急性心肌梗塞战略.ppt
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1、AMI Strategy How to Achieve Door-to-Balloon Times of 90 Minutes and What to Do Next?,Aaron Kugelmass, MD Director, Cardiac Cath Lab Associate Division Chief Henry Ford Hospital Detroit, Michigan, USA,Overview,Introduction The Argument for Primary PCI Overview of the Henry Ford Program Program Specif
2、ics Process Dictates Outcomes Alternative Opportunities,Acute MI: Introduction,1.1 million people yearly in the US* About 500,000 have STEMI 220,000 die from their AMI 50% of deaths in the first hour Outlook of hospitalized patients better,*AHA: 2001 Heart and stroke statistics,Acute MI: Early Manag
3、ement Reperfusion,Pharmacological (Thrombolysis) Fibrinolytics Antithrombins Platelet Inhibitors Mechanical (Direct/Primary PCI) Angioplasty Stent Thrombectomy Combined ? Facilitated PCI,Acute MI: Direct PCI Advantages,Rapid assessment of anatomy and hemodynamics TIMI-3 flow rates 75-95% in infarct
4、artery Low incidence of hemorrhagic stroke Can be done in patients with contraindications for thrombolysis Results superior to thrombolytics in randomized trials,Direct PTCA vs. Thrombolysis PAMI-1,N Engl J Med 1993; 328:673-679,Primary Angioplasty vs. Thrombolysis: Meta-analysis,Death p=0.02,Death+
5、MI p0.01,Weaver DW, JAMA 1997;278:2093-2098,Primary Angioplasty vs. Thrombolysis: Meta-analysis,Weaver DW, JAMA 1997;278:2093-2098,PCI vs Lysis Meta Analysis,Keeley E, Lancet 2003; 361: 1320,Lytics vs Transfer for PCI: DANAMI,Acute MI: Direct PCI Limitations,Only 20% of US hospitals have cath labs a
6、nd fewer have PTCA facilities To achieve results similar to randomized trials the following has to be met: PTCA within 90 minutes of presentation Skilled operator (75 cases/year) Skilled lab (200 cases/year) Surgical back up necessary,Is Time as Critical in Primary PCI?,30-day mortality,Time from on
7、set of CP to randomization,Zijlstra, Eur Heart J 2002;23:550,ACC/AHA Recommendations for Direct PCI in AMI 2004,Class I General: Patients presenting within 12 hours; if performed in a timely fashion by individuals skilled in the procedure and supported by experienced personnel in high volume centers
8、 Specific: Door To Balloon Time 1 hour Symptom 3 hours, PCI preferred 90min Within 36 hours of MI when patient develops cardiogenic shock, is 75 years and revascularization can be done within 18 hours of shock onset. 12 hours of symptoms and severe CHF or pulmonary edema,(2004) Http:/www.acc.org/cli
9、nical/guidelines,Primary PCI in the United States,Minority of US Hospitals Achieve a median Door to Balloon Time of 90 minutes or less Majority of MI occur during “Off Hours” (nights and weekends) Off Hour Primary PCI is associated with increased door to balloon times and mortality Henry Ford 2002 D
10、oor to Balloon 218 minutes Cath Lab to Balloon 60 minutes,Primary PCI Pathway An Opportunity for Process Improvement,Patient Presentation to Diagnosis 20 min Page Fellow, Fellow Responds 10 min Fellow Proceeds to ER 15 min Fellow Evaluates Patient 15 min Fellow Pages CCU Staff, Staff Responds 10 min
11、 + PCI, Fellow Pages Int Staff, Staff Responds 10 min Fellow goes to Cath Lab, Pages Team 10 min Patient Stays in ER or Goes to CICU Cath Team Arrives 60 min Find Patient and Transport 15 min Perform PCI 45 min Total 210 minutes,Process Change,Centralize Communications Focus Clinical Decision Making
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