ACEI在2013STEMI指南地位

1、ACEI在在2013版版ACC/AHA STEMI指南中的地位指南中的地位整理课件主要内容主要内容 2013版ACC/AHA STEMI指南主要变化 ACEI在ACC/AHA STEMI指南中的基石地位 FAMIS：第三代ACEI蒙诺在急性心梗中的研究整理课件2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial InfarctionDeveloped in Collaboration with American College of Emergency Physicians and Society for C

2、ardiovascular Angiography and Interventions American College of Cardiology Foundation and American Heart Association, Inc.2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction (Journal of the American College of Cardiology). Published on December 17, 2012整理课件Reperfusion Th

3、erapy for Patients with STEMI*Patients with cardiogenic shock or severe heart failure initially seen at a nonPCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). Angiography and r

4、evascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.整理课件Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals All communities should create and maintain a regional system of STEMI care that includes assessment

5、 and continuous quality improvement of EMS and hospital-based activities. Performance can be facilitated by participating in programs such as Mission: Lifeline and the D2B Alliance. I IIa IIb IIIPerformance of a 12-lead ECG by EMS personnel at the site of FMC is recommended in patients with symptoms

6、 consistent with STEMI. I IIa IIb III整理课件整理课件Primary PCI in STEMI整理课件整理课件Adjunctive Antithrombotic Therapy to Support Reperfusion With Primary PCI*The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.整理课件整理课件整理课件整理课件整理课件整理课件整理课件整理课件整理课件整理课件整理课件整理课件整理课件整理课件整理课件整理课件整理课

7、件整理课件整理课件整理课件整理课件整理课件整理课件整理课件Renin-Angiotensin-Aldosterone Renin-Angiotensin-Aldosterone System InhibitorsSystem InhibitorsRoutine Medical Therapies整理课件Renin-Angiotensin-Aldosterone System InhibitorsAn ACE inhibitor should be administered within the first 24 hours to all patients with STEMI with ant

8、erior location, HF, or EF less than or equal to 0.40, unless contraindicated. An ARB should be given to patients with STEMI who have indications for but are intolerant of ACE inhibitors. I IIa IIb IIII IIa IIb III整理课件Renin-Angiotensin-Aldosterone System InhibitorsAn aldosterone antagonist should be

9、given to patients with STEMI and no contraindications who are already receiving an ACE inhibitor and beta blocker and who have an EF less than or equal to 0.40 and either symptomatic HF or diabetes mellitus. ACE inhibitors are reasonable for all patients with STEMI and no contraindications to their

10、use. I IIa IIb IIII IIa IIb III整理课件Renin-Angiotensin-Aldosterone SystemBIRKENHGERLANCET 2007Vasoconstriction, Oxidative Stress, Cellular Growth整理课件ACEI与与ARB对心血管的保护作用不同对心血管的保护作用不同肾素肾素RPR受体受体AT2受体受体血管舒张血管舒张抗增殖抗增殖凋亡凋亡血管紧张素原血管紧张素原Ang IAng IIAT1受体受体血管收缩血管收缩细胞增殖细胞增殖基质形成基质形成醛固酮分泌醛固酮分泌血管舒张血管舒张一氧化氮一氧化氮前列腺素前列

11、腺素EDHF无活性肽无活性肽激肽原激肽原缓激肽缓激肽激肽释放酶激肽释放酶BK B2受体受体ACE ACEIACEIACEIACEI增加增加炎症因子炎症因子 PAI-1IRAP受体受体Ang AMP-A/MNEPAng(1-5)无活性肽无活性肽 Ang-(1-7)ACEAng(1-9) AT2受体受体 ACE2ACE2NEP& ACE血管舒张血管舒张抗增殖抗增殖Mas受体受体ARB廖玉华. 临床心血管病杂志, 2012, 28(8):561-562整理课件 FAMISPost Acute Myocardial InfarctionThe Fosinopril in Acute Myoca

12、rdial Infarction Study(急性心肌梗死后，福辛普利的应用研究)Claudio Borghi, et al., Am J Hypertens 1997; 10: 247S-254S整理课件研究目的研究目的：研究在出现症状6小时内溶栓的急性前壁心肌梗塞患者早期（ 100 mm Hg，则逐渐加倍至目标剂量每天20mg，或安慰剂，服用3个月整理课件结果1：福辛普利对左室收缩功能障碍 (射血分数45%)患者的影响福辛普利治疗相对于安慰剂组显著预防了左心室扩张整理课件结果2：2年内心力衰竭和死亡的累积发生率14.137.351.526.814.530.54517.50102030405

13、060总死亡总死亡CHF死亡死亡+CHF死亡死亡+NYHA -发生率（发生率（%）安慰剂安慰剂福辛普利福辛普利RR = 34.7%P = 0.04整理课件结果3：入院时没有CHF症状患者2年内死亡和CHF的累积发生率14.226.847.812.817.533.905101520253035404550总死亡总死亡CHF死亡死亡+CHF发生率（发生率（%）安慰剂安慰剂福辛普利福辛普利RR = 34.1%P = 0.05RR = 29.1%P = 0.04整理课件结果4:无左室功能障碍(射血分数40%) 患者2年内死亡和CHF的发生率8.618.410.86.414.626.215.510.60

14、51015202530死亡死亡+严重严重CHF死亡死亡+CHFCHF总死亡总死亡病人百分数病人百分数（%）安慰剂安慰剂福辛普利福辛普利RR = 37.8%P = 0.070RR = 28.1%P = 0.081RR = 31.9%P = 0.059RR = 43.0%P = 0.041整理课件结果5：安全性和耐受性不良反应发生率* 病人数 (%)不良反应类型安慰剂组蒙诺组n=134n=131咳嗽7(5.2) 8(6.1)+皮疹3(2.2) 0+实验室检查异常94(70.1) 106(80.9) +血肌酐升高8(6.0) 11(8.4) +血钾升高5(3.7) 6(4.6) +*不良反应的总发生率在两组没有显著性差异，+与安慰剂组相比， 整理课件FAMIS研