AMI再灌注治療策略

急性心肌梗死的再灌注

治療策略2023最新整理收集do

something急性心肌梗塞治療的進(jìn)展急性心肌梗塞治療的目標(biāo):縮小梗塞面積保護(hù)心功能防治併發(fā)癥降低死亡率心肌梗塞治療的關(guān)鍵：

迅速、完全、持續(xù)開通梗塞相關(guān)血管AMItreatment:ReperfusiontherapyThrombolytictherapyDirectangioplastyRescueangioplastyTransferangioplasty急性心肌梗塞的再灌注治療:一、溶栓治療THROMBOLYTICTHERAPYRationale

-atheroscleroticplaquerupture;-thrombusformation;-totalorsubtotalocclusion;-slowspontaneouslysis;-fibrinolysisISIS-2試驗TheISIS-2collaborativegroup.Lancet

1988;ii:349–60溶栓是最佳選擇急性心肌梗塞治療的進(jìn)展Thrombolytictherapywelldocumentedbenefitfromthrombolytictherapy

?ISIS?GUSTO

?GISSI?SAMI-ECSG

?TAMI?WWICST

?ASSET?APSAC

?AMIS?EMIPFTT試驗?zāi)挲g相關(guān)溶栓與死亡率的關(guān)系FTTCollaborativeGroup.Lancet.1994;343:311-322.THROMBOLYTICTHERAPY1/3reductioninoverallmortality40-50fewerdeath/1000patientstreatedLessremodeling/dilatationofLVbetterLVfunctionLessarrhythmiaImprovedshort-andlong-termsurvival

急性心肌梗塞治療的進(jìn)展GreaterBenefitfromearliertreatment

-有效性已被很多的大規(guī)模、多中心的實驗證實（GISSI-1、ISIS-2、ASSET）

-時間=心肌=生命

-沒有某種溶栓劑明顯優(yōu)于其它溶栓劑GUSTO：加速tPA6.3%，鏈激酶7.3%急性心肌梗死治療的溶栓治療AMI的溶栓治療

時間窗擴大：LATE試驗顯示6~12小時內(nèi)溶栓，死亡率下降25%，12~24小時則無效院前使用Coronaryarterypatencyat90minand30-daymortalityinGUSTO-1*p<0.05relativetoTIMIgrade0-1再灌注治療策略：溶栓治療溶栓治療不足之處再通率為60~80%且殘留狹窄再通者中達(dá)TIMI血流3級者約為50~60%再通者中，TIMI血流2級者再梗塞率高臨床缺少可靠再灌注指標(biāo)不是全部AMI患者都適合于溶栓(約25%)1~2%出血并發(fā)癥心肌缺血發(fā)生率高心源性休克效果差溶栓治療的好處有效對設(shè)備和人員培訓(xùn)要求低方便，迅速應(yīng)用廣泛應(yīng)用急性心肌梗塞的再灌注治療:二、直接PCI治療Treatment=ReperfusionTotalOcclusionpLCxPTCA/stent

orPAMI試驗結(jié)果PAMI試驗：395例入選，AMI發(fā)病6小時以內(nèi)

r-tPA（%）PTCA（%）死亡率6.52.6高危者死亡率10.42.6再梗/院內(nèi)死亡12.05.1顱內(nèi)出血0.50PrimaryPTCAvsThrombolysis

PAMITrial:in-hospitalmortalityP=0.01P<0.07>65P=0.03P=0.01GUSTOIIb試驗對比直接PTCA與溶栓治療對AMI的臨床療效，入選1138例發(fā)病后12小時內(nèi)的AMI患者，觀察30天內(nèi)死亡、再次MI和致殘性卒中的聯(lián)合發(fā)生率結(jié)論：在有經(jīng)驗的臨床中心，直接PTCA的近中期療效優(yōu)于t-PA溶栓

死亡再次MI卒中聯(lián)合發(fā)生率

P=0.37P=0.13P=0.11P=0.033NEnglLMed,1997,336:1621-1628PCI是最佳選擇STOPAMI試驗Schomigetal.NEnglJMed2000;343:385-91Kastratietal.Lancet2002;359:920-25CADILLAC:

MACE-6MonthsPTCA,noabciximabPTCA,abciximabStent,noabciximabStent,abciximab0%5%10%15%20%0306090120150180Days

toevent15.2%19.3%10.8%10.9%P=0.93P=0.0001StoneGR,etal.PresentedattheAHA72ndScientificSessions.1999A.II.030PrimaryPTCAvsThrombolyticTherapyForevery1000ptstreated,PTCAcomparedwithlytictherapy:20livessaved43re-MIprevented13ICHpreventedMeta-analysisof23trialssuggeststhatprimaryPTCAispreferredoverlytictherapyKeelyetal.Lancet2003直接PTCA的優(yōu)點

成功率高，90~95%降低腦卒中的發(fā)生率降低反復(fù)心肌缺血減低再次住院和死亡縮短住院時間增加EFCardiogenicshockandPrimaryPTCASHOCKTrial:

ERV組 Med組p病例數(shù) 152 15030天死亡率46.7% 56%0.1160天死亡率50.3% 63.1%0.27<75y 41.4% 56.8%<0.01(RR降低15.4%)>75y 效果更差A(yù)MI的直接PCI治療：

高?；颊攉@益更大四個亞組療效優(yōu)于溶栓組心源性休克前壁心梗心衰老年人>70歲直接PCI與溶栓治療：長期療效直接PTCA對設(shè)備和醫(yī)生的要求：

圖象質(zhì)量極佳的X光設(shè)備操作者技術(shù)優(yōu)良工作人員快速反應(yīng)：門口—氣囊時間最好小于1小時，不能大于2小時對AMI能快速作出診斷最好能備有GPⅡb/Ⅲa受體拮抗劑再灌注治療策略：直接PCI不足之處對設(shè)備和人員培訓(xùn)要求高治療廷遲(平均醫(yī)院-氣囊時間為120分鐘)沒有被廣泛應(yīng)用好處更有效，更高的再灌注率(80%以上達(dá)TIMI3級)顱內(nèi)出血少早期了解冠脈病理解剖和左室功能ReperfusionTherapyinPatientswithSTEMI

inRegistryStudies1999-20030%10%20%30%40%50%60%70%80%SwedenRIKS-HIAItalyBLITZ

USANRMI-4EuroHeartSurveyENACT

GRACEInt.ThrombolysisPrimaryPCI急性心肌梗塞的再灌注治療:三、溶栓失敗后補救性PCI治療補救性PCI2年存活隨訪Gibsonetal.Circulation2002;105:1909-13EllisSG,etal.Circulation.1994;90:2280-2284.TheRescueTrial151ptswithfirstanteriorMItreatedwithfibrinolytictherapySubsequentlyrandomizedtoconservativetherapy(ASA,heparin,vasodilator)vstherapyplusPTCAPTCAvsconservativetherapy92%technicalsuccesswithPTCAExerciseLVfunctionimproved

(43%+15%vs38%+13%,P=0.04)Mortalityreducedby50%inthePTCA-treatedgroup

(5%vs10%;P=0.18)Mortalityandsevereheartfailurereducedby64%

inPTCA-treatedgroup(6%vs17%;P=0.05)A.II.030Res?uePTCAafterfailedfibrinolysisRESCUEItrialPTCANoPTCAP=0.0011260623624480.60.70.80.91.0Time(weeks)Ellis,AmHeartJ2000;139:1046A.II.030%Survival四、首診到基層醫(yī)院的AMI病人，應(yīng)采取何種再灌注策略：溶栓治療？直接PCI？

AMI:轉(zhuǎn)院進(jìn)行直接PCI？存在溶栓禁忌，梗塞面積較大

-YES！溶栓失敗，12小時內(nèi)-YES！心源性休克，36小時內(nèi)-YES！沒有溶栓禁忌，時間窗以內(nèi)

-？ThePRAGUEStudy(N=300)p<0.00123.0%15.0%8.0%TheDANishtrialinAcuteMyocardialInfarction-2(DANAMI-2)

Atotalof1900patientswithST-elevationmyocardialinfarctionaretoberandomized800patientswillbeadmittedtoinvasivehospitals1100patientswillbeadmittedtoreferralhospitals.Halfofthe1100patientsadmittedtoreferralhospitalswillimmediatelybetransferredtoaninvasivecentertobetreatedwithprimaryangioplasty.STEMI隨機溶栓組（100mgtPA）直接PCI組AndersonHR,etal.NEnglJMed.2003;349:733–742DANAMI25,400,000人5個PCI中心24家醫(yī)院占丹麥總?cè)丝诘?2%轉(zhuǎn)運距離最遠(yuǎn)95公里平均31公里AndersonHR,etal.NEnglJMed.2003;349:733–742支持轉(zhuǎn)院行PCIDANAMI2AndersonHR,etal.NEnglJMed.2003;349:733–742支持轉(zhuǎn)院行PCITheDANishtrialinAcuteMyocardialInfarction-2(DANAMI-2)p=0.002P=0.05DANAMI2AndersonHR,etal.NEnglJMed.2003;349:733–742支持轉(zhuǎn)院行PCIThePRAGUE-2Study(N=850)胸痛<12h溶栓組n=421轉(zhuǎn)院PCIn=429主要終點：30天死亡率次要終點：30天死亡/再梗/中風(fēng)距離<120公里mortality結(jié)論：AMI急性期轉(zhuǎn)院PCI是安全的、可行的轉(zhuǎn)院PCI可明顯減少胸痛>3小時病人死亡率CAPTIM-1YearResults

SxtoTreatmentAnalysisTouboulP.Presentedat:The18thInternationalSymposiumonThrombolysisandInterventionalTherapyinAcuteMyocardialInfarction-GeorgeWashingtonUniversitySymposium;November16,2002;Chicago,Ill.Sx

2h0.0DeathSx

2h5.07.52.5Pre-hospitalLysisPrimaryPCI2.25.7DeathP=0.0570.07.510.02.5Pre-hospitalLysisPrimaryPCI5.93.7DeathP=0.475.0Percent-6項對比研究

-3750例病人

-轉(zhuǎn)院時間<3小時

溶栓Vs轉(zhuǎn)院PCI:薈萃分析

結(jié)論：轉(zhuǎn)院PCI優(yōu)于當(dāng)?shù)厝芩≒=0.08P=.015P<.001P<.001轉(zhuǎn)院的可行性和安全性

PRAGUE1

+

2試驗共轉(zhuǎn)運626例病人轉(zhuǎn)運距離:5–120km共死亡2例(0.3%)轉(zhuǎn)運期間共5例發(fā)生VFs(0.8%)因此，轉(zhuǎn)院是安全、可行的支持轉(zhuǎn)院行PCI再灌注策略—危險和獲益靜脈溶栓直接PCI時間時間討論轉(zhuǎn)院途中的安全性

-死亡率低，<1%

-并發(fā)癥低溶栓/PCI時間與死亡率的關(guān)系

-溶栓治療應(yīng)用時間與死亡率正相關(guān)

-轉(zhuǎn)院PCI關(guān)系不明顯PCI療效更確切，更高的有效再灌注率，抵消延遲治療的不足評估STEMI再灌注方式

-----FromACC/AHA2004STEMIGuidelinesJACCAugust4,2004;44:671-719評估STEMI再灌注方式

------ACC/AHA2004STEMIGuidelines步驟1：評估時間和危險性癥狀發(fā)作后的時間STEMI危險分層溶栓風(fēng)險轉(zhuǎn)運至熟練PCI導(dǎo)管室所需時間JACCAugust4,2004;44:671-719評估STEMI再灌注方式

------ACC/AHA2004STEMIGuidelines步驟2：決定應(yīng)首選溶栓還是PCI

如果時間少于3小時，且介入治療無耽擱，溶栓和PCI首選哪種都可以。JACCAugust4,2004;44:671-719評估STEMI再灌注方式

------ACC/AHA2004STEMIGuidelines溶栓首選，如果：早期就診（癥狀發(fā)作在3小時內(nèi)，行介入治療有耽擱）不適合選擇介入治療導(dǎo)管室被占用或不能用血管入路困難缺乏熟練PCI操作相關(guān)工作人員介入治療時間耽擱運輸時間延長Door-to-balloon比door-to-needlle時間超過1小時Contract-to-balloon或door-to-balloon時間超過90分鐘JACCAugust4,2004;44:671-719評估STEMI再灌注方式

------ACC/AHA2004STEMIGuidelinesPCI首選，如果：熟練PCI操作相關(guān)人員及有心外科支持Contract-to-balloon或door-to-balloon時間<90分鐘Door-to-balloon比door-to-needlle時間<1小時STEMI高危心源性休克Killip分級在3級或以上溶栓禁忌癥包括增加出血危險或顱內(nèi)出血較晚就診：癥狀發(fā)作后>3小時不能確定STEMI診斷JACCAugust4,2004;44:671-7192004年ESC的PCI指南中的AMI再灌注策略小結(jié)1迅速、完全、持久開通IRA是心梗治療的關(guān)鍵直接PCI臨床療效優(yōu)于溶栓治療但目前在我國溶栓治療仍是主導(dǎo)治療方法對首診在基層醫(yī)院的AMI病人，起病12小時以內(nèi)，轉(zhuǎn)院時間小于2小時，轉(zhuǎn)院PCI是安全、有效的，尤其是起病>3小時的病人小結(jié)2將AMI病人集中到大醫(yī)院治療是未來國際上的重大趨勢應(yīng)重新思考我國城市/城市鄰近地區(qū)的AMI再灌注治療模式應(yīng)進(jìn)一步PCI前是否需聯(lián)合用藥，Lysis?GPII/bIIIa?其他?RoutineMeasuresClassIOxygen1.Supplementaloxygenshouldbeadministeredtopatientswitharterialoxygendesaturation(SaO2lessthan90%).(LevelofEvidence:B)Analgesia1.Morphinesulfate(2to4mgIVwithincrementsof2-8mgIVrepeatedat5-15minuteintervals)istheanalgesicofchoiceformanagementofpainassociatedwithSTEMI.(LevelofEvidence:C)

Antmanetal.JACC

2004;44:679.RoutineMeasuresNitroglycerinClassI.Patientswithongoingischemicdiscomfortshouldreceivesublingualnitroglycerin(0.4mg)every5minutesforatotalof3doses,afterwhichanassessmentshouldbemadeabouttheneedforintravenousnitroglycerin.(LevelofEvidence:C)2.Intravenousnitroglycerinisindicatedforreliefofongoingischemicdiscomfort,controlofhypertension,ormanagementofpulmonarycongestion.(LevelofEvidence:C)ClassIII1.Nitratesshouldnotbeadministeredtopatientswithsystolicbloodpressurelessthan90mmHgorgreaterthanorequalto30mmHgbelowbaseline,severebradycardia(lessthan50bpm),tachycardia(morethan100bpm),orsuspectedRVinfarction.

(LevelofEvidence:C)2.Nitratesshouldnotbeadministeredtopatientswhohavereceivedaphosphodiesteraseinhibitorforerectiledysfunctionwithinthelast24hours(48hoursfortadalafil).(LevelofEvidence:B)Antmanetal.JACC

2004;44:679.RoutineMeasuresAspirinClassI1.AspirinshouldbechewedbypatientswhohavenottakenaspirinbeforepresentationwithSTEMI.Theinitialdoseshouldbe162mg(LevelofEvidence:A)to325mg(LevelofEvidence:C).Althoughsometrialsofhaveusedenteric-coatedaspirinforinitialdosing,morerapidbuccalabsorptionoccurswithnon-enteric-coatedaspirinformulations.

Antmanetal.JACC

2004;44:680.RoutineMeasures?-blockingagents

ClassI1.Oralbeta-blockertherapyshouldbeadministeredpromptlytothosepatientswithoutacontraindication,irrespectiveofconcomitantfibrinolytictherapyorperformanceofprimaryPCI.(LevelofEvidence:A)ClassIIa1.ItisreasonabletoadministerIVbeta-blockerspromptlytoSTEMIpatientswithoutcontraindications,especiallyifatachyarrhythmiaorhypertensionispresent.(LevelofEvidence:B)

Antmanetal.JACC

2004;44:680.InhibitionofRenin-Angiotensin-AldosteroneSystem

ClassI1.Anangiotensinconvertingenzyme(ACE)inhibitorshouldbeadministeredorallywithinthefirst24hoursofSTEMItopatientswithanteriorinfarction,pulmonarycongestion,or

LVEFlessthan0.40,intheabsenceofhypotension(systolicbloodpressurelessthan100mmHgorlessthan30mmHgbelowbaseline)orknowncontraindicationstothatClassofmedications.(LevelofEvidence:A)2.Anangiotensinreceptorblocker(ARB)shouldbeadministeredtoSTEMIpatientswhoareintolerantofACEinhibitorsandwhohaveeitherclinicalorradiologicalsignsofheartfailureorLVEFlessthan0.40.Valsartanandcandesartanhaveestablishedefficacyforthisrecommendation.(LevelofEvidence:C)

ClassIIa1.AnACEinhibitoradministeredorallywithinthefirst24hoursofSTEMIcanbeusefulinpatientswithoutanteriorinfarction,pulmonarycongestion,orLVEFlessthan0.40intheabsenceofhypotension(systolicbloodpressurelessthan100mmHgorlessthan30mmHgbelowbaseline)orknowncontraindicationstothatclassofmedications.Theexpectedtreatmentbenefitinsuchpatientsisless(5livessavedper1000patientstreated)thanforpatientswithLVdysfunction.(LevelofEvidence:B)Antmanetal.JACC

2004;44:690.NEW:STRICTGLUCOSECONTROLDURINGSTEMIClassI1.AninsulininfusiontonormalizebloodglucoseisrecommendedforpatientswithSTEMIandcomplicatedcourses.(LevelofEvidence:B)ClassIIa1.Duringtheacutephase(first24to48hours)ofthemanagementofSTEMIinpatientswithhyperglycemia,itisreasonabletoadministeraninsulininfusiontonormalizebloodglucose,eveninpatientswithanuncomplicatedcourse.(LevelofEvidence:B)

Antmanetal.JACC

2004;44:690.MagnesiumClassIIaItisreasonablethatdocumentedmagnesiumdeficitsbecorrected,especiallyin