急性心肌梗塞治疗的进展.ppt
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1、急性心肌梗塞治疗的进展,急性心肌梗塞治疗的进展,急性心肌梗塞治疗的目标:,缩小梗塞面积 保护心功能 防治併发症 降低死亡率,心肌梗塞治疗的关键:,迅速、完全、持续 开通梗塞相关血管,一、再灌注治疗,急性心肌梗塞的再灌注治疗:,溶栓治疗,THROMBOLYTIC THERAPY,Rationale - atherosclerotic plaque rupture; - thrombus formation; - total or subtotal occlusion; - slow spontaneous lysis; - fibrinolysis,ISIS-2试验,The ISIS-2 col
2、laborative group. Lancet 1988; ii: 34960,溶栓是最佳选择,急性心肌梗塞治疗的进展,Thrombolytic therapy well documented benefit from thrombolytic therapy ISIS GUSTO GISSI SAMI-ECSG TAMI WWICST ASSET APSAC AMIS EMIP,FTT试验年龄相关溶栓与死亡率的关系,FTT Collaborative Group. Lancet. 1994;343:311-322.,THROMBOLYTIC THERAPY,Benefit - 1/3 re
3、duction in overall mortality - 40-50 fewer death / 1000 patients treated - Less remodelling / dilatation of LV better LV function - Less arrhythmia - Improved short- and long-term survival,急性心肌梗塞治疗的进展,Greater Benefit from earlier treatment,急性心肌梗塞治疗的进展,Clear benefit up to 12 hrs from symptom onset,急性
4、心肌梗塞治疗的进展,Lack of difference in net clinical outcome with different thrombolytic regimens,冠心病诊断和治疗新进展,急性心肌梗死治疗的溶栓治疗 有效性已被很多的大规模、多中心的实验证实(GISSI-1、ISIS-2、ASSET) 时间=心肌=生命 没有某种溶栓剂明显优于其它溶栓剂GUSTO:加速tPA6.3%,链激酶7.3%,冠心病诊断和治疗新进展,溶栓治疗 时间窗扩大:LATE试验显示612小时内溶栓,死亡率下降25%,1224小时则无效 院前使用,急性心肌梗塞治疗的进展,P=0.001,急性心肌梗塞治疗
5、的进展,*GUSTO Angiographic Investigators: N Engl J Med 1993;329:1615-22,P=0.001,P=NS,急性心肌梗塞治疗的进展,Coronary artery patency at 90 min and 30-day mortality in GUSTO-1,*p0.05 relative to TIMI grade 0-1,再灌注治疗策略:溶栓治疗,溶栓治疗不足之处 再通率为6080%且残留狭窄 再通者中达TIMI血流3级者约为5060% 再通者中,TIMI血流2级者再梗塞率高 临床缺少可靠再灌注指标 不是全部AMI患者都适合于溶栓
6、(约25%) 12%出血并发症 心肌缺血发生率高 心源性休克效果差,溶栓治疗的好处 有效 对设备和人员培训要求低 方便,迅速应用 广泛应用,急性心肌梗塞的再灌注治疗:,二、直接PCI治疗,Treatment = Reperfusion,PAMI试验结果,PAMI试验:395例入选,AMI发病6小时以内,r-tPA( %) PTCA(%),死亡率 6.5 2.6 高危者死亡率 10.4 2.6 再梗/院内死亡 12.0 5.1 颅内出血 0.5 0,Primary PTCA vs Thrombolysis PAMI Trial: in-hospital mortality,P=0.01,P0.0
7、7,65,P=0.03,P=0.01,GUSTO IIb试验,对比直接PTCA与溶栓治疗对AMI的临床疗效,入选1138例发病后12小时内的AMI患者,观察30天内死亡、再次MI和致残性卒中的联合发生率 结论:在有经验的临床中心,直接PTCA的近中期疗效优于t-PA溶栓,死亡 再次MI 卒中 联合发生率,P=0.37 P=0.13 P=0.11 P=0.033,N Engl L Med, 1997,336:1621-1628,PCI是最佳选择,STOPAMI试验,Schomig et al. N Engl J Med 2000;343:385-91 Kastrati et al. Lancet
8、 2002;359:920-25,CADILLAC: MACE - 6 Months,0%,5%,10%,15%,20%,0,30,60,90,120,150,180,Days to event,15.2%,19.3%,10.8%,10.9%,Stone GR, et al. Presented at the AHA 72nd Scientific Sessions. 1999 A.II.030,Primary PTCA vs Thrombolytic Therapy,For every 1000 pts treated, PTCA compared with lytic therapy: 2
9、0 lives saved 43 re-MI prevented 13 ICH prevented,Meta-analysis of 23 trials suggests that primary PTCA is preferred over lytic therapy,Keely et al. Lancet 2003,直接PTCA的优点,成功率高,9095% 降低脑卒中的发生率 降低反复心肌缺血 减低再次住院和死亡 缩短住院时间 增加EF,Cardiogenic shock and Primary PTCA,SHOCK Trial: ERV 组 Med 组 p 病例数 152 150 30天
10、死亡率 46.7% 56% 0.11 60天死亡率 50.3% 63.1% 0.27 75 y 效果更差,AMI的直接PCI治疗: 高危患者获益更大,四个亚组疗效优于溶栓组 心源性休克 前壁心梗 心衰 老年人70岁,直接PCI与溶栓治疗:长期疗效,直接PTCA对设备和医生的要求:,图象质量极佳的X光设备 操作者技术优良 工作人员快速反应: 门口气囊时间最好小于1小时, 不能大于2小时 对AMI能快速作出诊断 最好能备有 GPb/a受体拮抗剂,再灌注治疗策略:直接PCI,不足之处 对设备和人员培训要求高 治疗廷迟(平均医院-气囊时间为120分钟) 没有被广泛应用,好处 更有效,更高的再灌注率(8
11、0%以上达TIMI3级) 颅内出血少 早期了解冠脉病理解剖和左室功能,Reperfusion Therapy in Patients with STEMI in Registry Studies 1999-2003,0%,10%,20%,30%,40%,50%,60%,70%,80%,Sweden,RIKS-HIA,Italy,BLITZ,USA,NRMI-4,Euro Heart,Survey,ENACT,GRACE,Int.,Thrombolysis,Primary PCI,急性心肌梗塞的再灌注治疗:,三、溶栓失败后补救性PCI治疗,补救性PCI 2年存活随访,Gibson et al.
12、Circulation 2002;105:1909-13,Ellis SG, et al. Circulation. 1994;90:2280-2284.,The Rescue Trial,151 pts with first anterior MI treated with fibrinolytic therapy Subsequently randomized to conservative therapy (ASA, heparin, vasodilator) vs therapy plus PTCA PTCA vs conservative therapy 92% technical
13、success with PTCA Exercise LV function improved (43% + 15% vs 38% + 13%, P=0.04) Mortality reduced by 50% in the PTCA-treated group (5% vs 10%; P=0.18) Mortality and severe heart failure reduced by 64% in PTCA-treated group (6% vs 17%; P=0.05),A.II.030,Resue PTCA after failed fibrinolysis RESCUE I t
14、rial,PTCA,No PTCA,P=0.001,12,6,0,62,36,24,48,0.6,0.7,0.8,0.9,1.0,Time,(weeks),Ellis, Am Heart J 2000; 139:1046,A.II.030,% Survival,四、首诊到基层医院的AMI病人,应采取何种再灌注策略: 溶栓治疗? 直接PCI?,AMI: 转院进行直接PCI?,存在溶栓禁忌,梗塞面积较大 -YES! 溶栓失败,12小时内 -YES! 心源性休克,36小时内 -YES! 没有溶栓禁忌,时间窗以内 -?,The PRAGUE Study (N=300),p0.001,23.0%,15.
15、0%,8.0%,The DANish trial in Acute Myocardial Infarction-2 (DANAMI-2),A total of 1900 patients with ST-elevation myocardial infarction are to be randomized 800 patients will be admitted to invasive hospitals 1100 patients will be admitted to referral hospitals. Half of the 1100 patients admitted to r
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