急性心肌梗死治疗进展霍勇

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,急性心肌梗死治疗进展,北京大学第一医院,霍勇,200,7,年,11,月,23,日,急性心肌堵塞治疗的进展,心肌堵塞治疗的关键：,迅速、完全、持续,开通堵塞相关血管,Primary PTCA,vs,Thrombolysis,PAMI Trial:in-hospital mortality,P=0.01,P65,P=0.03,P=0.01,评估,STEMI,再灌注方式,-,ACC/AHA 2004 STEMI Guidelines,步骤1：评估时间和危险性,病症发作后的时间,STEMI危险分层,溶栓风险,转运至熟练PCI导管室所需时间,JACC August 4,2004;44:671-719,再灌注策略,危险和获益,静脉溶栓 直接,PCI,时间 时间,评估,STEMI,再灌注方式,-,ACC/AHA 2004 STEMI Guidelines,步骤2：决定应首选溶栓还是PCI,如果时间少于3小时，且介入治疗无耽误，溶栓和PCI首选哪种都可以。,JACC August 4,2004;44:671-719,评估,STEMI,再灌注方式,-,ACC/AHA 2004 STEMI Guidelines,溶栓首选，如果：,早期就诊病症发作在3小时内，行介入治疗有耽误,不适合选择介入治疗,导管室被占用或不能用,血管入路困难,缺乏熟练PCI操作相关工作人员,介入治疗时间耽误,运输时间延长,Door-to-balloon比door-to-needlle时间超过1小时,或door-to-balloon时间超过90分钟,JACC August 4,2004;44:671-719,评估,STEMI,再灌注方式,-,ACC/AHA 2004 STEMI Guidelines,PCI首选，如果：,熟练PCI操作相关人员及有心外科支持,Door-to-balloon时间90分钟,Door-to-balloon比door-to-needlle时间3小时,不能确定STEMI诊断,JACC August 4,2004;44:671-719,2004,年,ESC,的,PCI,指南中的,AMI,再灌注策略,STEMI,病人中,ASA+,溶栓剂治疗增加的效果,ISIS-2 Collaborative Group.Lancet 1988;2:349-60,在17187例STEMI病人中进行的RCT比较:,链激酶(SK)、ASA 1月、SK+ASA、抚慰剂治疗,抚慰剂:588/4300(13.2%),0,0,血管性死亡的累积病例数,随机分组后的天数,7,14,21,28,35,100,200,300,400,500,600,Aspirin:461/4295(10.7%),Streptokinase:448/4300(10.4%),Streptokinase,aspirin:343/4292(8.0%),主要终点指标,:,动脉闭塞,(,或动脉造影,/,出院前发生死亡,/,心梗,),Placebo,Clopidogrel,P=0.00000036,Odds Ratio 0.64,(95%CI 0.53-0.76),1.0,0.4,0.6,0.8,1.2,1.6,Clopidogrel,better,Placebo,better,n=1752,n=1739,36%,Odds Reduction,Sabatine et al.,NEJM,2005;352:1179,COMMIT:,主要终点死亡,0,7,14,21,28,0,1,2,3,4,5,6,7,8,9,Days(up to 28 days),Clopidogrel,(7.5%),Placebo,(8.1%),RRR=7%,p=0.03,Mortality(%),Chen ZM et al.Oral presentation,ACC 2005.Available at:URL:,.Accessed April 2005.,STEMI,6,小时符合溶栓指征,医生根据情况选择溶栓剂,(TNK,TPA,rPA,SK),普通肝素,60 U/kg,负荷剂量,12 U/kg/h,维持,48,小时以上,依诺肝素,75 y:30 mg,负荷剂量,皮下,1.0 mg/kg q12h(,出院,)75 y:,无负荷剂量,皮下,0.75 mg/kg q12h(,出院,),CrCl 30:1.0 mg/kg q24 h,双盲双模拟期,30天随访,主要有效性终点：死亡或非致命性心梗主要平安性终点：TIMI严重出血事件,阿司匹林,(,ASA,),97%,在溶栓治疗开始,30min,内接受了研究药物治疗，中位住院时间,10,天,N=20,506,TNK:Tenecteplase;TPA:Tissue plasminogen activator;rPA:Reteplase;SK:Streptokinase;UFH:Unfractionated heparin;CrCl:Creatinine clearance,STEMI:ST-segment elevation myocardial infarction,;MI:Myocardialinfarction;TIMI:Thrombolysis in Myocardial Infarction,Primary End Point(ITT),Death or Nonfatal MI,Primary End Point(%),ENOX,UFH,Relative Risk0.83(0.77 to 0.90,),P0.0001,Days,9.9%,12.0%,Lost to follow up=3,17%RRR,在预先定义的各个亚组中，依诺肝素组显示出一致的疗效,患者人数,年龄（岁）,75,75,17,9472,532,性别,男性女性,15,6964,783,梗死部位,前壁,其他,8,93311,400,溶栓药物,链激酶,纤维蛋白特异性,4,13916,283,治疗开始时间,中位时间,中位时间,9,89910,394,糖尿病,无有,17,1893,060,MI,既往史,无有,17,7452,659,总计,20,479,0.5,1,相对风险,2,依诺肝素更优,普通肝素更优,206,7.924.8,9.926.3,1816,8.215.4,10.118.3,1123,12.57.9,14.010.2,1318,10.29.8,11.812.0,2312,8.711.0,11.312.5,1721,9.213.6,11.117.1,1720,9.214.3,11.117.8,17,9.9,12.0,风险降低,依诺肝素,普通肝素,The overall treatment effect of enoxaparin versus UFH is shown with the diamond symbol(left and right edges represent 95%confidence interval)and the dotted vertical line,出现终点事件的患者,(%),30,天结果,:,氯吡格雷联合依诺肝素疗效更好,事件发生率,12.2,11.4,绝对风险下降,15,绝对风险下降,24,P,值,0.0005,0.0006,n=14,752(78%),n=5,727(28%),CADILLAC:MACE-6 Months,PTCA,no abciximab,PTCA,abciximab,Stent,no abciximab,Stent,abciximab,0%,5%,10%,15%,20%,0,30,60,90,120,150,180,Days to event,15.2%,19.3%,10.8%,10.9%,P=0.93,P=0.0001,Stone GR,et al.Presented at the AHA 72nd Scientific Sessions.1999,TLR,、,TVR,、,MACE,和,TVF,的发生危险分别下降：,61%,、,62%,、,59%,和,53%.,OAT Trial:Study Design,Primary Endpoints:Death,MI,or NYHA class IV heart failure,PCI with stenting,n=1082,Medical Therapy,n=1084,2166 patients with angiography on day 3-28 post-MI revealing total occlusion of the infarct-related artery with poor or absent antegrade flow(TIMI flow grade 0 or 1);and meeting a criterion for increased risk:,defined as ejection fraction 50%,proximal occlusion of a major epicardial vessel with a large risk region,or both,OAT,研究引起的思考,Randomized,OAT Trial:Primary Endpoint,Primary Endpoint of death,reinfarction,NYHA class IV heart failure(%patients),Hazard Ratio 1.16,p=0.20,Hochman JS et al.N Engl J Med.2006;355(23):2395-407.Presented at AHA 2006,OAT,研究结果质疑,入选时间过长，入选患者人数较少导致研究效力下降,入选的患者仅仅占众多AMI患者的极小一局部,研究长期临床随访率较低:8%,Slow/No-Reflow发生率高达18：,研究对象多为存活心肌较少的患者,仅有8的患者使用了药物洗脱支架。,Cardiac Cell Therapy and STEAMI,Randomized-controlled BOne marrOw transfer to enhance,ST-elevation infarct regeneration(BOOST)trial,Intracoronary autologous BMC transfer improves echocardiographic parameters of diastolic function in patients after AMI.,Circulation.2006 Mar 14;113(10):1287-94.,Cardiac Cell Therapy and STEAMI,ASTAMI TRIAL,No effects of intracoronary injection of autologous mononuclear BMC on global left ventricular function.,N Engl J Med,2006;355,:,11991209,.,Cardiac Cell Therapy and STEAMI,REPAIR-AMI TRIAL,Intracoronary administration of BMC is associated with improved recovery of left ventricular contractile function in patients with acute myocardial infarction.,N Engl J Med,2006;355: