医学急性心肌梗死的药物溶栓和介入治疗.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,急性心肌梗死的药物溶栓和介入治疗,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?,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,溶栓与介入的比较,NRMI-2:,死亡率与时间的关系,Door-to-Balloon Time(minutes),校正了的死亡率,P=0.01,P=0.0007,P=0.0003,n=2,230,5,734,6,616,4,461,2,627,5,412,“,拖,”多久可以接受？,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-needle)1h,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-needle)1h,Medical contact-balloon time3h,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,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？,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?,Sx Door Needle Balloon,策略的变化,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,选择依据,1-,起病长短,选择依据,2-,拖延时间,起病早,ASA+Heparin 5000U;pre-hospital tPA vs primary PCI,p=0.29,p=0.61,p=0.13,p=0.12,p=0.06,30d events rate,Bonnefoy,Lancet,2002,；,360:825-29,Key trials for facilitate PCI,如果已经准备,PCI,不要乱给药了，不给更好,FINESSE,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,Meta analysis for F-PCI,prePCI TIMI flow not transfer to good outcome,Meta analysis for F-PCI,Facilitate PCI 2007 guideline,Pharmacoinvasive,概念的提出,转运是安全的,易化，立即，转运的综合,问题：那些无法在,90min,内,PCI,的患者接受半量瑞替普酶,+Ab,后，是该立即转运作,PCI,还是等到发现未再通再进行,转运补救,PCI?,180min,110min,D2B,转运与立即,PCI,的结合,Tenecteplase,溶栓后的病人何时转运？,1059,例高危患者均在,2h,内溶栓,提示：尽早转运做,PCI,有益；,发现了溶栓后早期介入的时间窗可以,提前到,3h,N Engl J Med,2009;360:2705-2718,.,32.5h,2.8h,转运与立即,PCI,的结合,:Sx2hTNK,Bohmer E etal:JACC2010;55:102-110,3d,2.7h,溶栓后,PCI Meta2010,溶栓后,PCI,获益,溶栓后PCI Meta-2011,30d,复合终点,溶栓后PCI Meta-2011,30d,缺血终点,30d,出血终点,30d,死亡率,Latest Guideline,What,s 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,Pt be divided into sent to capability of PCI institute or not,Emphasize PPCI ASAP,2010ESC介入指南,rt-PA,半量溶栓后早期,PCI,治疗急性,STEMI,疗效及安全性评价,Time intervals,lysis,2.0h 1.1h 0.5h 1.5h 6.8h,Median D-to-N time:1.6h Median D-to-B time:8.4h,symptom,onset,hospitalization,consent,signature,balloon infllation,2 with no lesions 50%diameter stenosis and 1 with unsuitable anatomy did not undergo PCI,6 had TIMI 0-1,34 had TIMI 2-3,50 enrolled and accepted half-dose rt-PA,40(81.6%)Achieved clinical criteria of reperfusion,1 was unwilling to undergo angiography,9(18.4%)underwent rescue PCI,4 had TIMI 2-3,5 had TIMI 0-1,Early PCI 75.5%,Final flow of IRA,Final flow of IRA,8 had TIMI 2-3,1 had TIMI 0-1,36 had TIMI 2-3,1 had TIMI 0-1,Procedural characteristics(n=46),Glycoprotein IIb/IIIa use,-no.(%)7(15.2%),Thrombectomy,-no.(%)0(0%),Coronary-artery bypass grafting,-no.(%)0(0%),Distal protection 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,48.532.1,37.925.6,p,0.01,Improved CTFC,Improved MBG,59.737.2,26.719.9,36.923.4,37.821.5,n=12,n=8,n=15,n=11,Optimal time of early PCI(Pilot),137.557.3,110.851.3,116.752.5,157.044.8,n=12,n=8,n=4,n=14,Optimal time of early PCI,(Pilot),Clinical outcomes at 30days after symptom onset(n=47),1.5%8.1%,Borgia1 et al.,1.0%-4.9%,1.2%-5.8%,Take Home Message,溶栓与介入的选择4个条件：发病时间，可能的拖延时间，患者本身风险度，年龄与梗死部位,溶栓后可以PCI，不管是否溶成，及时转运至有条件的中心是必要的,溶栓药物必须是短效与纤溶特异性的,溶栓后PCI的时间3小时以上是必须的，但最好12-24h,Thank you for your attention,