AMI再灌注治疗院前我们能做什么PPT课件.ppt

AMIAMI再灌注治疗，再灌注治疗，院前我们能做什么院前我们能做什么DOORNEEDLEBALLOON时间就是心肌！时间就是心肌！缩短时间D2B Times Surpass National Campaigns Goal Elizabeth H.Bradley,PhD.Yale School of Public Health.Friday,December 04,2009 The American College of Cardiology(ACC)Door-to-Balloon(D2B)联盟目标：STEMI 病人 D2B 90 minutes 达到 75%.从2005年4月到 2008年3月，614医院参加NCDR登记研究并加入 D2B 联盟3年中 82,610 住院患者D2B时间显著缩短Bradley EH,Nallamothu BK,Herrin J,et al.National efforts to improve door-to-balloon time:Results from the Door-to-Balloon Alliance.Bradley EH,Nallamothu BK,Herrin J,et al.National efforts to improve door-to-balloon time:Results from the Door-to-Balloon Alliance.J Am Coll J Am Coll Cardiol.Cardiol.2009;54:2423 2009;54:242324292429Table 1.Changes in Use of Recommended StrategiesTable 1.Changes in Use of Recommended StrategiesStrategyStrategy2005200520082008IncreaseIncreaseP P Value Value急诊通知导管急诊通知导管室室52.1%52.1%59.7%59.7%7.6%7.6%0.00090.0009单独呼叫系统单独呼叫系统激活导管室激活导管室30.6%30.6%37.3%37.3%6.7%6.7%0.00120.0012梯队梯队3030分钟内分钟内到达导管室到达导管室81.2%81.2%88.7%88.7%7.5%7.5%0.001 0.001即时资料反馈即时资料反馈61.2%61.2%78.6%78.6%17.4%17.4%0.001 0.001激活院前激活院前 ECGECG32.7%32.7%41.1%41.1%8.4%8.4%0.00010.0001Impressive 3-Year Increase62.8%of US patients had a D2B time within 90 min in 2006By 2008,the percentage had increased to 76.4%,slightly better than the initial goal of 75%set at the start of the campaigncontinued to improve beyond the end of the study period(March 31,2008).81.7%of eligible patients had D2B times 90 minutes from June 30,2009The average D2B time from an average of 121 minutes at the end of 2005,to an average of 80 minutes as of June 30,2009Still Room for ImprovementDirect transportation to catheterization laboratory by emergency teams reduces door-to-balloon time Extend accomplishment out into the community so that patients presenting to smaller hospitals and can have faster times from first contact with the health care system until reperfusion我们还有巨大差距！策略上的争论易化 PCI易化 PCI 是指发病 12 h 内拟行 PCI 的患者于 PCI 前使用血栓溶解药物，以期缩短开通IRA 时间，使药物治疗和 PCI 更有机结合以 ASSENT 4 为代表的临床研究结果表明，易化PCI 结果劣于直接 PCI。目前已完全否定了应用全量溶栓剂后立即行易化 PCI 的策略然对出血风险很低的轻、高危的 STEMI 患者 90 min不能立即 PCI 时可考虑应用经皮冠状动脉介入治疗指南(2009)-中华医学会心血管病学分会荟萃分析：Keeley等对比较直接 PCI和易化PCI疗效的 17项随机对照临床试验进行了，所纳入STEM I患者数分别为 2 267例和 2 237例最终冠脉血流达到 TIMI 3级者的比例相似(89%vs 88%)：易化PCI组冠脉血流在术后立即达到 TIMI 3级者多于直接PCI组(37%vs 15%)易化 PCI组死亡率较高(5%vs 3%)：非致死性M I率较高(3%vs 2%)，靶血管的紧急血运重建率较高(4%vs 1%)，大出血率也较高(7%vs 5%)易化 PCI组不良反应发生率的增高主要原因：溶栓药易化 PC I亚组出血性脑卒中和总的脑卒中发生率均显著增高(分别为 0.7%vs 0.1%和 1.1%vs 0.3%)。产生机理可能是早期激活血小板的副作用，无有效的抗血小板作用动脉粥样硬化斑块出血n n可能溶栓到PCI时间短n n缺乏良好的抗血小板治疗TRANSFER-AMI TrialBackgroundPatients with STEMI in the hospitals that do not have the capability of PCI often cannot undergo timely primary PCI and therefore receive fibrinolysisThe role and optimal timing of routine PCI after fibrinolysis have not been established.MethodsRandomized;nonblinded trial;52 sites in three provinces in Canada1059 high-risk patients with STEMI and who were receiving fibrinolytic therapy at centers that did not have the capability of performing PCI All patients received aspirin,tenecteplase,and heparin or enoxaparin;concomitant clopidogrel was recommendedThe primary end point was the composite of death,reinfarction,recurrent ischemia,new or worsening congestive heart failure,or cardiogenic shock within 30 daysResults88.7%of the patients assigned to standard treatment a median of 32.5 hours after randomization and in 98.5%of the patients assigned to routine early PCI a median of 2.8 hours after randomization At 30 days,the primary end point occurred in 11.0%of the patients who were assigned to routine early PCI and in 17.2%of the patients assigned to standard treatment (P=0.004)There were no significant differences between the groups in the incidence of major bleedingConclusionsAmong high-risk patients who had a myocardial infarction with ST-segment elevation and who were treated with fibrinolysis,transfer for PCI within 6 hours after fibrinolysis was associated with significantly fewer ischemic complications than was standard treatment.院前用药的变化院前用药的变化是否需要增加氯吡格雷的负荷量氯吡格雷600mg可以更迅速地抑制血小板聚集抑制血小板聚集抑制血小板聚集(%)(%)103103名非名非STST段抬高的段抬高的ACSACS患者随机分配接受患者随机分配接受300300、600600或或900 mg 900 mg 氯氯吡格雷吡格雷0 0Montalescot et al.JACC 2006;48:931-80 0505010102020303040401 12 23 34 45 56 6时间时间(小时小时)5 mol/L ADP*p0.05 与300 mg相比900 mg900 mg600 mg600 mg300 mg300 mg600 mg600 mg300 mg300 mg*900 mg900 mg*600mg LD 2600mg LD 2小时的抑制水平与小时的抑制水平与300mg LD 6300mg LD 6小时相当小时相当THANK YOUSUCCESS2024/2/29 周四29可编辑高负荷剂量未显著增加出血300 mg 300 mg n=35n=35600 mg600 mgn=34n=34900 mg900 mgn=34n=34 住院期间出血例数住院期间出血例数住院期间出血例数住院期间出血例数*严重严重严重严重 中等中等中等中等 微量微量微量微量 总计总计总计总计0 01 1101011110 00 0101010100 01 113131414*按 GUSTO 分级定义ARMYDA-2:600mg负荷剂量显著降低主要终点事件p=0.041p=0.0414%4%12%12%0%0%2%2%4%4%6%6%8%8%10%10%12%12%14%14%600mg600mg300mg 300mg 死亡、心梗及靶血管血运重建死亡、心梗及靶血管血运重建%Patti G.et al,Circulation.2005;111:2099-2106600mg的波立维负荷剂量可降低血栓事件的发生率292292名连续接受名连续接受300300或或600 mg 600 mg 氯吡格雷氯吡格雷负荷剂量支架植入的负荷剂量支架植入的NSTE ACSNSTE ACS患者患者Cuisset et al.J Am Coll Cardiol 2006;48:133945无心血管事件生存无心血管事件生存(%)(%)100100808090909595p0.0024300 mg600 mg事件率事件率(%)(%)心血管心血管事件事件0 012.512.52.52.57.57.510.010.0脑卒中脑卒中300 mg300 mg600 mg600 mg3020100 08585时间时间(天天)ACSACS事件事件ST*心血管心血管死亡死亡5.05.0ST*=支架血栓形成GPGPb/ab/a受体拮抗剂在受体拮抗剂在STEMISTEMI的的临床应用临床应用 a b a b A AB BB BB BUA/NSTEMI行PCI的患者，如未服用氯吡格雷，应给予一种血小板糖蛋白IIb/IIIa受体拮抗剂。在实施诊断性CAG前或PCI术前即可给药均可。STEMI行PCI的患者，可尽早应用血小板糖蛋白IIb/IIIa受体拮抗剂。接受择期PCI并置入支架的高危患者或高危病变（如ACS、近期MI、桥血管狭窄、冠状动脉慢性闭塞病变及CAG可见的血栓病变等），可应用血小板糖蛋白IIb/IIIa受体拮抗剂，但应充分权衡出血与获益风险。3420092009中国经皮冠状动脉介入治疗指南中国经皮冠状动脉介入治疗指南 PCIPCI术的药物治疗术的药物治疗UA/NSTEMI行PCI的患者，如已服用氯吡格雷，可同时给予一种血小板糖蛋白IIb/IIIa受体拮抗剂。B BFINESSE TrialResultsA total of 2452 patients were randomly assigned to a treatment group Significantly more patients had early ST-segment resolution with combination-facilitated PCI(43.9%)than with abciximab-facilitated PCI(33.1%)or primary PCI(P=0.01 and P=0.003,respectively).The primary endpoint occurred in 9.8%,10.5%,and 10.7%of(P=0.55)90-day mortality rates were 5.2%,5.5%,and 4.5%,respectively(P=0.49).ConclusionsNeither facilitation of PCI with reteplase plus abciximab nor facilitation with abciximab alone significantly improved the clinical outcomes,as compared with abciximab given at the time of PCI,in patients with ST-segment elevation myocardial infarction.ON-TIME StudiesON-TIME 1:No significant benefit for low bolus dose Tirofiban in AMI 低负荷剂量、不提前使用替罗非班在急性心梗中的应用无显著获益ON-TIME 2 Registry Study:注册研究 Open label Tirofiban,high bolus dose 开放标签，高剂量替罗非班 (N=416,Zwolle+Nieuwegein)ON-TIME 2 Randomized Study:随机研究 Tirofiban high bolus dose double-blind 高负荷剂量替罗非班PrehospitalPrehospital Tirofiban in AMI Tirofiban in AMI 在在急性心梗患者给予急性心梗患者给予院前应用院前应用替罗非班替罗非班Hamm CW et al.Abstract 413-5.Presented April 1,2008,at the American College of Cardiology 57th Annual Meeting in Chicago,IL.在救护车或转诊中心被确诊为急性心梗在救护车或转诊中心被确诊为急性心梗(STEMI)(STEMI)ASA+600 mg Clopidogrel+UFHASA+600 mg Clopidogrel+UFH冠脉造影冠脉造影替罗非班替罗非班安慰剂安慰剂PCI 手术室冠脉造影冠脉造影必要时必要时使用替罗非使用替罗非班班持续使用替罗非班持续使用替罗非班*ON-TIME-2 N=9846/2006-11/2007PCI*Bolus:25 g/kg&0.15 g/kg/min infusionHamm CW et al.Abstract 413-5.Presented April 1,2008,at the American College of Cardiology 57th Annual Meeting in Chicago,IL.转运Event-free Survival 无事件生存率Ongoing Tirofiban In Myocardial Infarction EvaluationP=0.012 Hamm CW et al.Abstract 413-5.Presented April 1,2008,at the American College of Cardiology 57th Annual Meeting in Chicago,IL.66.7%74.0%1年全因死亡率ACC2009RR:0.78(95%CI:0.53-1.14,p=0.157)RR:0.77(95%CI:0.46-1.29,p=0.276)N=984N=414Double BlindOpen Label-36%-37%Safety Endpoint:Bleeding安全性终点：出血事件Ongoing Tirofiban In Myocardial Infarction Evaluation0.1154.0%Hamm CW et al.Abstract 413-5.Presented April 1,2008,at the American College of Cardiology 57th Annual Meeting in Chicago,IL.不同的解释 there was no significant difference in Thrombolysis In Myocardial Infarction(TIMI)grade 3 flow or blush grade and no significant difference in major bleeding or minor bleeding.There was no significant difference in death,recurrent MI,or urgent target-vessel revascularization(TVR)between the tirofiban and placebo groups at 30 daysJACC Vol.54,No.23,2009December 1,2009:220541也许当前最重要的工作是：普及急性心肌梗死的急救知识谢 谢！4856Thank you!THANK YOUSUCCESS2024/2/29 周四57可编辑