急性心肌梗死直接PCI课件

1、ACCF/AHA/SCAI关于AMI直接PCI指南解析Yida Tang, MD, PhDDept. of Cardiology, Fuwai HospitalChinese Academy of Medical SciencesNational Center for Cardiovascular Disease 2010 ESC coronary revascularization guideline 2011 ACC AHA PCI guideline 2012 ACC AHA NSTEMI guideline 2012 ESC Definition of MI Guideline 201

2、2 ESC NSTEMI Guideline 2013 ACC AHA definition of MI 2013 ACC AHA STEMI guideline 2013 ESC STEMI GuidelineClass of Recommendation (COR)CORBenefit/RiskKey Words(The procedure or treatment)Class IBenefit RiskShould be performed/administeredIs recommendedIs indicatedIs useful/effective/beneficialClass

3、IIaBenefitRiskIs reasonableCan be useful/effective/beneficialIs probably recommended or indicatedClass IIbBenefit RiskMay/might be considered or be reasonableUsefulness/effectiveness is unknown/unclear/uncertain or not well establishedClass III No BenefitNot helpful No proven benefitIs not recommend

4、ed/indicatedShould not be performed/administeredIs not useful/beneficial/effectiveClass III HarmHarmfulExcess cost without benefit or harmfulPotentially harmfulCauses harmShould not be performed/administeredGNL 2011Level of Evidence (LOE)LOECriteriaAMultiple populations evaluatedData derived from mu

5、ltiple randomized clinical trials or meta-analysesBLimited populations evaluatedData derived from a single randomized trial or nonrandomized studiesCVery limited populations evaluatedOnly consensus opinion of experts, case studies, or standard of careGNL 2011STEMI急诊PCI方式直接(primary, direct)PCI：不溶栓直接行

6、PCI补救(rescue, salvage)PCI：溶栓失败后行PCI即刻(immediate)PCI：溶栓成功对严重残余狭窄行PCI延迟(delayed, deferred)PCI：溶栓后1-7天行PCIPCI in STEMI*IndicationsCORLOEPrimary PCI*STEMI symptoms within 12 hIASevere heart failure or cardio-genic shockIBContraindications to fibrinolytic therapy with ischemic symptoms 24 hours after STE

7、MIIIbBTotally occluded infarct artery 24 h after STEMI in a hemodyamically stable asymptomatic patient without evidence of severe ischemiaIII: No BenefitBGNL 2011新版PCI指南的要点分析作为整体目标，应当在STEMI发生后12小时内并且在首次医疗接触后90分钟内实施直接PCICardiogenic ShockRecommendationCORLOEImmediate coronary angiography in patients w

8、ith STEMI with severe heart failure or cardiogenic shock who are suitable candidates for revascularizationIBPCI for patients with acute MI who develop cardiogenic shock and are suitable candidatesIBHemodynamic support device for patients with cardiogenic shock after STEMI who do not quickly stabiliz

9、e with pharmacological therapyIBGNL 2011IABP应用率：13.5%心源性休克或严重低血压状态No-reflow心肺复苏最大可能保障IRA开通新版PCI指南的要点分析 STEMI并发心源性休克者，若能耐受，尽早行冠脉造影 药物稳定血流动力学困难者尽早行IABP支持UA/NSTEMI: Choice of Strategy* RecommendationCORLOEAn early invasive strategy* in patients who have refractory angina or hemodynamic or electrical in

10、stability (without serious comorbidities or contraindications to such procedures) IBAn early invasive strategy* in initially stabilized patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events IAThe selection of PCI or CABG as the

11、 means of revascularization in the patient with ACS should generally be based on the same considerations as those without ACS IBA conservative strategy recommended (over an early invasive strategy) in women with low-risk featuresIBAn early invasive strategy (within 12 to 24 hours of admission) chose

12、n over a delayed invasive strategy for initially stabilized high-risk patients*IIaBAn initial conservative (i.e., a selectively invasive) strategy in initially stabilized patients who have an elevated risk for clinical events (including troponin positive patients)*IIbCAn early invasive strategy* in

13、patients with extensive comorbidities in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization, in patients with acute chest pain and a low likelihood of ACS, or in patients who will not consent to revascularization regardless of the fin

14、dingsIII No BenefitCGNL 2011优选介入治疗首先优选药物治疗Recurrent angina or ischemia at rest or with low level activities despite intensive medical therapy Elevated cardiac biomarkers (TnT or TnI)New or presumably new ST-depression Signs or symptoms of heart failureHemodynamic instabilityHigh risk score (e.g., GR

15、ACE, TIMI)Sustained ventricular tachycardiaPCI within 6 moPrior CABGDiabetes mellitusMild to moderate renal dysfunctionReduced LV function (LVEF 40%)Low risk score (e.g., GRACE, TIMI)Absence of high-risk featuresHigh risk for catheterization-related complicationsPatient not a revascularization candi

16、date (with either PCI or CABG)Patient prefers conservative therapy GNL 2011新版PCI指南要点分析NSTEMIUPLM PCI to Improve Survival (ACS)CORLOEIIaFor UA/NSTEMI if not a CABG candidateBIIaFor STEMI when distal coronary flow is TIMI grade 3 and PCI can be performed more rapidly and safely than CABGCGNL 2011新版PCI

17、指南的要点分析对于无保护左主干是罪犯病变并且冠脉远端血流不足TIMI 3级的急性STEMI患者，PCI可以提高存活，并且与CABG比较，可迅速和安全实施PCIUPLM Revascularization to Improve SurvivalRevasc MethodCORLOECABGIBPCIIIaFor SIHD when both of the following are present:Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood

18、 of good long-term outcome (e.g., a low SYNTAX score of 22, ostial or trunk left main CAD) Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (e.g., STS-predicted risk of operative mortality 5%)BIIaFor UA/NSTEMI if not a CABG candidateBIIaFor STEMI when

19、 distal coronary flow is TIMI grade 3 and PCI can be performed more rapidly and safely than CABGCIIbFor SIHD when both of the following are present:Anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term

20、outcome (e.g., low-intermediate SYNTAX score of 2%)BIII: HarmFor SIHD in patients (versus performing CABG) with unfavorable anatomy for PCI and who are good candidates for CABGBGNL 2011PCI in Hospitals Without On-Site Surgical BackupRecommendationCORLOEPrimary PCI in hospitals without onsite cardiac

21、 surgery (provided that appropriate planning for program development has been accomplished) IIaBElective PCI in hospitals without onsite cardiac surgery (provided that appropriate planning for program development has been accomplished, and rigorous clinical and angiographic criteria are used for pro

22、per patient selection) IIbBPrimary or elective PCI in hospitals without on-site cardiac surgery capabilities without a proven plan for rapid transport to a cardiac surgery operating room in a nearby hospital or without appropriate hemodynamic support capability for transferIII HarmCGNL 2011新版PCI指南的要

23、点分析在没有心脏外科支持的医院，如果已经有相应的临床路径和预备措施，可以实施直接PCICoronary StentsRisk of restenosis needs to be weighted against the likelihood of the patient to be able to tolerate and comply with (prolonged) DAPTRecommendationCORLOEDES as an alternative to BMS to reduce the risk of restenosis in cases in which the risk

24、of restenosis is increased and the patient is likely to be able to tolerate and comply with prolonged DAPT IElective PCI: AUA/NSTEMI: CSTEMI: ABefore implantation of a DES, interventional cardiologist discussion with the patient regarding the need for and duration of DAPT and the ability of the pati

25、ent to comply with and tolerate DAPT ICUse of balloon angioplasty or BMS (instead of DES) in patients with high bleeding risk, inability to comply with 12 months of DAPT, or with anticipated invasive or surgical procedures within the next 12 months during which time DAPT may be IBPCI with coronary s

26、tenting in cases in which the patient is not likely to be able to tolerate and to comply with DAPT III - HarmBDES implantation in cases in which the patient is not likely to be able to tolerate and comply with prolonged DAPT, or this cannot be determined prior to stent implantation III - HarmBGNL 20

27、11Clinical Situations Associated With DES or BMS Selection PreferenceDES Generally Preferred Over BMS (efficacy considerations)BMS Preferred Over DES (safety considerations)Left main diseaseSmall vessels In-stent restenosisBifurcation lesionsLong lesionsMultiple lesionsSaphenous vein graft lesionsDi

28、abetic patientsPatients unable to tolerate or comply with prolongedDAPTAnticipated surgery requiring discontinuation of DAPT within 12 monthsHigh risk of bleedingGNL 2011STEMI患者中DES优于BMSThe EXAMINATION (a clinical Evaluation of Xience-V stent in Acute Myocardial INfArcTION) trial新版PCI指南：DES如果再狭窄风险增高

29、并且患者可以耐受和依从长期DAPT，可应用DES替代BMS，减少再狭窄风险Vascular AccessRecommendationCORLOERadial artery access to decrease access site complicationsIIaAGNL 2011STEMI患者桡动脉路径较股动脉路径安全RIFLE STEACS：对比分析STEMI桡股动脉穿刺路径穿刺部位出血并发症减少47%，MACCE无差异 新版CABG指南的要点分析急诊CABG的指征： -直接PCI失败或不能实施 -冠脉解剖适合CABG -静息时有大面积心肌持续缺血和（或）血流动力学障碍对非手术治疗无效血

30、栓抽吸术不能减少1年时MI面积MUSTELA: A Prospective, Randomized Trial of Thrombectomy vs. no Thrombectomy in Patients with STEMI and Thrombus-Rich Lesions 前瞻随机入选了208例患者，分为抽吸和非抽吸组，抽吸组患者再分为机械和手动抽吸方式所有患者均为STMEI血栓负荷较重（TIMI血栓3级）MUSTELA结果血栓抽吸组术后TIMI 3级血流高达90.4%，对照组81.7%（P=.07），60min时STR 70%以上抽吸组57.4%，对照组37.3%（P=.004）3个

31、月MR表明血栓抽吸组延迟增强面积为20.4%，对照组为19.3%（P=.54）1年时无MACE生存率分别为92.3%和93.9%（P=.57）亚组分析显示使用机械抽吸患者（54例）相比手动抽吸的（50例）造影成功率更高（P=.02）整体成功率分别为94.4% 和78.0% (P=.02)但3个月时MRI却发现两组梗死面积无显著差异手动抽吸装置成功输送率为98%，机械抽吸装置为100%AMI冠脉内阿昔单抗并不优于静脉应用AIDA STEMI (Abciximab Intracoronary versus intravenous Drug Application in ST-Elevation M

32、yocardial Infarction)试验入选27家医院2065例STEMI患者，随机分为在直接PCI中冠脉内（0.25 mg/kg）组（1032例）或静推阿昔单抗组（1033例），2组患者在随后12h内均以0.125g/kg/min输注均服用500mgASA+600mg氯吡格雷或60mg普拉格雷90天临床终点事件ICIVOR (95% CI)P主要终点7.0%7.6%0.91(0.91-1.28)0.58死亡4.5%3.6%1.24(0.78-1.97)0.36再次MI1.8%1.8%1.00(0.51-1.96)0.99新发充血性心衰2.4%4.1%0.57(0.33-0.97)0.04ICIVP 院内脑卒中0.5%0.76%0.70支架内血栓形成1.7