β受體阻滯劑在PCI中的應(yīng)用

β受體阻滯劑在PCI術(shù)的應(yīng)用河北醫(yī)科大學(xué)第二醫(yī)院常亮當(dāng)前第1頁\共有34頁\編于星期五\16點(diǎn)提綱◆β受體阻滯劑藥理◆心率增快增加冠心病患者的臨床事件◆β受體阻滯劑在PCI圍手術(shù)期的應(yīng)用當(dāng)前第2頁\共有34頁\編于星期五\16點(diǎn)藥理學(xué)及作用機(jī)制主要機(jī)制：對抗兒茶酚胺類腎上腺素能遞質(zhì)毒性尤其是通過β1受體介導(dǎo)的心臟毒性，是此類藥物發(fā)揮心血管保護(hù)作用。其他機(jī)制：1.抗高血壓作用2.抗心肌缺血作用3.阻斷腎小球旁細(xì)胞β1受體，抑制腎素-AngII-醛固酮系統(tǒng)。4.改善心臟功能增加LVEF:5.抗心律失常作用6.其他：抑制β腎上腺素能通路介導(dǎo)的心肌細(xì)胞凋亡、抑制血小板聚集、減少對粥樣硬化斑塊的機(jī)械應(yīng)激、防止斑塊破裂等。當(dāng)前第3頁\共有34頁\編于星期五\16點(diǎn)心率增快增加冠心病患者的風(fēng)險(xiǎn)！當(dāng)前第4頁\共有34頁\編于星期五\16點(diǎn)Theeffectofheartrateonlocalhaemodynamicforcesontheendothelium.Mechanismswherebyanelevatedheartrateleadstoadverseoutcomesinpatientswithcoronaryarterydisease.當(dāng)前第5頁\共有34頁\編于星期五\16點(diǎn)ImpactofLeftVentricularEjectionFractiononClinicalOutcomesOverFiveYearsAfterInfarct-RelatedCoronaryArteryRecanalization(fromtheOccludedArteryTrial[OAT])Inconclusion,optimalmedicaltherapyremainstheoveralltreatmentofchoiceforstablepatientswithapersistenttotalocclusionoftheinfarct-relatedarteryafteracutemyocardialinfarction,irrespectiveofthebaselineEF.Inpatientswithnormalormoderatelyimpairedleftventricularcontractility,PCIreducedtheneedforsubsequentrevascularizationbutdidnototherwiseimproveoutcomes.(AmJCardiol2010;105:10–16)包括美托洛爾在內(nèi)的最佳藥物治療仍然是冠心病治療的基石！當(dāng)前第6頁\共有34頁\編于星期五\16點(diǎn)β阻滯劑在急性心肌梗死的應(yīng)用Setting/indicationClassLeveli.v.administrationForreliefofischaemicpainTocontrolhypertension,sinustachycardiaPrimarypreventionofsuddencardiacdeathSustainedventriculartachycardiaSupraventriculartachyarrhythmiasTolimitinfarctsizeAllpatientswithoutcontraindicationsOraladministrationAllpatientswithoutcontraindicationsIIIIIIIaIIbIBBBCCAAA當(dāng)前第7頁\共有34頁\編于星期五\16點(diǎn)β阻滯劑在慢性穩(wěn)定性心絞痛的應(yīng)用Expertconsensusdocumentonβ-adrenergicreceptorblockers.EuropeanHeartJournal.2004,25:1341–1362.Setting/indicationClassLevelPreviousinfarctionToimprovesurvivalToreducereinfarctionToprevent/controlischaemiaNopreviousinfarctionToimprovesurvivalToreducereinfarctionToprevent/controlischaemiaIIIIIIAAACBA當(dāng)前第8頁\共有34頁\編于星期五\16點(diǎn)HeartRateasanIndependentPrognosticRiskFactorinPatientswithAcuteMyocardialInfarctionUndergoingPrimaryPercutaneousCoronaryInterventionCONCLUSION:InpatientswithacutemyocardialinfarctionundergoingprimaryPCI,elevatedheartrate(80bpmorgreater)identifiesthoseatincreasedriskofdeath.Itisunknownwhetherheartratereductionwillresultinimprovedoutcomeinthissettingofpatients.急性心肌梗死患者急診行PCI，心率增快的患者發(fā)生院內(nèi)死亡的風(fēng)險(xiǎn)明顯增高！當(dāng)前第9頁\共有34頁\編于星期五\16點(diǎn)β阻滯劑在心肌梗塞后二級預(yù)防的應(yīng)用Setting/indicationClassLevelAllpatientswithoutcontraindications,inde?nitelyToimprovesurvivalTopreventreinfarctionPrimarypreventionofsuddencardiacdeathToprevent/treatlateventriculararrhythmiasIIIIIIaAAAAB當(dāng)前第10頁\共有34頁\編于星期五\16點(diǎn)β阻滯劑在非ST段抬高ACS的應(yīng)用Setting/indicationClassLevelEarlybene?t,reductionofischaemiaEarlybene?t,preventionMILong-termsecondarypreventionIIIBBB當(dāng)前第11頁\共有34頁\編于星期五\16點(diǎn)PURE研究：我國社區(qū)冠心病患者的β受體阻滯劑使用率低于中低收入國家平均水平Y(jié)usufS,etal.Lancet.2011;378:1231-1233.中國屬于中低收入國家當(dāng)前第12頁\共有34頁\編于星期五\16點(diǎn)實(shí)踐與指南的差距：β阻滯劑在中國冠心病患者中使用現(xiàn)狀中華醫(yī)學(xué)會心血管病學(xué)分會中華心血管病雜志編輯委員會.β腎上腺素能受體阻滯劑在心血管疾病應(yīng)用專家共識.使用率低使用時(shí)間滯后劑量較低獲益漸少當(dāng)前第13頁\共有34頁\編于星期五\16點(diǎn)

β受體阻滯劑在PCI圍手術(shù)期的應(yīng)用當(dāng)前第14頁\共有34頁\編于星期五\16點(diǎn)β受體阻斷劑在非心臟手術(shù)期間的使用一直受到重視!當(dāng)前第15頁\共有34頁\編于星期五\16點(diǎn)但是在PCI圍手術(shù)期間的使用？2009FocusedUpdates:ACC/AHAGuidelinesfortheManagementofPatientsWithST-ElevationMyocardialInfarction.2007FocusedUpdateoftheACC/AHA/SCAI2005GuidelineUpdateforPercutaneousCoronaryIntervention..Antithrombotic：1.UH,LMWH2.GPIIb/IIIaInhibitors3.Bivalirudinβ-block？statin

？Antiplatelet：1.Aspirin

2.clopidogrel

當(dāng)前第16頁\共有34頁\編于星期五\16點(diǎn)β受體阻斷劑在PCI圍手術(shù)期間的使用術(shù)前術(shù)中術(shù)后當(dāng)前第17頁\共有34頁\編于星期五\16點(diǎn)PCI術(shù)前使用β阻滯劑減少術(shù)后CK-MB的上升SaminK.Sharma,AnnapoornaKini,JonathanD.Marmur,etal.

CardioprotectiveEffectofPrior?-BlockerTherapyinReducingCreatineKinase-MBElevationAfterCoronaryIntervention.Circulation.2000,102:166-172PCI術(shù)前使用β阻滯劑與未使用組術(shù)后CK-MB增高的發(fā)生率及增高程度比較當(dāng)前第18頁\共有34頁\編于星期五\16點(diǎn)術(shù)前使用β阻滯劑對AMIPCI術(shù)后臨床預(yù)后的影響HarjaiKJ,StoneGW,BouraJ,etal.Effectsofpriorbeta-blockertherapyonclinicaloutcomesafterprimarycoronaryangioplastyforacutemyocardialinfarction.AmJCardiol2003;91:655–60.AMIPCI術(shù)前使用BB與未使用兩組術(shù)后并發(fā)癥、住院期間及一年隨訪臨床預(yù)后的比較當(dāng)前第19頁\共有34頁\編于星期五\16點(diǎn)AMIPCI術(shù)前靜注β阻滯劑提高術(shù)后生存率AmirHalkin,CindyL.Grines,DavidA.Cox,et.al.ImpactofintravenousBeta-Blockadebeforeprimaryangioplastyonsurvivalinpatientsundergoingmechanicalreperfusiontherapyforacutemyocardialinfarction.JAmCollCardiol,2004;43:1780-1787.術(shù)前靜脈注射BB與未注射組隨訪30天及一年生存率的比較當(dāng)前第20頁\共有34頁\編于星期五\16點(diǎn)RABBITII研究PCI術(shù)中冠狀動脈內(nèi)注射β阻滯劑漸少術(shù)后不良事件發(fā)生率BarryFUretsky;ErnstRSchwarz;AbdulfatahOsman,etal.IntracoronaryBetaBlockade(BB)DuringPercutaneousCoronaryIntervention(PCI):30DayResultsoftheRandomizedAngioplastyBetaBlockerIntracoronaryTrialII(RABBITII).Circulation.2006;114:II_547

當(dāng)前第21頁\共有34頁\編于星期五\16點(diǎn)急性心肌梗塞PCI術(shù)后使用β阻滯劑對臨床預(yù)后的影響StevenJ.Kernis,KishoreJ.Harjai,GreggW.Stone,et.al.Doesbeta-blockertherapyimproveclinicaloutcomesofacutemyocardialinfarctionaftersuccessfulprimaryangioplasty?JACC,43（10）:1773-1779.術(shù)后使用BB組較未使用組顯著降低死亡率及主要心臟不良事件率當(dāng)前第22頁\共有34頁\編于星期五\16點(diǎn)急性心肌梗塞PCI術(shù)后使用β阻滯劑對臨床預(yù)后的影響AMIPCI術(shù)后使用β阻滯劑顯著漸少六個(gè)月死亡風(fēng)險(xiǎn)當(dāng)前第23頁\共有34頁\編于星期五\16點(diǎn)PCI術(shù)后使用β阻滯劑減少一年死亡率PCI術(shù)后使用BB與未使用組隨訪一年生存率的比較.P=0.0014.AlbertW.Chan,MartinJ.Quinn,DeepakL.Bhatt,et.al,MortalityBenefitofBeta-BlockadeAfterSuccessfulElectivePercutaneousCoronaryIntervention.JournaloftheAmericanCollegeofCardiology.2002,40(4)670-675.當(dāng)前第24頁\共有34頁\編于星期五\16點(diǎn)AmHeartJ2003;145:875-81當(dāng)前第25頁\共有34頁\編于星期五\16點(diǎn)Conclusions-AdrenergicreceptorblockersprescribedafterPCIreducedtheriskofclinicalrestenosis,targetlesionrestenosis,andMACEinthiscohortof4840patients.Themechanismbywhich-blockersconferredaprotectiveeffectagainstrestenosisremainstobedetermined.(AmHeartJ2003;145:875-81.)PCI術(shù)后長期使用β受體阻斷劑可以明顯減少再狹窄導(dǎo)致的臨床事件！當(dāng)前第26頁\共有34頁\編于星期五\16點(diǎn)圍PCI期間使用β受體阻斷劑基于以下幾個(gè)方面抗炎與穩(wěn)定斑塊心肌保護(hù)預(yù)防再狹窄！當(dāng)前第27頁\共有34頁\編于星期五\16點(diǎn)Thesefindingssuggestthatmetoprololcouldinhibitthedevelopmentof

atherosclerosisandstabilizevulnerableplaquebyregulationoflipidandreductionofinflammation,inwhich

thechangefromlowshearstresstophysiologicalshearstressaroundplaquemayplayanimportantrole.當(dāng)前第28頁\共有34頁\編于星期五\16點(diǎn)當(dāng)前第29頁\共有34頁\編于星期五\16點(diǎn)當(dāng)前第30頁\共有34頁\編于星期五\16點(diǎn)Conclusions:Theintravenousadministrationofmetoprololbeforecoronaryreperfusionresultsinlargermyocardialsalvagethanitsoraladministrationinitia