急诊PCI治疗要点ppt课件

急诊急诊PCIPCI治疗要点治疗要点首首 都都 医医 科科 大大 学学 附附 属属北北 京京 朝朝 阳阳 医医 院院 心心 脏脏 中中 心心王乐丰王乐丰急诊PCI治疗要点急诊PCI治疗要点王乐丰急诊PCI治疗要点1急性心肌梗塞治疗的目标:缩小梗塞面积保护心功能防治并发症降低死亡率急诊PCI治疗要点急性心肌梗塞治疗的目标:缩小梗塞面积急诊PCI治疗要点2TimeDependentTimeDependentWavefrontofNecrosisWavefrontofNecrosis 无论何种血运重建无论何种血运重建方式，都应强调：方式，都应强调：时间就是心肌，时间就是心肌，时间就是生命时间就是生命急诊PCI治疗要点Time Dependent 无论何种血运重建方式，都应强调3症状识别症状识别症状识别症状识别呼叫急救系统呼叫急救系统呼叫急救系统呼叫急救系统急诊科急诊科急诊科急诊科心导管室心导管室心导管室心导管室院前处理院前处理院前处理院前处理再灌注治疗时间延迟再灌注治疗时间延迟再灌注治疗时间延迟再灌注治疗时间延迟心肌细胞丢失增加心肌细胞丢失增加延迟治疗就是否定治疗延迟治疗就是否定治疗急诊PCI治疗要点症状识别呼叫急救系统急诊科心导管室院前处理再灌注治疗时间延迟4时间就是心肌时间就是心肌0h 1h 2h 3h 4h 5h 6h0h 1h 2h 3h 4h 5h 6h心心肌肌坏坏死死程程度度 血管闭塞时间血管闭塞时间急诊PCI治疗要点时间就是心肌0h 1h 5时间对再灌注抢救的意义0 0 0.5 0.5 hrshrs 预防梗死预防梗死0.5 0.5 2 2 hrs hrs 大量挽救心肌大量挽救心肌+IRAIRA开通的益处开通的益处2 2 6 6 hrshrs 心肌挽救降低心肌挽救降低,IRAIRA开通的益处开通的益处 6 6 hrshrs 基本不挽救心肌基本不挽救心肌,但有但有IRAIRA开通的益处开通的益处急诊PCI治疗要点时间对再灌注抢救的意义0 0.5 hrs 预防梗死急诊6时间就是生命时间就是生命 对急性冠脉综合征（对急性冠脉综合征（ACSACS），降低死亡率和改），降低死亡率和改善预后的关键是及时、正确的诊断与治疗。善预后的关键是及时、正确的诊断与治疗。AMIAMI发发生生后后，从从起起病病到到获获得得积积极极干干预预的的时时间间间间隔隔与与心心肌肌坏坏死死的的面面积积、并并发发症症和和存存活活率率直直接接相相关关：在在起起病病后后7070分分钟钟内内接接受受治治疗疗患患者者的的死死亡亡率率是是1.2%1.2%，而在，而在6 6小时内接受治疗患者的死亡率为小时内接受治疗患者的死亡率为6%6%急诊PCI治疗要点时间就是生命 对急性冠脉综合征（ACS），降7Door to B 时间和一年死亡率的关系时间和一年死亡率的关系 2小时就诊：小时就诊：DtoB时间时间1.5h1.9%DtoB时间时间1.5h3.9%2小时就诊小时就诊:DtoB时间时间1.5h5.1%DtoB时间时间1.5h4.8%BrodieJACC2003急诊PCI治疗要点Door to B 时间和一年死亡率的关系2小时就诊：D 8NRMI2:NRMI2:随着随着D-BD-B时间的延长死亡率增加时间的延长死亡率增加急诊PCI治疗要点NRMI 2:随着D-B时间的延长死亡率增加急诊PCI治疗要9急诊PCI治疗要点急诊PCI治疗要点10北京朝阳医院单中心急诊北京朝阳医院单中心急诊北京朝阳医院单中心急诊北京朝阳医院单中心急诊PCIPCIPCIPCI结果分析结果分析结果分析结果分析时间段（分）时间段（分）平均平均onset-dooronset-dooronset-dooronset-door183150183150183150183150door-labdoor-labdoor-labdoor-lab7459745974597459door-consultdoor-consultdoor-consultdoor-consult3.52.13.52.13.52.13.52.1consult-consentconsult-consentconsult-consentconsult-consent3744374437443744consent-labconsent-labconsent-labconsent-lab3111311131113111onset-balloononset-balloononset-balloononset-balloon278159278159278159278159door-balloondoor-balloondoor-balloondoor-balloon9858985898589858lab-balloonlab-balloonlab-balloonlab-balloon2510251025102510onset-labonset-labonset-labonset-lab257164257164257164257164急诊PCI治疗要点北京朝阳医院单中心急诊PCI结果分析时间段（分）平均onse11北京朝阳医院单中心急诊北京朝阳医院单中心急诊PCIPCI结果分析结果分析 对上表数据需要说明：对上表数据需要说明：参与绿色通道的医护人员基本能保证在参与绿色通道的医护人员基本能保证在3030分钟内全部到位分钟内全部到位 时间耽误环节时间耽误环节 在患者家中：胸痛不及时求助医生，平均花费时间在在患者家中：胸痛不及时求助医生，平均花费时间在3 3小时左右小时左右 在急诊科：患者及家属商量及做出决定耗费很多时间，平均在在急诊科：患者及家属商量及做出决定耗费很多时间，平均在6060分钟左右分钟左右急诊PCI治疗要点北京朝阳医院单中心急诊PCI结果分析对上表数据需要说明：急诊12冠脉堵塞再灌注远端栓塞炎症细胞聚集炎症细胞聚集内皮损伤内皮损伤组织水肿组织水肿血小板血小板/纤维素聚集纤维素聚集氧自由基氧自由基微血管收缩微血管收缩血栓、粥样斑块远端微循环栓塞血栓、粥样斑块远端微循环栓塞 No-reflow重视无复流现象的防治重视无复流现象的防治急诊PCI治疗要点冠脉堵塞再灌注远端栓塞炎症细胞聚集内皮损伤组织水肿血小板/纤13无复流的相关临床因素无复流的相关临床因素 IwakuraIwakura对对199199例前壁例前壁AMIAMI患者行直接患者行直接PCIPCI治疗及心治疗及心肌声学造影检查。肌声学造影检查。LogisticLogistic多因素分析提示，心肌多因素分析提示，心肌受损程度（受损程度（Q Q波计数），室壁运动积分，干预前波计数），室壁运动积分，干预前梗塞相关血管血流，以及缺乏梗塞前心绞痛是无梗塞相关血管血流，以及缺乏梗塞前心绞痛是无再流现象的独立预测因素再流现象的独立预测因素 ToshiyukiToshiyuki等的研究则表明缺乏梗塞前心绞痛是发等的研究则表明缺乏梗塞前心绞痛是发生无再流现象唯一的强有力预测因素生无再流现象唯一的强有力预测因素 朝阳医院一组研究表明：症状开始到再灌注的时朝阳医院一组研究表明：症状开始到再灌注的时间、梗塞前心绞痛、间、梗塞前心绞痛、KillipKillip心功能分级、心功能分级、Q Q波计数波计数是无复流的预测因素是无复流的预测因素 急诊PCI治疗要点无复流的相关临床因素Iwakura对199例前壁AMI患者行14预预 后后 与冠脉前向血流恢复正常的病人相比，无复流病与冠脉前向血流恢复正常的病人相比，无复流病人在急性心肌梗塞早期易出现心力衰竭，左室进人在急性心肌梗塞早期易出现心力衰竭，左室进行性扩张和重构，持续无复流的病人有较高的病行性扩张和重构，持续无复流的病人有较高的病死率和再梗塞率住院期间，死率和再梗塞率住院期间，无复流组的无复流组的CKCKCKCK峰值较高，恶性心律失常发生率较峰值较高，恶性心律失常发生率较高，心脏破裂较多，泵衰竭较多，重复高，心脏破裂较多，泵衰竭较多，重复PTCAPTCAPTCAPTCA患者患者较多，较多，LVEFLVEFLVEFLVEF值较低，心源性死亡较多值较低，心源性死亡较多 发生无复流现象的患者近远期预后差，再次住院发生无复流现象的患者近远期预后差，再次住院率和各种事件率（心肌梗死、心功能不全、并发率和各种事件率（心肌梗死、心功能不全、并发症及死亡率等）均较高。症及死亡率等）均较高。急诊PCI治疗要点预 后与冠脉前向血流恢复正常的病人相比，无复流病人在急性心肌15OcclusionOcclusionOcclusionOcclusionPenetrationPenetrationPenetrationPenetrationSlowFlowSlowFlowSlowFlowSlowFlowNormalFlowNormalFlowNormalFlowNormalFlowTIMI0TIMI0TIMI0TIMI0TIMI1TIMI1TIMI1TIMI1TIMI2TIMI2TIMI2TIMI2TIMI3TIMI3TIMI3TIMI3%Mortality%Mortality%Mortality%Mortality9.3%9.3%9.3%9.3%6.1%6.1%6.1%6.1%3.7%3.7%3.7%3.7%p0.0001vsTIMI0/1p0.0001vsTIMI0/1p0.0001vsTIMI0/1p0.0001vsTIMI0/1p0.0001vsTIMI2p0.0001vsTIMI2p0.0001vsTIMI2p0.0001vsTIMI2P=0.003vsTIMI0/1P=0.003vsTIMI0/1P=0.003vsTIMI0/1P=0.003vsTIMI0/1Team2Team2Team2Team2Team2Team2Team2Team2Team2Team2Team2Team2GermanGermanGermanGermanGermanGermanGermanGermanGermanGermanGermanGermanGUSTO1GUSTO1GUSTO1GUSTO1GUSTO1GUSTO1GUSTO1GUSTO1GUSTO1GUSTO1GUSTO1GUSTO1TAMI1-7TAMI1-7TAMI1-7TAMI1-7TAMI1-7TAMI1-7TAMI1-7TAMI1-7TAMI1-7TAMI1-7TAMI1-7TAMI1-7TIMI1,4TIMI1,4TIMI1,4TIMI1,45,10B5,10B5,10B5,10BTIMI1,4TIMI1,4TIMI1,4TIMI1,45,10B5,10B5,10B5,10BTIMI1,4TIMI1,4TIMI1,4TIMI1,45,10B5,10B5,10B5,10BCM Gibson 1998 in Acute Coronary SyndromesCM Gibson 1998 in Acute Coronary SyndromesSampleSizeofPooledAnalysis:SampleSizeofPooledAnalysis:SampleSizeofPooledAnalysis:SampleSizeofPooledAnalysis:5,4985,4985,4985,498101010101616161633333333343434344444444427272727888444131313131919191999915151515181818182929292934343434Restorationof“Normal”EpicardialFlowYieldsBetterOutcomesRestorationof“Normal”EpicardialFlowYieldsBetterOutcomesRestorationof“Normal”EpicardialFlowYieldsBetterOutcomesRestorationof“Normal”EpicardialFlowYieldsBetterOutcomesUnfortunatelyrateofUnfortunatelyrateofUnfortunatelyrateofUnfortunatelyrateofagreementonly71%agreementonly71%agreementonly71%agreementonly71%急诊PCI治疗要点OcclusionPenetrationSlow FlowN16急诊PCI治疗要点急诊PCI治疗要点17FZ 2008-10心肌心肌blush分级和分级和30天死亡，天死亡，或死亡或死亡/心梗发生率的关系心梗发生率的关系Myocardial blush gradeMyocardial blush gradeP=0.001P=0.001TAPASTAPAS研究研究急诊PCI治疗要点FZ 2008-10心肌blush分级和30天死亡，或死亡18FZ 2008-12心肌心肌blush分级和分级和1年死亡，年死亡，或死亡或死亡/心梗发生率的关系心梗发生率的关系Myocardial blush gradeMyocardial blush gradeP=0.001P=0.001TAPASTAPAS研究研究急诊PCI治疗要点FZ 2008-12心肌blush分级和1年死亡，或死亡/19EMERALDEMERALD研究：远端保护装置作用被否定研究：远端保护装置作用被否定急诊PCI治疗要点EMERALD研究：远端保护装置作用被否定急诊PCI治疗要点20急诊PCI治疗要点急诊PCI治疗要点21急诊PCI治疗要点急诊PCI治疗要点22急诊PCI治疗要点急诊PCI治疗要点231071 STEMI patients randomized1071 STEMI patients randomized535 were assigned to535 were assigned tothrombus aspirationthrombus aspiration3333 did not undergo PCIdid not undergo PCI502 underwent primary PCI502 underwent primary PCI295295 underwent TA followed byunderwent TA followed bydirect stentingdirect stenting153 underwent TA with additional153 underwent TA with additionalballoon dilationballoon dilation 54 54 had crossover to conventionalhad crossover to conventionalPCIPCI536 were assigned to536 were assigned toconventional PCIconventional PCI33 did not undergo PCI33 did not undergo PCI503 underwent primary PCI503 underwent primary PCI485485 underwent balloon dilationunderwent balloon dilationfollowed by stentingfollowed by stenting 12 12 underwent conventional PCIunderwent conventional PCIwith additional TAwith additional TA 6 6 had crossover to TAhad crossover to TA530 complete follow-up at 1 year530 complete follow-up at 1 year530 complete follow-up at 1 year530 complete follow-up at 1 yearTAPASTAPAS研究：研究：血栓抽吸导管作用血栓抽吸导管作用得到肯定得到肯定急诊PCI治疗要点1071 STEMI patients randomized24Svilaas T et al.NEJM 2008;358:557-FZ 2008-8Primary endpoint:Myocardial blush gradeP 0.001 P 0.001 Patients(%)Patients(%)Thrombus aspirationThrombus aspirationConventional PCIConventional PCI急诊PCI治疗要点Svilaas T et al.NEJM 2008;35825Svilaas T et al.NEJM 2008;358-557-FZ 2008-9ST-segment elevation resolutionPatients(%)Patients(%)Thrombus aspirationThrombus aspirationConventional PCIConventional PCIP 0.001P 0.001急诊PCI治疗要点Svilaas T et al.NEJM 2008;35826一年心源性死亡下降一年心源性死亡下降46%46%急诊PCI治疗要点一年心源性死亡下降46%急诊PCI治疗要点27对比血栓抽吸导管和常规对比血栓抽吸导管和常规对比血栓抽吸导管和常规对比血栓抽吸导管和常规PCIPCIPCIPCI的荟萃分析的荟萃分析的荟萃分析的荟萃分析心肌灌注分级（心肌灌注分级（心肌灌注分级（心肌灌注分级（MBGMBGMBGMBG）3 3 3 3级比率分别为级比率分别为级比率分别为级比率分别为52.152.152.152.1和和和和 31.7%)31.7%)31.7%)31.7%)急诊PCI治疗要点对比血栓抽吸导管和常规PCI的荟萃分析心肌灌注分级（MBG28明显降低了明显降低了3030天死亡率天死亡率(分别为分别为1.7vs.3.1%1.7vs.3.1%）急诊PCI治疗要点明显降低了30天死亡率(分别为1.7 vs.3.1%）急诊293030NEW NEW RecommendationRecommendationAspiration thrombectomy isreasonable for patientsundergoing primary PCII I I I I IIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIII I I I I IIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIII I I I I IIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIIIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIIB急诊PCI治疗要点30NEW RecommendationAspiration30PCIinSTEMIPCIinSTEMIPCIinSTEMIPCIinSTEMI%p=0.023p=0.023p=0.023p=0.023p0.05p0.05p0.05p0.05p=0.005p=0.005p=0.005p=0.005PTCAN=483PTCAN=483PTCAN=483PTCAN=483StentN=401StentN=401StentN=401StentN=401StentN=301StentN=301StentN=301StentN=301PTCAorStentN=2082PTCAorStentN=2082PTCAorStentN=2082PTCAorStentN=2082StentN=400StentN=400StentN=400StentN=400p=0.038p=0.038p=0.038p=0.038p=0.01p=0.01p=0.01p=0.0130303030天终点事件天终点事件天终点事件天终点事件 (死亡死亡死亡死亡,再梗再梗再梗再梗,急诊再血管化急诊再血管化急诊再血管化急诊再血管化)IIb/IIIaIIb/IIIa受体拮抗剂受体拮抗剂急诊PCI治疗要点PCI in STEMI%p=0.023p0.05p=0.31DEBATERDEBATER研究研究急诊PCI治疗要点DEBATER研究急诊PCI治疗要点32阿昔单抗组及对照组阿昔单抗组及对照组3030天靶血管重建失败（天靶血管重建失败（TVFTVF）发生率）发生率 急诊PCI治疗要点阿昔单抗组及对照组30天靶血管重建失败（TVF）发生率 急诊33阿昔单抗组及对照组阿昔单抗组及对照组1 1年年MACEMACE发生率发生率 急诊PCI治疗要点阿昔单抗组及对照组1年MACE发生率 急诊PCI治疗要点34AMIAMIAMIAMI患者于急救车或基层医院诊断并给予患者于急救车或基层医院诊断并给予患者于急救车或基层医院诊断并给予患者于急救车或基层医院诊断并给予ASA+600mgASA+600mgASA+600mgASA+600mg氯吡格雷氯吡格雷氯吡格雷氯吡格雷 +静脉肝素静脉肝素静脉肝素静脉肝素AngiogramAngiogramAngiogramAngiogram替罗非班替罗非班替罗非班替罗非班*安慰剂安慰剂安慰剂安慰剂转运转运PCIcenterPCIcenterAngiogramAngiogramAngiogramAngiogramTirofibanTirofibanTirofibanTirofibanprovisionalprovisionalprovisionalprovisionalTirofibanTirofibanTirofibanTirofibancontdcontdcontdcontdON-TIME-2ON-TIME-2N=984N=9846/2006-11/20076/2006-11/2007PCIPCI*Bolus:25g/kg&0.15g/kg/mininfusionBolus:25g/kg&0.15g/kg/mininfusionBolus:25g/kg&0.15g/kg/mininfusionBolus:25g/kg&0.15g/kg/mininfusion急诊PCI治疗要点AMI患者于急救车或基层医院诊断并给予Angiogram替罗35PCIPCI术前后术前后STST段回落情况段回落情况Ongoing Tirofiban In Myocardial Infarction EvaluationOngoing Tirofiban In Myocardial Infarction Evaluation14.39.114.39.114.39.114.39.112.19.412.19.412.19.412.19.45.98.15.98.15.98.15.98.14.86.34.86.34.86.34.86.314.59.114.59.114.59.114.59.110.99.210.99.210.99.210.99.24.45.34.45.34.45.34.45.33.34.33.34.33.34.33.34.30.0020.0020.0220.0220.0280.028p=0.84p=0.84mmmm随机时随机时造影前造影前术后术后6060分钟分钟术后术后9090分钟分钟急诊PCI治疗要点PCI术前后ST段回落情况Ongoing Tirofiban363030天无事件生存率天无事件生存率Ongoing Tirofiban In Myocardial Infarction EvaluationOngoing Tirofiban In Myocardial Infarction EvaluationP=0.013P=0.013P=0.013P=0.01374.0%74.0%66.7%66.7%急诊PCI治疗要点30天无事件生存率Ongoing Tirofiban In 371 1年无事件生存率年无事件生存率P=0.007P=0.007open label open label&double-blind,n=1.155 double-blind,n=1.155急诊PCI治疗要点1 年无事件生存率P=0.007open label&383939It is reasonable to start treatment with It is reasonable to start treatment with glycoprotein IIb/IIIa receptor antagonists at the glycoprotein IIb/IIIa receptor antagonists at the time of primary PCI(with or without stenting)in time of primary PCI(with or without stenting)in selected patients with STEMI:selected patients with STEMI:abciximababciximabtirofiban and eptifibatidetirofiban and eptifibatideUse of Glycoprotein IIb/IIIa Receptor Antagonists in STEMII I I I I IIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIII I I I I IIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIII I I I I IIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIIIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIIBI I I I I IIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIII I I I I IIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIII I I I I IIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIIIIaIIaIIaIIaIIaIIaIIbIIbIIbIIbIIbIIbIIIIIIIIIIIIIIIIIIAModified Modified RecommendationRecommendationIIb/IIIaIIb/IIIa受体拮抗剂受体拮抗剂尚未过时尚未过时急诊PCI治疗要点39 It is reasonable to st39大剂量氯吡格雷大剂量氯吡格雷额外收益额外收益急诊PCI治疗要点大剂量氯吡格雷额外收益急诊PCI治疗要点40急诊PCI治疗要点急诊PCI治疗要点41急诊PCI治疗要点急诊PCI治疗要点42急诊PCI治疗要点急诊PCI治疗要点43谢 谢！北京朝阳医院北京朝阳医院北京朝阳医院北京朝阳医院Beijing Chaoyang HospitalBeijing Chaoyang Hospital急诊PCI治疗要点谢 谢！北京朝阳医院急诊PCI治疗要点44