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S.Chiu Wong MD,FACCAssociate Professor of MedicineWeill Medical College of Cornell UniversityDirector,Cardiac Catheterization LaboratoriesThe New York Presbyterian Hospital-Cornell CampusThe ACC Symposium at the Great Wall Meeting,Beijing ChinaOctober 17,2004Thrombolysis or Primary PCI in the Treatment of Acute MI2021/01/211S.Chiu Wong MD,FACCAssociatPatho-anatomy of AMIFibrinolysis for AMIFibrinolysis Vs.Primary PCIAdjunct Pharmacology and StrategiesCurrent Recommendations in Treatment of AMIThrombolysis or PCI in AMI Summary2021/01/212Patho-anatomy of AMIThrombolysPatho-anatomy of AMIFibrinolysis for AMIFibrinolysis Vs.Primary PCIAdjunct Pharmacology and StrategiesCurrent Recommendations in Treatment of AMIThrombolysis or PCI in AMI 2021/01/213Patho-anatomy of AMIThrombolysCirculation,Volume XLV,January 1972.Page 215-230Coronary Arteries in Fatal AcuteMyocardial InfarctionBy WILLIAM C.ROBERTS,M.D.SUMMARY The coronary arteries are diffusely involved by atherosclerotic plaques in fatal acute myocardial infarction(AMI).The degree of luminal narrowing may vary but plaques are present in practically every millimeter of extramural coronary artery.Usually the lumens of at least two of the three major coronary arteries are narrowed 75%by old plaques in patients who die suddenly(75 yrs and treated 12 hrs from sx onset were.The earlier treatment initiation,the greater the benefit and thus re-affirm the concept of “time is muscle.”2021/01/2110Thrombolysis or PCI in AMI ThNot every patient is eligible for thrombolytic treatmentCerebral/vascular bleedPercent AMI pts with TIMI 3 flow following thrombolysis is less than ideal Thrombolysis or PCI in AMI Limitations of Thrombolysis in AMI Patients2021/01/2111Not every patient is eligible Thrombolysis or PCI in AMI Contraindications for fibrinolytics in AMIContraindicationsPrevious hemorrhagic stroke at any time;other strokes or cerebrovascular events within 1 yrKnown intracranial neoplasmActive internal bleeding(does not include menses)Suspected aortic dissectionAdapted from Ryan TJ,et al.ACC/AHA guidelines for the management of patients with AMI.J Am Coll Cardiol 1996;28:132814282021/01/2112Thrombolysis or PCI in AMI CoRelative contraindicationsSevere uncontrolled hypertension on presentation(blood pressure 180/110 mm Hg)or chronic history of severe hypertensionHistory of prior cerebrovascular accident or known intracerebral pathology not covered in contraindicationsCurrent use of anticoagulants in therapeutic doses(international normalized ratio 23);known bleeding diathesisRecent trauma(within 24 wk),including head trauma or traumatic or prolonged(10 min)cardiopulmonary resuscitation or major surgery Noncompressible vascular puncturesRecent(within 24 wk)internal bleedingFor streptokinase/anistreplase:prior exposure(especially within 5 d2 yr)or prior allergic reactionPregnancy and Active peptic ulcerAdapted from Ryan TJ,et al.ACC/AHA guidelines for the management of patients with AMI.J Am Coll Cardiol 1996;28:13281428Thrombolysis or PCI in AMI Contraindications for fibrinolytics in AMI2021/01/2113Relative contraindicationsSevePrevious large-scale randomized thrombolytic studies would suggest that only 15-20%of Acute MI(AMI)patients are considered eligible for reperfusion therapy by conventional criteriaMore recent observational studies*with broader inclusion criteria would estimate that approximately 45 to 50%of AMI pts were eligible(ie.12 hrs symptom onset,chest pain with 2mm ST in any 2 contiguous ECG leads or new LBBB)and 32-45%of pts actually received thrombolytic agents.Thrombolysis or PCI in AMI Eligibility for Thrombolysis in AMI PatientsKarlson BW et al Circ 1990;82:1140-6,*French JK et al BMJ 1996;312:1637-41*Reikvm et al Int J Cardiol 1997;61:79-832021/01/2114Previous large-scale randomizeNot every patient is eligible for thrombolytic treatmentCerebral/vascular bleed and re-infarctionPercent AMI pts with TIMI 3 flow following thrombolysis is less than ideal Thrombolysis or PCI in AMI Limitations of Thrombolysis in AMI Patients2021/01/2115Not every patient is eligible ReteplaseN=8260Reteplase+Reopro N=8326OR(95%CI)P value30-day mortality5.9%5.6%0.95(0.84-1.08)0.43Re-MI up to 7 days3.52.30.66(0.72-0.93)75yrs1.12.11.91(0.95-3.84)0.069Sever/Mod.Bleed2.34.62.03(1.7-2.42)0.0001Thrombolysis or PCI in AMI GUSTO V:Primary and Secondary Endpoints16,588 pts within 6hrs of STEMI randomized to standard dose of reteplase(n=8260)or-dose reteplase and full-dose Reopro(n=8328).The GUSTOV Investigators.Lancet 2001;357:1905-142021/01/2116ReteplaseReteplase+Reopro N=8Not every patient is eligible for thrombolytic treatmentCerebral/vascular bleedPercent AMI pts with TIMI 3 flow following thrombolysis is less than ideal Thrombolysis or PCI in AMI Limitations of Thrombolysis in AMI Patients2021/01/2117Not every patient is eligible The 90 Minute Wall:The 90 Minute Wall:60%Rates of TIMI Grade 3 Flow%TIMI 3 Flow%TIMI 3 Flow2021/01/2118The 90 Minute Wall:60%Rates oIncidence and Patho-anatomy of AMIFibrinolysis for AMIFibrinolysis Vs.Primary PCIAdjunct Pharmacology and StrategiesCurrent Recommendations in Treatment of AMIThrombolysis or PCI in AMI 2021/01/2119Incidence and Patho-anatomy ofGrines,C.L.et al.N Engl J Med 1993;328:673-679Thrombolysis or PCI in AMI PAMI:In-Hospital Reinfarction and Death395 Pts were enrolled in 12 sites with AMI within 12 hrs of symptom onset and randomized to immediate PTCA(n=195)vs.tPA(n=200)By 6 months,reMI or death had occurred in 15.8%of pts treated with tPA and 8.5%treated with PTCA(p=0.02).2021/01/2120Grines,C.L.et al.N Engl J Thrombolysis or PCI in AMI Short(4-6wks)-term clinical Outcomes Post 1 PTCA Vs.ThrombolysisKeeley et al,Lancet 2003;361:13-20Summary of 23 trials totaling 7,739 pts(PTCA=3,872 and Thrombolysis=3,867 pts)27%65%54%47%2021/01/2121Thrombolysis or PCI in AMI KeeThrombolysis or PCI in AMI Advantages and Disadvantages of 1 PTCA Vs.ThrombolysisAdvantagesDisadvantagesSuperior vessel patency and TIMI 3 flowLack of generalized availabilityEarly definition of coronary anatomy allows risk stratificationDelay in mobilizing cath labReduced rates of recurrent ischemia,re-MI,death,and strokeSkilled interventional cardiologys requiredImproved survival in high risk patientsNo large single mortality trial data availableReduced intracranial bleedShorter length of hospital stayAllows reperfusion when thrombolytics are contra-indicated2021/01/2122Thrombolysis or PCI in AMI AdIncidence and Patho-anatomy of AMIFibrinolysis for AMIFibrinolysis Vs.Primary PCIAdjunct Pharmacology and StrategiesCurrent Recommendations in Treatment of AMIThrombolysis or PCI in AMI 2021/01/2123Incidence and Patho-anatomy ofThrombolysis or PCI in AMI The ADMIRAL TrialMulti-center 300 pts randomized,double-blind placebo controlled study to demonstrate the superiority of abciximab over placebo in primary PTCA with stenting in acute myocardial infarctionMontalescot G et al NEJM 2001;344:1895-19032021/01/2124Thrombolysis or PCI in AMI ThThrombolysis or PCI in AMI ADMIRAL:Frequency of TIMI III FLOWP=0.01P=0.04P=0.33P=0.04Montalescot G et al NEJM 2001;344:1895-19032021/01/2125Thrombolysis or PCI in AMI ADThrombolysis or PCI in AMI ADMIRAL:Composite Endpoint 6 monthP=0.13Montalescot G et al NEJM 2001;344:1895-1903P=0.32P=0.049P=0.02Reopro improves coronary patency before stenting,and clinical outcome at 30 days and 6 monthsN=149N=1512021/01/2126Thrombolysis or PCI in AMI ADThrombolysis or PCI in AMI CAPTIM:Study DesignPrimary Composite Endpoint-30-day Death,Reinfarction,Disabling StrokeBonnefoy E,et al.Lancet 2002;360:825-9AMI within 6 hours1200 planned840 enrolledPrehospitalThrombolysisn=419PrimaryAngioplastyn=421Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction2021/01/2127Thrombolysis or PCI in AMI CAThrombolysis or PCI in AMI CAPTIM:Study DesignP=0.61P=0.13P=0.12P=0.29Bonnefoy E,et al.Lancet 2002;360:825-9Primary PTCA was not better than pre-hospital thrombolysis with transfer for possible rescue PTCA in pts with 4 mm elevation),Sx 12 hrs5 PCI centers(n=443)and 22 referring hospitals(n=1,129),transfer in 3 hrsLytic therapyFront-loaded tPA 100 mg(n=782)Death/Re-MI/Stroke at 30 DaysThrombolysis or PCI in AMI DANAMI-2:Study DesignPrimary PCIwith transfer(n=567)Primary PCIwithout transfer(n=223)Stopped early by safety and efficacy committeeAnderson HR et al NEJM 2003;349:733-422021/01/2129High-risk ST elevation MI patiDeath/MI/Stroke(%)LyticPrimary PCIP=0.0003P=0.002CombinedTransfer SitesP=0.048Non-Transfer SitesThrombolysis or PCI in AMI DANAMI-2:Primary ResultsRRR 45%LyticPrimary PCILyticPrimary PCIRRR 40%RRR 45%Anderson HR et al NEJM 2003;349:733-422021/01/2130Death/MI/Stroke(%)LyticPrLyticPrimary PCIP=0.35DeathThrombolysis or PCI in AMI DANAMI-2:ResultsLyticPrimary PCIP=0.15StrokeLyticPrimary PCIP0.0001Recurrent MIAnderson HR et al NEJM 2003;349:733-4296%OF PTS WERE TRANSFERRED FROM REFERRAL HOSP.TO INVASIVE CETNER WITHIN 2 HRS2021/01/2131LyticPrimary PCIP=0.35DeathThrThrombolysis or PCI in AMI Prague 2:Long distant transfer vs.Thrombolysis in AMIMulticenter Czech study involving 850 pts with ST elevation MI within 12 hrs of symptom onset.Primary end point was 30-day moratlity,and composite secondary end points were:death,re-MI,stroke at 30 days.Widimsky P et al Eur Heart J 2003;24:94-1042021/01/2132Thrombolysis or PCI in AMI PrThrombolysis or PCI in AMI Prague 2:Long distant transfer vs.Thrombolysis in AMIP=0.12P=NSP0.02P 3 hrs of symptom onset,PCI results in better clinical outcome despite long distance transfer.Widimsky P et al Eur Heart J 2003;24:94-1042021/01/2133Thrombolysis or PCI in AMI PrTime to PerfusionVolume of Hospital and experience of OperatorThrombolysis or PCI in AMIWhat Else is Important in AMI Treatment Strategy?Additional important parameters to maximize quality of care in the treatment of AMI patients2021/01/2135Time to PerfusionThrombolysis N=27,080,P 0.00001Thrombolysis or PCI in AMINRMI-2:Primary PCI Door-to-Balloon time vs.MortalityDoor-to-Balloon Time(minutes)2021/01/2136N=27,080,P 0.00001ThrombolThrombolysis or PCI in AMI Mortality rates with primary PCI as a function of PCI-related time delayP=0.006020406080100PCI-Related Time Delay(door-to-balloon-door to needle)Absolute Risk Difference in Death(%)Absolute Risk Difference in Death(%)-5051015Circle sizes=sample size of the individual studySolid line=weighted meta-regression Nallamothu BK,Bates ER.Am J Cardiol.2003;92:824-662 minBenefitFavors PCIHarmFavors LysisFor Every 10 min delay to PCI:1%reduction in mortality difference towards lyticsMeta-analysis of 23 studies with 7419 pts2021/01/2137Thrombolysis or PCI in AMI MoTime to PerfusionVolume of Hospital and experience of OperatorThrombolysis or PCI in AMIWhat Else is Important in AMI Treatment Strategy?Additional important parameters to maximize quality of care in the treatment of AMI patients2021/01/2138Time to PerfusionThrombolysis Thrombolysis or PCI in AMINRMI-2:Hospital Volume of Primary PCI vs.Mortality N=4,740 14,078 8,262P=0.033P=0.00010.860.672021/01/2139Thrombolysis or PCI in AMI NIncidence and Patho-anatomy of AMIFibrinolysis for AMIFibrinolysis Vs.Primary PCIAdjunct Pharmacology and StrategiesCurrent Recommendations in Treatment of AMIThrombolysis or PCI in AMI 2021/01/2140Incidence and Patho-anatomy ofThrombolysis or PCI in AMI Importance of Early Reperfusion Therapy in STEMIOutcomes Dependent Upon:Time to treatment-TIME IS STILL MUSCLE Early and full restoration in coronary blood flowSustained restoration of flow 2021/01/2141Thrombolysis or PCI in AMI ImThrombolysis or PCI in AMI Pharmacological ReperfusionAvailable ResourcesClass I1.STEMI patients presenting to a facility without the capability for expert,prompt intervention with primary PCI within 90 minutes of first medical contact should undergo fibrinolysis unless contraindicated.(Level of Evidence:A)Antman et al.JACC 2004;44:682.2021/01/2142Thrombolysis or PCI in AMI PhaThrombolysis or PCI in AMI Fibrinolytic TherapyClass I In the absence of contraindication,fibrinolytic therapyshould be administered to STEMI patients with symptom onset within the prior 12 hours&ST elevation 2.In the absence of contraindications,fibrinolytic therapyshould be administered to STEMI patients with symptom onset within the prior 12 hours and new or presumably new LBBB.(Level of Evidence:A)Antman et al.JACC 2004;44:682-3.2021/01/2143Thrombolysis or PCI in AMI FiThrombolysis or PCI in AMI Primary Percutaneous Coronary InterventionClass I 1.General considerations:The procedure should be supported by experienced personnel in an appropriate laboratory environment(performs more than 200 PCI procedures per year,of which at least 36 are primary PCI for STEMI,and has cardiac surgery capability).(Level of Evidence:A)Antman et al.JACC 2004;44:682.2021/01/2144Thrombolysis or PCI in AMI PrThrombolysis or PCI in AMI Primary Percutaneous Coronary InterventionClass I 2.Specific Considerations:a.Primary PCI should be performed as quickly as possible,with a goal of a medical contactto-balloon or door-to-balloon time of within 90 minutes.(Level of Evidence:B)b.If the symptom duration is within 3 hours and the expected door-to-balloon time minus the expected door-to-needle time is:i)within 1 hour,primary PCI is generally preferred.(Level of Evidence:B)ii)greater than 1 hour,fibrinolytic therapy(fibrin-specific agents)is generally preferred.(Level of Evidence:B)c.If symptom duration is greater than 3 hours,primary PCI is generally preferred and should be performed with a medical contactto-balloon or door-to-balloon time as brief as possible,with a goal of within 90 minutes.(Level of Evidence:B)Antman et al.JACC 2004;44:6842021/01/2145Thrombolysis or PCI in AMI PrPrimary Percutaneous Coronary Intervention Facilitated PCIClass IIb1.Facilitated PCI might be performed as a reperfusion strategy in higher-risk patients when PCI is not immediately available and bleeding risk is low.2.(Level of Evidence:B)Antman et al.JACC 2004;44:686.2021/01/2146Primary Percutaneous Coronary Fibrinolytic Therapy Combination Therapy with GP IIb/IIIaClass III1.Combination pharmacological reperfusion with abciximab and half-dose reteplase or tenecteplase should not be given to patients aged greater than 75 years because of an increased risk of ICH.(Level of Evidence:B)Antman et al.JACC 2004;44:683.2021/01/2147Fibrinolytic Therapy CombinatAdapted from Figure 3;Antman et al.JACC 2004;44:682If presentation is 75 PPCI cases per year/Team experience 36 PPCI cases per year Delay to invasive strategyProlonged transport(Door-to Balloon)(Door-to-needle)time is 1 HRMedical contact-to-balloon time is than 90 minThrombolysis or PCI in AMIWhich Strategy to Choose?2021/01/2148Adapted from Figure 3;Antman THANKSFORWATCHING谢谢大家观看为了方便教学与学习使用，本文档内容可以在下载后随意修改，调整。欢迎下载！时间：20XX.XX.XX汇报人：XXX2021/01/2149THANKS FOR WATCHING谢谢大家观看为了方便教
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