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急診PCI的若干問題急診PCI的若干問題Endothelialprogenitorcell(EPC)capturingstentsHighdoseGPIIb/IIIainhibitorspre-hospitalizationManualthrombusaspiration(TA)duringPPCIPredictorsofstentthrombosisafterPPCI急診PCI的若干問題Endothelialprogenitorcell(ERandomization50GenousTM50CrCo6-monthclinical,angio
&
IVUSFUGENIUS-STEMITrial2007.8-9,SinglecenterprospectiveASA100mg/day
+
clopidogrel75mg/day30daysGPIIb/IIIainhibitorsandthromboaspirationatthediscretionofthephysicianPresentedbyDr.PavelCervinkaatACC.09/i2,Orlando,FLRandomization50GenousTM50CrCGENIUS-STEMITrial6-monthclinicaloutcomeMACECVDeathsMITLRSTP=0.03P=NSP=0.04P=NSP=NSGenousTMCrCo2410PresentedbyDr.PavelCervinkaatACC.09/i2,Orlando,FLGENIUS-STEMITrialMACE
GENIUS-STEMITrialConclusionsTheuseofEPCcapturestentsinthesettingofSTEMIisfeasible
&
safe.RateofMACEat6-monthFUwassignificantlyhigherinGenousTMgroupthanCrCostents.WarrisomeistherateoflatestentthrombosisinEPCscapturestentgroup.Largerrandomizedtrialsaremandatory.PresentedbyDr.PavelCervinkaatACC.09/i2,Orlando,FLGENIUS-STEMITrialTheuseof直接PCI患者院前與導(dǎo)管室應(yīng)用大劑量替羅非班的比較ON-TIME-2研究AGIR-2研究直接PCI患者院前與導(dǎo)管室應(yīng)用Prospective,multicentre,placebo-controlled,randomisedSTEMI30min-24hrs5000UFH,500mgASA,600mgClopidogrelAngiogramTirofiban*PlaceboTransportationPCIcentreAngiogramTirofibanprovisionalTirofibancont’dON-TIME-2oneyrfollow-up
n=9842006.6-2007.11PPCI*Bolus:25μg/kg&0.15μg/kg/mininfusionFollow-upON-TIME-2ChristianW.Hammetal.Prospective,multicentre,placConclusionsHighdosetirofibanontopofclopidogrel(600mg)intheprehospitalsettingissafePre-Hospitalinitiationoftirofiban(HDB)improvesSTresolutionbefore&afterprimaryPCINoincreaseinbleedingriskImprovesoutcomeofprimaryPCIforAMIStrongtrendtoreducedmortalitycontinuesover1yearfollow-upInpatientsundergoingprimaryPCImortalityissignificantlylower.Highestefficacyinelderly(>65yrs),inKillipclass2andinearlypresenters.ON-TIME-2ChristianW.Hammetal.ConclusionsHighdosetirofibanMICUPatient
callSTEMIundergoingprimaryPCISTEMI20min-12h600mgclopidogrel250mgaspirinUFH60U/kgTirofiban
25μg/kgbolus,0.15ug/kgivgttAngiographyAngiographyPre-hospitalMICU
transportationCathlabRandomize
OpenLabelMedical
DispatcherTirofiban
25μg/kgbolus,0.15ug/kgivgttAGIR2(n=156)(n=156)PPCIEricBonnefoyetal.MICUPatient
callSTEMIundergoi0.61.20123456DeathSevereBleedingAcutestentthrombosisStrokeCathlabtirofibanPre-Hospitaltirofiban%p=NSp=NSp=NSp=NSIn-hospitaleventsP=NSOnadmission
toCathlabP=NSP=NSInitialTIMIgrade2-3STsegmentresolution>70%39.744.298.1978.715.255.452.6020406080100120%FinalTIMIgrade2-3P=NSCathlabtirofibanPre-hospitaltirofibanSurrogatesofreperfusionOnehr
afterPCIAGIR2ResultsandConclusionTheresultsdonotsupportthenecessitytoinitiatetirofibanadministrationinpre-hospitalsettingsEricBonnefoyetal.0.61.2012345急診PCI血栓抽吸裝置的應(yīng)用
Manualthrombusaspiration(TA)duringPPCIErythrocyte-richthrombiPlatelet/fibrin-richthrombiCombinedthrombiEdematouscomponentsAtheroscleroticcomponents45231454FreshFormalinfixedFormalinfixedHEHEYANhongbingetal.急診PCI血栓抽吸裝置的應(yīng)用
ManualthrombusTAPASand1-yearfollow-up0%1%2%3%4%5%6%7%8%AllcausemortalityCardiacdeathReinfarctionTAPAS1-yearfollow-upP=0.04P=0.02P=0.05AspConAspConAspConpatient0%20%40%60%80%100%45.717.126.3AspConMBG0-1MBG2MBG3MyocardialBlushGradeP＜0.00156.630.812.644.237.917.90%20%40%60%80%100%STR＜30%STR30-70%MBG＞70%AspConResolutionofST-segmentElevationP＜0.001VlaarP,etal.Lancet2008;371:1915-20;SvilaasT,etal.NEnglJ2008;358:557-676FExportaspirationcatheterintention-to-treattrialRoutineutilizationofTAn=535forTAn=536forconventionalPPCIFollow-upfor1yrTAPASand1-yearfollow-up4.77mortalityAmeta-analysisofadjunctivethrombectomyandembolicprotectiondevicesinSTEMI1996-200830randomizedtrialsn=6415patients＜12hnativevesselSTEMIEndpoints:
AllcausemortalityMACEStrokeBavryAA.etal.,EuropeanHeartJ.2008;29:2989–30016month5month4month13trialsn=30265trialsn=93412trialsn=2442mortalityAmeta-analysisofad＜12hSTEMITIMI0-1n=49successfulaspirationwithvisiblematerialDIVERCEandZEEKYANhongbingetal.0.590.520.480.50.520.540.560.580.6146257.9050100150200250300PresenceofplaquematerialPresenceofthrombusonlyPresenceofplaquematerialPresenceofthrombusonlyLVEF16hrpost-proceduralP＜0.02P＜0.02PeakCK-MBpost-proceduraln=28n=28n=21n=28n=21PlaquematerialRemovingplaquematerialsfromtheculpritlesionis
beneficialShouldTAberoutinelyperformedinTIMI2-3patients?Needstrials＜12hSTEMIYANhongbingetalArethereanydifferencesofdevicesoperabilityandclinicalimpactsamongdifferenttypeaspirationcatheters?YANhongbingetal.ChinMedJ2009;122(6):648-654SizedistributionofthrombiP=0.02forsmall,P=0.09formoderateandP=0.03forlargethrombi.
largesmallmoderateFrequencyofdual-wiresArethereanydifferencesofdClinicalimpactsofDiverCEvsZEEKYANhongbingetal.ChinMedJ2009;122(6):648-654ClinicalimpactsofDiverCEvAMI直接PCI支架血栓的預(yù)測因素：
HORIZONS-AMI試驗(yàn)AMI直接PCI支架血栓的預(yù)測因素：
HORIZONS-AMNolimitationsfordrug-elutingstentsinSTEMIpatients1yr
EndpointsDESTaxus,n=2257(%)BMSExpress,n=749(%)Hazardratio(95%CI)Ischemictargetlesionrevascularization9(0.43–0.83)SafetyMACE8.18.01.02(0.76–1.36)All-causemortality9(0.64–1.55)MI1(0.54–3.22)Stroke1.00.71.52(0.58–4.00)Stentthrombosis2(0.58–1.45)Binaryrestenosis,perlesion,at13mo10.022.90.44(0.33–0.57)TCT2008:TranscatheterCardiovascularTherapeutics20thAnnualScientificSymposiumOctober12-17,2008,Washington,DCEndpointsNolimitationsfordrug-elutinIndependentPredictorsofST(CoxModel)AcuteSTSubacuteSTLateSTIndependentPredictorsofST(ConclusionsAcute,subacute&lateSTappeartoberelatedtodifferentfactorsthemostimportantpredictorsofacute&subacuteSTevents:Pharmacologicaltherapy,vesselflow,lesioncharacteristics&number&lengthofstentsthemostimportantpredictorsoflateSTevents:Patientrelatedfactorsincludingcigarettesmoking&priorMIThetypeofstentimplanted(DESvs.BMS)wasnotrelatedtoSTduringanytimeintervalupto1-yearSTwithin1-yearoccurredwithsimilarfrequencyinpatientstreatedwithUFH+GPI&bivalirudinaloneHowever,acuteSTwasmorecommonwithbivalirudin,especiallywithinthe1st5hours,whereasSTtendedtobelesscommonwithbivalirudinthanwithUFH+GPIbetween24hours&1-yearConclusionsAcute,subacute&lThankyou!Thankyou!GENIUS-STEMI
Trial6monthangio&IVUSdata
Genous
Cr-Co
PvalueANGIODATA
N=44N=47Latelumenloss(mm)0.89±0.590.79±0.47NSRestenosis(>50%)2013NS
(QCA:PieMedicalIm)IVUSN=41N=42meanin-stentNIH(mm3)49.7±48
40.0±22.8NS
(Volcano,pullback0.5%mm/s)(QIVAPieMedicalIm)
NIH:NeointimalhyperplasiainsidethestentGENIUS-STEMITrial急診PCI的若干問題急診PCI的若干問題Endothelialprogenitorcell(EPC)capturingstentsHighdoseGPIIb/IIIainhibitorspre-hospitalizationManualthrombusaspiration(TA)duringPPCIPredictorsofstentthrombosisafterPPCI急診PCI的若干問題Endothelialprogenitorcell(ERandomization50GenousTM50CrCo6-monthclinical,angio
&
IVUSFUGENIUS-STEMITrial2007.8-9,SinglecenterprospectiveASA100mg/day
+
clopidogrel75mg/day30daysGPIIb/IIIainhibitorsandthromboaspirationatthediscretionofthephysicianPresentedbyDr.PavelCervinkaatACC.09/i2,Orlando,FLRandomization50GenousTM50CrCGENIUS-STEMITrial6-monthclinicaloutcomeMACECVDeathsMITLRSTP=0.03P=NSP=0.04P=NSP=NSGenousTMCrCo2410PresentedbyDr.PavelCervinkaatACC.09/i2,Orlando,FLGENIUS-STEMITrialMACE
GENIUS-STEMITrialConclusionsTheuseofEPCcapturestentsinthesettingofSTEMIisfeasible
&
safe.RateofMACEat6-monthFUwassignificantlyhigherinGenousTMgroupthanCrCostents.WarrisomeistherateoflatestentthrombosisinEPCscapturestentgroup.Largerrandomizedtrialsaremandatory.PresentedbyDr.PavelCervinkaatACC.09/i2,Orlando,FLGENIUS-STEMITrialTheuseof直接PCI患者院前與導(dǎo)管室應(yīng)用大劑量替羅非班的比較ON-TIME-2研究AGIR-2研究直接PCI患者院前與導(dǎo)管室應(yīng)用Prospective,multicentre,placebo-controlled,randomisedSTEMI30min-24hrs5000UFH,500mgASA,600mgClopidogrelAngiogramTirofiban*PlaceboTransportationPCIcentreAngiogramTirofibanprovisionalTirofibancont’dON-TIME-2oneyrfollow-up
n=9842006.6-2007.11PPCI*Bolus:25μg/kg&0.15μg/kg/mininfusionFollow-upON-TIME-2ChristianW.Hammetal.Prospective,multicentre,placConclusionsHighdosetirofibanontopofclopidogrel(600mg)intheprehospitalsettingissafePre-Hospitalinitiationoftirofiban(HDB)improvesSTresolutionbefore&afterprimaryPCINoincreaseinbleedingriskImprovesoutcomeofprimaryPCIforAMIStrongtrendtoreducedmortalitycontinuesover1yearfollow-upInpatientsundergoingprimaryPCImortalityissignificantlylower.Highestefficacyinelderly(>65yrs),inKillipclass2andinearlypresenters.ON-TIME-2ChristianW.Hammetal.ConclusionsHighdosetirofibanMICUPatient
callSTEMIundergoingprimaryPCISTEMI20min-12h600mgclopidogrel250mgaspirinUFH60U/kgTirofiban
25μg/kgbolus,0.15ug/kgivgttAngiographyAngiographyPre-hospitalMICU
transportationCathlabRandomize
OpenLabelMedical
DispatcherTirofiban
25μg/kgbolus,0.15ug/kgivgttAGIR2(n=156)(n=156)PPCIEricBonnefoyetal.MICUPatient
callSTEMIundergoi0.61.20123456DeathSevereBleedingAcutestentthrombosisStrokeCathlabtirofibanPre-Hospitaltirofiban%p=NSp=NSp=NSp=NSIn-hospitaleventsP=NSOnadmission
toCathlabP=NSP=NSInitialTIMIgrade2-3STsegmentresolution>70%39.744.298.1978.715.255.452.6020406080100120%FinalTIMIgrade2-3P=NSCathlabtirofibanPre-hospitaltirofibanSurrogatesofreperfusionOnehr
afterPCIAGIR2ResultsandConclusionTheresultsdonotsupportthenecessitytoinitiatetirofibanadministrationinpre-hospitalsettingsEricBonnefoyetal.0.61.2012345急診PCI血栓抽吸裝置的應(yīng)用
Manualthrombusaspiration(TA)duringPPCIErythrocyte-richthrombiPlatelet/fibrin-richthrombiCombinedthrombiEdematouscomponentsAtheroscleroticcomponents45231454FreshFormalinfixedFormalinfixedHEHEYANhongbingetal.急診PCI血栓抽吸裝置的應(yīng)用
ManualthrombusTAPASand1-yearfollow-up0%1%2%3%4%5%6%7%8%AllcausemortalityCardiacdeathReinfarctionTAPAS1-yearfollow-upP=0.04P=0.02P=0.05AspConAspConAspConpatient0%20%40%60%80%100%45.717.126.3AspConMBG0-1MBG2MBG3MyocardialBlushGradeP＜0.00156.630.812.644.237.917.90%20%40%60%80%100%STR＜30%STR30-70%MBG＞70%AspConResolutionofST-segmentElevationP＜0.001VlaarP,etal.Lancet2008;371:1915-20;SvilaasT,etal.NEnglJ2008;358:557-676FExportaspirationcatheterintention-to-treattrialRoutineutilizationofTAn=535forTAn=536forconventionalPPCIFollow-upfor1yrTAPASand1-yearfollow-up4.77mortalityAmeta-analysisofadjunctivethrombectomyandembolicprotectiondevicesinSTEMI1996-200830randomizedtrialsn=6415patients＜12hnativevesselSTEMIEndpoints:
AllcausemortalityMACEStrokeBavryAA.etal.,EuropeanHeartJ.2008;29:2989–30016month5month4month13trialsn=30265trialsn=93412trialsn=2442mortalityAmeta-analysisofad＜12hSTEMITIMI0-1n=49successfulaspirationwithvisiblematerialDIVERCEandZEEKYANhongbingetal.0.590.520.480.50.520.540.560.580.6146257.9050100150200250300PresenceofplaquematerialPresenceofthrombusonlyPresenceofplaquematerialPresenceofthrombusonlyLVEF16hrpost-proceduralP＜0.02P＜0.02PeakCK-MBpost-proceduraln=28n=28n=21n=28n=21PlaquematerialRemovingplaquematerialsfromtheculpritlesionis
beneficialShouldTAberoutinelyperformedinTIMI2-3patients?Needstrials＜12hSTEMIYANhongbingetalArethereanydifferencesofdevicesoperabilityandclinicalimpactsamongdifferenttypeaspirationcatheters?YANhongbingetal.ChinMedJ2009;122(6):648-654SizedistributionofthrombiP=0.02forsmall,P=0.09formoderateandP=0.03forlargethrombi.
largesmallmoderateFrequencyofdual-wiresArethereanydifferencesofdClinicalimpactsofDiverCEvsZEEKYANhongbingetal.ChinMedJ2009;122(6):648-654ClinicalimpactsofDiverCEvAMI直接PCI支架血栓的預(yù)測因素：
HORIZONS-AMI試驗(yàn)AMI直接PCI支架血栓的預(yù)測因素：
HORIZONS-AMNolimitationsfordrug-elutingstentsinSTEMIpatients1yr
EndpointsDESTaxus,n=2257(%)BMSExpress,n=749(%)Hazardratio(95%CI)Ischemictargetlesionrevascularization9(0.43–0.83)SafetyMACE8.18.01.02(0.76–1.36)All-causemortality9(0.64–1.55)MI1(0.54–3.22)Stroke1.00.71.52(0.58–4.00)Stentthrombosis2(0.58–1.45)Binaryrestenosis,perlesion,at13mo10.022.90.44(0.33–0.57)TCT2008:TranscatheterCardiovascularTherapeutics20thAnnualScientificSymposiumOctober12-17,2008,Washington,DCEndpointsNolimitationsfordrug-elutinIndependentPredictorsofST(CoxModel)AcuteSTSubacuteSTLateSTIndependentPredictorsofST(ConclusionsAcute,subacute&lateSTappear
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