powerpoint 演示文稿 - AMI再灌注治疗

,*,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,AMI再灌注治疗，院前我们能做什么,张斌,广东省人民医院,广东省心血管病研究所,DOOR,NEEDLE,BALLOON,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, 2021 The American College of Cardiology (ACC),Door-to-Balloon (D2B) 联盟目标：STEMI 病人 D2B 90 minutes 到达 75%.,从2005年4月到 2021年3月，614医院参加NCDR登记研究并参加 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.,J Am Coll Cardiol.,2009;54:24232429,Table 1. Changes in Use of Recommended Strategies,Strategy,2005,2008,Increase,P,Value,急诊通知导管室,52.1%,59.7%,7.6%,0.0009,单独呼叫系统激活导管室,30.6%,37.3%,6.7%,0.0012,梯队30分钟内到达导管室,81.2%,88.7%,7.5%, 0.001,即时资料反馈,61.2%,78.6%,17.4%, 0.001,激活院前 ECG,32.7%,41.1%,8.4%,0.0001,Impressive 3-Year Increase,62.8% of US patients had a D2B time within 90 min in 2006,By 2021, the percentage had increased to 76.4%, slightly better than the initial goal of 75% set at the start of the campaign,continued to improve beyond the end of the study period (March 31, 2021).,81.7% of eligible patients had D2B times 90 minutes from June 30, 2021,The average D2B time from an average of 121 minutes at the end of 2005, to an average of 80 minutes as of June 30, 2021,Direct 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,Still Room for Improvement,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说明，易化PCI 结果劣于直接 PCI。目前已完全否认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(2021)-中华医学会心血管病学分会,荟萃分析：,Keeley等比照较直接 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,最终冠脉血流到达 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到达 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组不良反响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,可能溶栓到PCI时间短,缺乏良好的抗血小板治疗,可能原因,It is possible that the time between fibrinolysis and PCI (median, 90 to 104 minutes) was too short in these trials, with the result that persistent fibrinolytic activity led to increased bleeding complications,The lack of adequate ant iplatelet therapy in these trials may have also conferred a predisposition to thrombotic complications.,Fibrinolysis is followed by increased platelet activation and aggregation, and stent implantation early after fibrinolysis without adequate antiplatelet therapy may be associated with increased rates of acute stent thrombosis,TRANSFER-AMI Trial,Background,Patients with STEMI in the hospitals that do not have the capability of PCI often,cannot undergo timely primary PCI,and therefore receive fibrinolysis,The role and,optimal timing,of routine PCI after fibrinolysis have not been established.,Methods,Randomized; nonblinded trial; 52 sites in three provinces in Canada,1059,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 recommended,The primary end point was the composite of death, reinfarction, recurrent ischemia, new or worsening congestive heart failure, or cardiogenic shock within 30 days,Results,88.7% 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 bleeding,Conclusions,Among 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.,院前溶栓与院内溶栓的比较,六项涉及6434例急性心肌梗死患者随机临床试验的汇总分析显示，与院内溶栓比较，院前溶栓明显降低住院总死亡率17。院前溶栓平均节省时间约1个小时,法国全国急诊室注册登记入选1922例ST段抬高心肌梗死患者，其中的180例9接受了院前静脉溶栓治疗，住院死亡率在院前溶栓、院内溶栓和直接PCI组分别为3.3、8.0和6.7，1年生存率三组分别为94、89和89，,与其他再灌注方式比较，死亡率降低更为显著,院前溶栓与直接PCI的比较,CAPTIM试验比较院前溶栓和直接PCI，从出现病症到治疗开始的时间院前溶栓组为130分钟，比直接PCI早了1个小时，两组30日主要复合终点死亡、非致命心肌梗死和非致命脑卒中分别为8.2和6.2，P0.29，死亡分别为3.8和4.8，P0.61。,独立分析病症开始2小时以内和2小时后随机分组患者，2小时以内随机分组患者院前溶栓和直接PCI 30日死亡分别为2.2和5.7，P=0.058，心源性休克分别为1.3和5.3，P=0.032,两组三重复合终点死亡、再梗死和致残性脑卒中没有显著性差异7.4比6.6，P=0.86,在2小时分组的患者，两组30日死亡率分别为5.9和3.7，P=0.47，直接PCI组偏低，心源性休克两组没有显著性差异,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,600,m,g,可以更迅速地抑制血小板聚集,抑制血小板聚集 (%),103,名非,ST,段抬高的,ACS,患者随机分配接受,300、600,或,900 mg 氯吡格雷,0,Montalescot,et al.,JACC 2006;48:931-8,0,50,10,20,30,40,1,2,3,4,5,6,时间(小时),5,mol/L ADP,*p0.05,与300,mg,相比,900 mg,600 mg,300 mg,600 mg,300 mg,*,*,*,900 mg,*,*,*,600mg LD 2,小时的抑制水平与,300mg LD 6,小时相当,高负荷剂量未显著增加出血,300 mg,n = 35,600 mg,n = 34,900 mg,n = 34,住院期间出血例数*,严重,中等,微量,总计,0,1,10,11,0,0,10,10,0,1,13,14,*按,GUSTO,分级定义,ARMYDA-2:600mg负荷剂量显著降低主要终点事件,p = 0.041,4%,12%,0%,2%,4%,6%,8%,10%,12%,14%,600mg,300mg,死亡、心梗及靶血管血运重建%,Patti G. et al, Circulation. 2005; 111:2099-2106,600mg,的波立维负荷剂量可降低血栓事件的发生率,292,名连续接受,300,或,600 mg 氯吡格雷,负荷剂量支架植入的,NSTE ACS,患者,Cuisset,et al.,J Am Coll Cardiol 2006; 48:133945,无心血管事件生存 (%),100,80,90,95,p0.0024,300 mg,600 mg,事件率 (%),心血管事件,0,12.5,2.5,7.5,10.0,脑卒中,300 mg,600 mg,30,20,10,0,85,时间(天),ACS事件,ST*,心血管死亡,5.0,ST* = 支架血栓形成,GPb/a受体拮抗剂在STEMI的临床应用, a b ,A,B,B,B,UA/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。,33,2021中国经皮冠状动脉介入治疗指南,PCI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,FINESSE Trial,Results,A 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,).,Conclusions,Neither 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 Studies,ON-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,Prehospital,Tirofiban in AMI,在,急性心梗患者给予院前应用替罗非班,Hamm CW et al. Abstract 413-5. Presented April 1, 2021, 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(STEMI),ASA + 600 mg Clopidogrel + UFH,冠脉造影,替罗非班,抚慰剂,PCI,手术室,冠脉造影,必要时,使用替罗非班,持续使用替罗非班,*,ON-TIME -2,N=984,6/2006-11/2007,PCI,*Bolus: 25 g/kg & 0.15 g/kg/min infusion,Hamm CW et al. Abstract 413-5. Presented April 1, 2021, at the American College of Cardiology 57th Annual Meeting in Chicago, IL.,转运,Event-free Survival,无事件生存率,On,going,T,irofiban,I,n,M,yocardial Infarction,E,valuation,P = 0.012,Hamm CW et al. Abstract 413-5. Presented April 1, 2021, at the American College of Cardiology 57th Annual Meeting in Chicago, IL.,66.7%,74.0%,1,年全因死亡率,ACC2021,RR: 0.78 (95% CI: 0.53-1.14, p=0.157),RR: 0.77 (95% CI: 0.46-1.29, p=0.276),N=984,N=414,Double Blind,Open Label,-36%,-37%,Safety Endpoint: Bleeding平安性终点：出血事件,On,going,T,irofiban,I,n,M,yocardial Infarction,E,valuation,0.115,4.0%,Hamm CW et al. Abstract 413-5. Presented April 1, 2021, 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 days,JACC Vol. 54, No. 23, 2021,December 1, 2021:220541,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！,47,药物介入治疗：,院前溶栓+即刻PCI,ESC 2021,