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心肌梗死的药物介入策略

心肌梗死的药物介入策略. 何 奔 MD FACC 上海交通大学仁济医院. 时间就是心肌,就是生命. 时间对再灌注抢救的意义. 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. 90 年代中已证明溶栓治疗的益处 与安慰剂对比. 2003 年,心梗治疗 -- 溶栓与介入对比 ---We know. 是否意味着都做 PCI?

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心肌梗死的药物介入策略

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  1. 心肌梗死的药物介入策略 何 奔 MD FACC 上海交通大学仁济医院

  2. 时间就是心肌,就是生命 时间对再灌注抢救的意义 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

  3. 90年代中已证明溶栓治疗的益处与安慰剂对比

  4. 2003年,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……

  5. 我们还需要溶栓吗?

  6. 溶栓与介入的比较

  7. NRMI-2: 死亡率与时间的关系 “拖” 多久可以接受? P=0.0007 P=0.0003 P=0.01 校正了的死亡率 n = 2,230 6,616 4,461 2,627 5,412 5,734 Door-to-Balloon Time (minutes)

  8. 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-needle)>1h Medical contact-balloon time>1.5h 下列情形下介入更好 熟练的队伍且有外科保障 (Door-balloon)-(Door-needle)<1h Medical contact-balloon time<1.5h 髙危患者 心源性休克或Killip≥3级 溶栓有禁忌或可能增加出血危险 到院太迟,症状发作>3h 诊断STEMI有疑问 2004ACC/AHAAMI指南的选择的推荐 如果3小时之内到院,没有特别情况,两种方案均可

  9. 我们已经知道 • PCI优于溶栓 • 但是PCI慢于溶栓,慢可用疗效弥补,但有个度 • 这个“度”的把握很重要 北京的调查显示,D2B时间达标比例低 如何选择溶栓与介入? 溶栓后还可以介入?

  10. 从策略的变化看再灌注 Sx Door Needle Balloon 2003 Greg Stone(Lancet): PPCI regardness of nearest cath suite 3 floors or 3 hrs away 2007JACC ACCAHA guideline Lytic if anticipated PPCI is >90min give lytic within 30min

  11. 溶栓与PCI选择之考虑 至少有部分病人,溶栓可能优于PCI Who? When? Where? What? Which?

  12. 选择依据1---起病长短

  13. 选择依据2---拖延时间NRMI资料 192509例患者,645个中心 114min是个坎 但:所有病人一样吗? Circulation 2006;114:2019-25

  14. .Am J Cardiol. 2003;92:824-6 P = 0.006 死亡的绝对危险差异 (%) -5 0 5 10 15 0 20 40 60 80 100 PCI相关的时间延误 (入院-球囊扩张时间—入院-溶栓时间) 选择依据2---拖延时间起病早<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. 获益 支持PCI 62 分钟 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,RR=1.08

  15. 选择依据3---患者本身风险DANAMI-2发现转运PCI有益于高危者选择依据3---患者本身风险DANAMI-2发现转运PCI有益于高危者

  16. 选择依据4年龄,梗死部位,就诊时间 Circulation 2006;114:2019-25

  17. 直接PCI的可接受延搁时间取决于患者病情 Z=0.59X-0.033Y-0.0003W-1.3 Z=PPCI对TT的益处;X=本身死亡率;Y=PCI延误 W=患者症状到就诊时间

  18. 越是高危,PPCI越经“拖”

  19. 直接PCI的可接受延搁时间取决于患者病情 • 50yM diabetic Pt,3h Ant STEMI 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

  20. 溶栓后还可以PCI吗?

  21. 溶栓成功后的PCI--- 不行到可行的过程

  22. Immediate PCI

  23. Immediate PCI---no good Be abandoned for many years

  24. Immediate PCI?80-90’s 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 & Thienopydine not used Stent not available

  25. ACC/AHA2004 AMI Guideline described early angiogram after successful lytic • Routine ,Immediately after lytic Tx ClassIII • Following successful lytic Tx in Asx Pts without ischemia Class IIb

  26. ACC/AHA2005 PCIGuideline described early angiogram after successful lytic Little bit improved?

  27. 06 ESC AMI guideline :OK

  28. Key trials for immediate PCI OK

  29. CAPITAL further support routine PCI after lysis

  30. 07 further meta-analysis:new evidence of PCI reasonable after lysis

  31. 溶栓后立即或缺血驱动PCI荟萃 Wijeysundera H: Am Heart J 2008;156:564-572

  32. 为什么又行了? • 介入的发展:支架、IIb/IIIa • 溶栓药的发展:短效溶栓药 • 介入的时机选对了

  33. 溶栓失败后的PCI--- 不得不行到可行的过程

  34. Rescue PCI—early

  35. Rescue PCI(GUSTO-1)

  36. GUSTO-1---不补救更好

  37. Key trial for rescue PCI

  38. Meta analysis of Rescue PCI2007

  39. 易化PCI---与溶栓后PCI有区别 区别在哪里?

  40. PACT

  41. PACT

  42. CAPTIM 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 PCI p=0.29 p=0.61 p=0.13 p=0.06 p=0.12 30d events rate Bonnefoy, Lancet 2002 ;360:825-29

  43. Key trials for facilitate PCI 如果已经准备PCI,不要乱给药了,不给更好

  44. PCI前常规abciximab或PCI时嘱情abciximab的比较 不管是否有半量瑞替普酶溶栓 结果一样且院前应用Ab出血增多 Finesse+OnTime2:PCI前Ab无益处 FINESSE

  45. Meta analysis for F-PCIprePCI TIMI flow not transfer to good outcome

  46. Meta analysis for F-PCI

  47. Facilitate PCI 2007 guideline

  48. Pharmacoinvasive概念的提出

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