急性心肌梗死的再灌注治疗课件.ppt

急性心肌梗死的再灌注 治疗的方法与选择,山东省立医院 急救中心,STEMI治疗原则,挽救濒死的心肌，防止梗死扩大 及时处理严重心律失常、泵衰竭和各种并发症 保护和维持心脏功能,治疗方法,STEMI,,一般治疗,再灌注治疗,,再灌注疗法药物-介入-手术, 药物溶栓 PTCA支架术PCI直接/补救/择期 CABG 其他激光、基因工程,溶栓治疗仍是目前首选,欧洲20年来心梗溶栓试验荟萃 中国医学论坛报网络版 总第 902 期,时间就是心肌，就是生命,,,0 - 0.5 hrs预防梗死 0.5 2 hrs 大量挽救心肌 IRA开通的益处 2 6 hrs心肌挽救降低, IRA开通的益处 6 hrs基本不挽救心肌, 但有IRA开通的益处,Timeline of AMI Treatment,,,,,,Sx Door Needle Balloon,“拖” 多久可以接受,NRMI-2 死亡率与时间的关系,P0.01,P0.0007,P0.0003,Door-to-Balloon Time minutes,起病早3h到院者PCI/溶栓的衡量,圆的尺寸 单独研究的样本大小. 实 线加权meta回归.,62 分钟,获益 支持PCI,受损 支持溶栓,PCI 每延迟10分钟，与溶栓间的死亡率的差异将减少1 Sx-B每延长30min，RR1.08,. Am J Cardiol. 2003;92824-6,2004ACC/AHAAMI指南的选择的推荐,下列情形下溶栓更好 到院很早（3h）介入可能延迟 介入不可选 导管室没空 血管入路有困难 没有熟练的医生 介入延迟 Door-balloon-Door-needle1h Medical contact-balloon time1.5h,下列情形下介入更好 熟练的队伍且有外科保障 Door-balloon-Door-needle3h 诊断STEMI有疑问,如果3小时之内到院，没有特别情况，两种方案均可,STEMI直接PCI对院内溶栓治疗,STEMI就地溶栓与转运PCI,STEMI再灌注治疗重要的时间段,STEMI再灌注治疗的获益与时间延迟相关,ACC/AHA STEMI Guidelines 2007 Update,再灌注治疗直接PCI,再灌注治疗溶栓,指南区分3h界限的根据,,*有PCI条件具备24小时进行PCI的条件及有经验的团队，并且D2B时间在90分钟内。 *高危发病时合并有心源性休克、重度充血性心力衰竭和或肺水肿、恶性心律失常、中度或大面积心肌梗死前壁心梗、合并右室心梗或心前区ST段压低的下壁心梗。 *高龄年龄75岁。,STEMI患者处理流程图,2010ESC介入指南,,,心梗治疗--溶栓与介入对比---We know,是否意味着都做PCI PCI时间肯定要比直接注射药物长，不是所有医疗机构都具有PCI条件。所以一系列问题需要研究,直接PCI的可接受延搁时间取决于患者病情,Z0.59X-0.033Y-0.0003W-1.3,ZPPCI对TT的益处；X本身死亡率；YPCI延误 W患者症状到就诊时间,指南对高危患者更倾向PCI的根据DANAMI-2发现转运PCI有益于高危者,,越是高危，PPCI越经“拖”,共识之背景---给患者最合适的措施,PCI之于AMI最有效 AMI也以PCI最有效 但时间 各地发展不平衡（经济，社会，认识） 美国年初AMI新指南 近年许多观念变化,北京的调查显示，D2B时间达标比例低,Should PCI be pered after successful thrombolysis,Immediate PCI80-90s data suggest harmful,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 3602705-2718.,32.5h,2.8h,转运与立即PCI的结合Sx2hTNK,Bohmer E etalJACC2010;55102-110,3d,2.7h,PPCI介入时间的变化,,Temporal Dynamics of Primary PCI,Time is muscle, time is life Patients with STEMI who present early achieve greater myocardial salvage from primary PCI than those presenting more than 12 hours after symptom onset. STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact as a systems goal.,ACC/AHA STEMI Guidelines 2007 Update,Time Matters, but Should NOT Preclude PCI,Could primary PCI still beneficial later than 12 hours after STEMI A paper published online April 8, 2009 of European Heart Journal support that late presenters still achieve substantial reductions in final infarct size FIS from intervention.,A total of 396 out of 619 screened patients who underwent primary PCI for STEMI were divided into 2 groups early presenters n 341, who were treated 12 hours after symptom onset, and late presenters n 55, who received PCI between 12 and 72 hours. Myocardial perfusion imaging with Tc-99m SPECT was pered at the time of enrollment to measure area at risk AAR and at 30 days post-PCI to measure final infarct size FIS, percent of the LV myocardium, salvage index percent of non-infarcted AAR, LVEF, end-diastolic volume EDV, and end-systolic volume ESV.,European Heart Journal Advance Access published online on April 8, 2009,Infarct size and myocardial salvage after primary angioplasty in patients presenting with symptoms for 12 h vs. 1272 h,FIS is larger in late presenters 12 h than early presenters after primary angioplasty for STEMI. However, substantial myocardial salvage can be obtained beyond the 12 h limit, even when the infarct-related artery is totally occluded.,Outcomes of Early vs. Late Presenters,European Heart Journal Advance Access published online on April 8, 2009,Supporttings of lengthening the treatmentwindow for STEMI patients,BRAVE-2, a randomized study published in 2005 that showed stenting reduced infarct size more than conservative therapy in stable STEMI patients who presented between 12 and 48 hours. In February 2009, the BRAVE-2 researchers reported in a research letter published in the Journal of the American Medical Association that PCI in late presenters may also reduce 4-year mortality.,Transfer-AMI--Design,High-risk patients treated with fibrinolytic therapy were randomized to - immediate transfer for PCl pharmaco- invasive strategy or - standard treatment including rescue PCl for ongoing chest pain and less than 50 resolution of ST-elevation at 60-90 min or hemodynamic instability,Cantor et al. N Eng J Med 2009;36026.,2009 Updated Guidelines,...reasonable to transfer patients who receive fibrinolytic therapy to a PCI-capable facility as soon as possible where either PCI can be pered when needed or as a pharmacoinvasive strategy,“Facilitated PCI and Rescue Pcr no longer used in the guidelines Therapeutic choices for reperfusion in STEMI can be described without these potentially misleading labels,谢谢 ,谢谢,