急性心肌死的藥物溶栓及介入治療ppt課件

1、心肌梗死的藥物心肌梗死的藥物/ /介入策略介入策略時間就是心肌，就是生命0 - 0.5 hrs 預(yù)防梗死0.5 2 hrs 大量挽救心肌 + ira開通的益處2 6 hrs心肌挽救降低, ira開通的益處 6 hrs基本不挽救心肌, 但有ira開通的益處90年代中已證明溶栓治療的益處與安慰劑對比2003年，心梗治療-溶栓與介入對比-we know是否意味著都做pci? pci時間肯定要比直接注射藥物長，不是所有醫(yī)療機(jī)構(gòu)都具有pci條件。所以一系列問題需要研究溶栓與介入的比較nrmi-2: 死亡率與時間的關(guān)系“拖拖” 多久可以接受？多久可以接受？2004acc/ahaami指南的選擇的推薦指南的

2、選擇的推薦下列情形下溶栓更好下列情形下溶栓更好 到院很早（3h）介入可能延遲 介入不可選 導(dǎo)管室沒空 血管入路有困難 沒有熟練的醫(yī)生 介入延遲(door-balloon)-(door-needle)1hmedical contact-balloon time1.5h下列情形下介入更好下列情形下介入更好 熟練的隊(duì)伍且有外科保障(door-balloon)-(door-needle)1hmedical contact-balloon time3h 診斷stemi有疑問如果3小時之內(nèi)到院，沒有特別情況，兩種方案均可我們已經(jīng)知道我們已經(jīng)知道 pci優(yōu)于溶栓 但是pci慢于溶栓，慢可用療效彌補(bǔ)，但有個度

3、 這個“度”的把握很重要北京的調(diào)查顯示，d2b時間達(dá)標(biāo)比例低如何選擇溶栓與介入？如何選擇溶栓與介入？ 溶栓后還可以介入？溶栓后還可以介入？溶栓與溶栓與pcipci選擇之考慮選擇之考慮至少有部分病人，溶栓可能優(yōu)于至少有部分病人，溶栓可能優(yōu)于pciwho? when? where? what? which? sx door needle balloon策略的變化策略的變化2003 greg stone(lancet): ppci regardness of nearest cath suite 3 floors or 3 hrs away2007jacc accaha guidelinelytic

4、 if anticipated ppci is 90min give lytic within 30min選擇依據(jù)1-起病長短選擇依據(jù)2-拖延時間p = 0.006020406080100pci相關(guān)的時間延誤 (入院-球囊擴(kuò)張時間入院-溶栓時間)-5051015圓的尺寸 = 單獨(dú)研究的樣本大小.實(shí) 線= 加權(quán)meta回歸. . am j cardiol. 2003;92:824-662 分鐘獲益支持pci受損支持溶栓pci 每延遲10分鐘，與溶栓間的死亡率的差異將減少1%sx-b每延長30min，rr=1.08選擇依據(jù)2-拖延時間nrmi資料192509例患者，645個中心circulatio

5、n 2006；114：2019-25114min是個坎但：所有病人一樣嗎？選擇依據(jù)3-患者本身風(fēng)險danami-2發(fā)現(xiàn)轉(zhuǎn)運(yùn)pci有益于高危者選擇依據(jù)選擇依據(jù)4年齡，梗死部位，就診時間circulation 2006；114：2019-25直接直接pci的可接受延擱時間取決于患者病情的可接受延擱時間取決于患者病情z=0.59x-0.033y-0.0003w-1.3z=ppci對tt的益處；x=本身死亡率；y=pci延誤w=患者癥狀到就診時間越是高危，ppci越經(jīng)“拖”直接直接pci的可接受延擱時間取決于患者病情的可接受延擱時間取決于患者病情 50ym diabetic pt,3h ant ste

6、mi hemodynamically stable; trs=3;mortality=4.4% d2b-d2n=43min 74-ym pt,3hant stemi hemodynamically unstable trs=5;mortality=12.4% d2b-d2n=200min溶栓后還可以溶栓后還可以pcipci嗎？嗎？溶栓成功后的溶栓成功后的pci-不行到可行的過程不行到可行的過程immediate pciimmediate pci-no goodbe abandoned for many yearsimmediate pci？80-90s data suggest harmful

7、 lytic activated platelet,more thrombogenic prone to hemorragic in intracoronary lesion more vascular complications aspirin not given with thrombolysis low dose heparine,noact monitor gp iib/iiia antagonist & thienopydine not used stent not availableacc/aha2004 ami guideline described early angi

8、ogram after successful lytic routine ,immediately after lytic tx classiii following successful lytic tx in asx pts without ischemia class iibacc/aha2005 pciguideline described early angiogram after successful lyticlittle bit improved?06 esc ami guideline :okkey trials for immediate pci okcapital fur

9、ther support routine pci after lysis07 further meta-analysis：new evidence of pci reasonable after lysis溶栓后立即或缺血驅(qū)動溶栓后立即或缺血驅(qū)動pci薈萃薈萃wijeysundera h: am heart j 2008;156:564-572為什么又行了？ 介入的發(fā)展：支架、iib/iiia 溶栓藥的發(fā)展：短效溶栓藥 介入的時機(jī)選對了溶栓失敗后的溶栓失敗后的rescue pci-不得不行到可行的過程不得不行到可行的過程 rescue pciearlyrescue pci(gusto-1)gu

10、sto-1-不補(bǔ)救更好 key trial for rescue pcimeta analysis of rescue pci2007易化易化pci-與溶栓后與溶栓后pci有區(qū)別有區(qū)別區(qū)別在哪里？區(qū)別在哪里？pactpactcaptim trial arouse some hope 840 pts in 27 tertiary care french hospitals with mobile care units 2mm ste-mi - asa + heparin 5000u; pre-hospital tpa vs primary pcip=0.29p=0.61p=0.13p=0.12p

11、=0.06bonnefoy, lancet 2002 ；key trials for facilitate pci如果已經(jīng)準(zhǔn)備pci,不要亂給藥了，不給更好finesse pci前常規(guī)abciximab或pci時囑情abciximab的比較 不管是否有半量瑞替普酶溶栓 結(jié)果一樣且院前應(yīng)用ab出血增多 finesse+ontime2：pci前前ab無益處無益處meta analysis for f-pciprepci timi flow not transfer to good outcomemeta analysis for f-pcifacilitate pci 2007 guideline

12、 pharmacoinvasive概念概念的提出的提出轉(zhuǎn)運(yùn)是安全的易化，立即，轉(zhuǎn)運(yùn)的綜合易化，立即，轉(zhuǎn)運(yùn)的綜合問題：那些無法在90min內(nèi)pci的患者接受半量瑞替普酶+ab 后，是該立即轉(zhuǎn)運(yùn)作pci還是等到發(fā)現(xiàn)未再通再進(jìn)行 轉(zhuǎn)運(yùn)補(bǔ)救pci?180min110mind2b轉(zhuǎn)運(yùn)與立即轉(zhuǎn)運(yùn)與立即pci的結(jié)合的結(jié)合tenecteplase溶栓后的病人何時轉(zhuǎn)運(yùn)？1059例高危患者均在2h內(nèi)溶栓提示：盡早轉(zhuǎn)運(yùn)做pci有益；發(fā)現(xiàn)了溶栓后早期介入的時間窗可以提前到3h n engl j med 2009; 360:2705-2718. 32.5h2.8h轉(zhuǎn)運(yùn)與立即轉(zhuǎn)運(yùn)與立即pci的結(jié)合的結(jié)合:sx2htnkb

13、ohmer e etal:jacc2010;55:102-1103d2.7h溶栓后pci meta2010溶栓后pci獲益溶栓后pci meta-201130d 復(fù)合終點(diǎn)溶栓后pci meta-201130d缺血終點(diǎn)30d出血終點(diǎn)30d死亡率latest guideline, whats new? triage and transfer for pci ,esp in high risk ,but no emphasize surgical backup abandon the many terms of ppci,immediate, rescue lytic then pci safe p

14、t be divided into sent to capability of pci institute or not emphasize ppci asap2010esc介入指南rt-pa半量溶栓后早期半量溶栓后早期pci治療急性治療急性stemi 療效及安全性評價療效及安全性評價time intervalslysis2.0h 1.1h 0.5h 1.5h 6.8hmedian d-to-n time: 1.6h median d-to-b time: 8.4hsymptom onsethospitalizationconsent signature balloon infllation2

15、 with no lesions 50% diameter stenosis and 1 with unsuitable anatomy did not undergo pci6 had timi 0-134 had timi 2-350 enrolled and accepted half-dose rt-pa 40(81.6%) achieved clinical criteria of reperfusion1 was unwilling to undergo angiography 9(18.4%) underwent rescue pci 4 had timi 2-35 had ti

16、mi 0-1early pci 75.5%final flow of ira final flow of ira 8 had timi 2-31 had timi 0-136 had timi 2-31 had timi 0-1procedural characteristics (n=46) glycoprotein iib/iiia use, - no.(%) 7 ( 15.2 % ) thrombectomy, - no.(%) 0 ( 0 % ) coronary-artery bypass grafting, - no.(%) 0 ( 0 % ) distal protection

17、device, - no.(%) 0 ( 0 % ) coronary stents, - no.(%) 45 ( 97.8 % ) complications - no.(%) minor dissection 1 ( 2.2 % ) no reflow 2 ( 4.3 % ) (ppci 5-25%)improved timi grade flow 48.532.137.925.6p0.01improved ctfc improved mbg 59.737.226.719.936.923.437.821.5n=12n=8n=15n=11optimal time of early pci (pilot) 137.557.3110.851.3116.752.5157.044.8n=12n=8n=4n=14optimal time of early pci (pil