β受体阻滞剂在PCI中的应用

β受体阻滞剂在PCI术的应用提纲◆β受体阻滞剂药理◆心率增快增加冠心病患者的临床事件◆β受体阻滞剂在PCI围手术期的应用药理学及作用机制主要机制：对抗儿茶酚胺类肾上腺素能递质毒性尤其是通过β1受体介导的心脏毒性，是此类药物发挥心血管保护作用。其他机制：1.抗高血压作用2.抗心肌缺血作用3.阻断肾小球旁细胞β1受体，抑制肾素-AngII-醛固酮系统。4.改善心脏功能增加LVEF:5.抗心律失常作用6.其他：抑制β肾上腺素能通路介导的心肌细胞凋亡、抑制血小板聚集、减少对粥样硬化斑块的机械应激、防止斑块破裂等。心率增快增加冠心病患者的风险！Theeffectofheartrateonlocalhaemodynamicforcesontheendothelium.Mechanismswherebyanelevatedheartrateleadstoadverseoutcomesinpatientswithcoronaryarterydisease.ImpactofLeftVentricularEjectionFractiononClinicalOutcomesOverFiveYearsAfterInfarct-RelatedCoronaryArteryRecanalization(fromtheOccludedArteryTrial[OAT])Inconclusion,optimalmedicaltherapyremainstheoveralltreatmentofchoiceforstablepatientswithapersistenttotalocclusionoftheinfarct-relatedarteryafteracutemyocardialinfarction,irrespectiveofthebaselineEF.Inpatientswithnormalormoderatelyimpairedleftventricularcontractility,PCIreducedtheneedforsubsequentrevascularizationbutdidnototherwiseimproveoutcomes.(AmJCardiol2010;105:10–16)包括倍他乐克在内的最佳药物治疗仍然是冠心病治疗的基石！β阻滞剂在急性心肌梗死的应用Setting/indicationClassLeveli.v.administrationForreliefofischaemicpainTocontrolhypertension,sinustachycardiaPrimarypreventionofsuddencardiacdeathSustainedventriculartachycardiaSupraventriculartachyarrhythmiasTolimitinfarctsizeAllpatientswithoutcontraindicationsOraladministrationAllpatientswithoutcontraindicationsIIIIIIIaIIbIBBBCCAAAβ阻滞剂在慢性稳定性心绞痛的应用Expertconsensusdocumentonβ-adrenergicreceptorblockers.EuropeanHeartJournal.2004,25:1341–1362.Setting/indicationClassLevelPreviousinfarctionToimprovesurvivalToreducereinfarctionToprevent/controlischaemiaNopreviousinfarctionToimprovesurvivalToreducereinfarctionToprevent/controlischaemiaIIIIIIAAACBAHeartRateasanIndependentPrognosticRiskFactorinPatientswithAcuteMyocardialInfarctionUndergoingPrimaryPercutaneousCoronaryInterventionCONCLUSION:InpatientswithacutemyocardialinfarctionundergoingprimaryPCI,elevatedheartrate(80bpmorgreater)identifiesthoseatincreasedriskofdeath.Itisunknownwhetherheartratereductionwillresultinimprovedoutcomeinthissettingofpatients.急性心肌梗死患者即使行PCI，心率增快的患者发生院内死亡的风险明显增高！β阻滞剂在心肌梗塞后二级预防的应用Setting/indicationClassLevelAllpatientswithoutcontraindications,indefinitelyToimprovesurvivalTopreventreinfarctionPrimarypreventionofsuddencardiacdeathToprevent/treatlateventriculararrhythmiasIIIIIIaAAAABβ阻滞剂在非ST段抬高ACS的应用Setting/indicationClassLevelEarlybenefit,reductionofischaemiaEarlybenefit,preventionMILong-termsecondarypreventionIIIBBB实践与指南的差距：β阻滞剂在中国冠心病患者中使用现状中华医学会心血管病学分会中华心血管病杂志编辑委员会.β肾上腺素能受体阻滞剂在心血管疾病应用专家共识.使用率低使用时间滞后剂量较低获益渐少

β受体阻滞剂在PCI围手术期的应用β受体阻断剂在非心脏手术期间的使用一直受到重视!但是在PCI围手术期间的使用？2009FocusedUpdates:ACC/AHAGuidelinesfortheManagementofPatientsWithST-ElevationMyocardialInfarction.2007FocusedUpdateoftheACC/AHA/SCAI2005GuidelineUpdateforPercutaneousCoronaryIntervention..Antithrombotic：1.UH,LMWH2.GPIIb/IIIaInhibitors3.Bivalirudinβ-block？statin

？Antiplatelet：1.Aspirin

2.clopidogrel

β受体阻断剂在PCI围手术期间的使用术前术中术后PCI术前使用β阻滞剂渐少术后CK-MB的上升SaminK.Sharma,AnnapoornaKini,JonathanD.Marmur,etal.

CardioprotectiveEffectofPriorß-BlockerTherapyinReducingCreatineKinase-MBElevationAfterCoronaryIntervention.Circulation.2000,102:166-172PCI术前使用β阻滞剂与未使用组术后CK-MB增高的发生率及增高程度比较术前使用β阻滞剂对AMIPCI术后临床预后的影响HarjaiKJ,StoneGW,BouraJ,etal.Effectsofpriorbeta-blockertherapyonclinicaloutcomesafterprimarycoronaryangioplastyforacutemyocardialinfarction.AmJCardiol2003;91:655–60.AMIPCI术前使用BB与未使用两组术后并发症、住院期间及一年随访临床预后的比较AMIPCI术前静注β阻滞剂提高术后生存率AmirHalkin,CindyL.Grines,DavidA.Cox,et.al.ImpactofintravenousBeta-Blockadebeforeprimaryangioplastyonsurvivalinpatientsundergoingmechanicalreperfusiontherapyforacutemyocardialinfarction.JAmCollCardiol,2004;43:1780-1787.术前静脉注射BB与未注射组随访三个月及一年生存率的比较RABBITII研究PCI术中冠状动脉内注射β阻滞剂渐少术后不良事件发生率BarryFUretsky;ErnstRSchwarz;AbdulfatahOsman,etal.IntracoronaryBetaBlockade(BB)DuringPercutaneousCoronaryIntervention(PCI):30DayResultsoftheRandomizedAngioplastyBetaBlockerIntracoronaryTrialII(RABBITII).Circulation.2006;114:II_547

急性心肌梗塞PCI术后使用β阻滞剂对临床预后的影响StevenJ.Kernis,KishoreJ.Harjai,GreggW.Stone,et.al.Doesbeta-blockertherapyimproveclinicaloutcomesofacutemyocardialinfarctionaftersuccessfulprimaryangioplasty?JACC,43（10）:1773-1779.术后使用BB组较未使用组显著降低死亡率及主要心脏不良事件率急性心肌梗塞PCI术后使用β阻滞剂对临床预后的影响AMIPCI术后使用β阻滞剂显著渐少六个月死亡风险PCI术后使用β阻滞剂渐少一年死亡率P