre-hospital)anytimeAll doctorNo time delayRCT documentedPrimary PCITIMI 3 flow: 80-90% Re-MI rate: 1h)P=0.01P=0.0007P=0.0003NRMI 2: Primary PCI door-to- balloon time vs mortalityn = 2,2305,734Door-to-b