1、时间就是心肌，就是生命0-0.5 hrs 预防梗死0.5 2 hrs 大量挽救心肌+IRA开通的益处2 6 hrs心肌挽救降低,IRA开通的益处 6 hrs基本不挽救心肌,但有IRA开通的益处2021/1/12290年代中已证明溶栓治疗的益处与安慰剂对比2021/1/1232003年，心梗治疗-溶栓与介入对比-We know是否意味着都做PCI?PCI时间肯定要比直接注射药物长，不是所有医疗机构都具有PCI条件。所以一系列问题需要研究2021/1/124溶栓与介入的比较2021/1/125NRMI-2:死亡率与时间的关系“拖拖”多久可以接受？多久可以接受？2021/1/1262004ACC/A
2、HAAMI2004ACC/AHAAMI指南的选择的推荐指南的选择的推荐下列情形下溶栓更好下列情形下溶栓更好 到院很早（3h）介入可能延迟 介入不可选 导管室没空 血管入路有困难 没有熟练的医生 介入延迟(Door-balloon)-(Door-needle)1hMedical contact-balloon time1.5h下列情形下介入更好下列情形下介入更好 熟练的队伍且有外科保障(Door-balloon)-(Door-needle)1hMedical contact-balloon time3h 诊断STEMI有疑问如果3小时之内到院，没有特别情况，两种方案均可2021/1/127我们已
3、经知道我们已经知道 PCI优于溶栓 但是PCI慢于溶栓，慢可用疗效弥补，但有个度 这个“度”的把握很重要北京的调查显示，D2B时间达标比例低如何选择溶栓与介入？如何选择溶栓与介入？溶栓后还可以介入？溶栓后还可以介入？2021/1/128溶栓与溶栓与PCIPCI选择之考虑选择之考虑至少有部分病人，溶栓可能优于至少有部分病人，溶栓可能优于PCIWho?When?Where?What?Which?2021/1/129 Sx Door Needle Balloon策略的变化策略的变化2003 Greg Stone(Lancet):PPCI regardness of nearest cath suit
4、e 3 floors or 3 hrs away2007JACC ACCAHA guidelineLytic if anticipated PPCI is 90min give lytic within 30min2021/1/1210选择依据1-起病长短2021/1/1211选择依据2-拖延时间P=0.006020406080100PCI相关的时间延误(入院-球囊扩张时间入院-溶栓时间)-5051015圆的尺寸=单独研究的样本大小.实 线=加权meta回归.Am J Cardiol.2003;92:824-662 分钟获益支持PCI受损支持溶栓PCI 每延迟10分钟，与溶栓间的死亡率的差异将
5、减少1%Sx-B每延长30min，RR=1.082021/1/1212选择依据2-拖延时间NRMI资料192509例患者，645个中心Circulation 2006；114：2019-25114min是个坎但：所有病人一样吗？2021/1/1213选择依据3-患者本身风险DANAMI-2发现转运PCI有益于高危者2021/1/1214选择依据选择依据4 4年龄，梗死部位，就诊时间Circulation 2006；114：2019-252021/1/1215直接直接PCIPCI的可接受延搁时间取决于患者病情的可接受延搁时间取决于患者病情Z=0.59X-0.033Y-0.0003W-1.3Z=P
6、PCI对TT的益处；X=本身死亡率；Y=PCI延误W=患者症状到就诊时间2021/1/1216越是高危，PPCI越经“拖”2021/1/1217直接直接PCIPCI的可接受延搁时间取决于患者病情的可接受延搁时间取决于患者病情 50yM diabetic Pt,3h Ant STEMI hemodynamically stable;TRS=3;Mortality=4.4%D2B-D2N=43min 74-yM Pt,3hAnt STEMI hemodynamically unstable TRS=5;Mortality=12.4%D2B-D2N=200min2021/1/1218溶栓后还可以溶栓
7、后还可以PCIPCI吗？吗？2021/1/1219溶栓成功后的溶栓成功后的PCI-不行到可行的过程不行到可行的过程2021/1/1220Immediate PCIImmediate PCI2021/1/1221Immediate PCI-no goodImmediate PCI-no goodBe abandoned for many years2021/1/1222Immediate PCIImmediate PCI？80-9080-90s data suggest harmfuls data suggest harmfullytic activated platelet,more lyti
8、c activated platelet,more thrombogenicthrombogenicProne to hemorragic in intracoronary Prone to hemorragic in intracoronary lesionlesionMore vascular complicationsMore vascular complications Aspirin not given with thrombolysis Low dose heparine,noACT monitor GP IIb/IIIa antagonist&Thienopydine not u
9、sed Stent not available2021/1/1223ACC/AHA2004 AMI Guideline ACC/AHA2004 AMI Guideline described early angiogram after described early angiogram after successful lyticsuccessful lytic Routine,Immediately after lytic Tx ClassIII Following successful lytic Tx in Asx Pts without ischemia Class IIb2021/1
10、/1224ACC/AHA2005 PCIGuidelineACC/AHA2005 PCIGuideline described early angiogram after described early angiogram after successful lyticsuccessful lyticLittle bit improved?2021/1/122506 ESC AMI guideline:OK06 ESC AMI guideline:OK2021/1/1226Key trials for immediate PCI OKKey trials for immediate PCI OK
11、2021/1/1227CAPITAL further support routine PCI CAPITAL further support routine PCI after lysisafter lysis2021/1/12282021/1/12292021/1/123007 further meta-analysis07 further meta-analysis：new evidence of PCI reasonable after lysisnew evidence of PCI reasonable after lysis2021/1/1231溶栓后立即或缺血驱动溶栓后立即或缺血
12、驱动PCIPCI荟萃荟萃Wijeysundera H:Am Heart J 2008;156:564-5722021/1/1232为什么又行了？介入的发展：支架、IIb/IIIa 溶栓药的发展：短效溶栓药 介入的时机选对了2021/1/1233溶栓失败后的溶栓失败后的Rescue PCI-不得不行到可行的过程不得不行到可行的过程2021/1/1234 Rescue PCIearly2021/1/1235Rescue PCI(GUSTO-1)2021/1/1236GUSTO-1-不补救更好2021/1/1237 Key trial for rescue PCIKey trial for resc
13、ue PCI2021/1/1238Meta analysis of Rescue PCI20072021/1/1239易化易化PCI-与溶栓后与溶栓后PCI有区别有区别区别在哪里？区别在哪里？2021/1/1240PACT2021/1/1241PACT2021/1/1242CAPTIM Trial arouse some hope CAPTIM Trial arouse some hope 840 pts in 27 tertiary care French hospitals with mobile care units 2mm STE-MI-ASA+Heparin 5000U;pre-ho
14、spital tPA vs primary PCIp=0.29p=0.61p=0.13p=0.12p=0.06Bonnefoy,Lancet 2002；2021/1/1243Key trials for facilitate Key trials for facilitate PCIPCI如果已经准备PCI,不要乱给药了，不给更好2021/1/1244FINESSEFINESSE PCI前常规abciximab或PCI时嘱情abciximab的比较 不管是否有半量瑞替普酶溶栓 结果一样且院前应用Ab出血增多 Finesse+OnTime2：PCI前前Ab无益处无益处2021/1/1245Met
15、a analysis for F-PCIprePCI TIMI flow not transfer to good outcome2021/1/1246Meta analysis for F-PCI2021/1/1247Facilitate PCI 2007 guideline 2021/1/1248Pharmacoinvasive概念概念的提出的提出2021/1/1249转运是安全的2021/1/1250易化，立即，转运的综合易化，立即，转运的综合问题：那些无法在90min内PCI的患者接受半量瑞替普酶+Ab 后，是该立即转运作PCI还是等到发现未再通再进行 转运补救PCI?180min11
16、0minD2B2021/1/1251转运与立即转运与立即PCIPCI的结合的结合Tenecteplase溶栓后的病人何时转运？1059例高危患者均在2h内溶栓提示：尽早转运做PCI有益；发现了溶栓后早期介入的时间窗可以提前到3h N Engl J Med 2009;360:2705-2718.32.5h2.8h2021/1/1252转运与立即转运与立即PCIPCI的结合的结合:Sx2hTNKSx2hTNKBohmer E etal:JACC2010;55:102-1103d2.7h2021/1/1253溶栓后PCI Meta20102021/1/1254溶栓后PCI获益2021/1/1255溶
17、栓后PCI Meta-201130d 复合终点2021/1/1256溶栓后PCI Meta-201130d缺血终点30d出血终点30d死亡率2021/1/1257Latest Guideline,Whats new?Triage and transfer for PCI,esp in high risk,but no emphasize surgical backup Abandon the many terms of PPCI,immediate,rescue Lytic then PCI safe Pt be divided into sent to capability of PCI i
18、nstitute or not Emphasize PPCI ASAP2021/1/12582010ESC介入指南2021/1/1259rt-PA半量溶栓后早期半量溶栓后早期PCI治疗急性治疗急性STEMI 疗效及安全性评价疗效及安全性评价2021/1/1260Time intervalslysis2.0h 1.1h 0.5h 1.5h 6.8hMedian D-to-N time:1.6h Median D-to-B time:8.4hsymptom onsethospitalizationconsent signature balloon infllation2021/1/12612 wi
19、th no lesions 50%diameter stenosis and 1 with unsuitable anatomy did not undergo PCI6 had TIMI 0-134 had TIMI 2-350 enrolled and accepted half-dose rt-PA 40(81.6%)Achieved clinical criteria of reperfusion1 was unwilling to undergo angiography 9(18.4%)underwent rescue PCI 4 had TIMI 2-35 had TIMI 0-1
20、Early PCI 75.5%Final flow of IRA Final flow of IRA 8 had TIMI 2-31 had TIMI 0-136 had TIMI 2-31 had TIMI 0-12021/1/1262Procedural characteristics(n=46)Glycoprotein IIb/IIIa use,-no.(%)7(15.2%)Thrombectomy,-no.(%)0(0%)Coronary-artery bypass grafting,-no.(%)0(0%)Distal protection device,-no.(%)0(0%)Co
21、ronary stents,-no.(%)45(97.8%)Complications-no.(%)Minor dissection 1(2.2%)No reflow 2(4.3%)(PPCI 5-25%)2021/1/1263Improved TIMI grade flow 2021/1/126448.532.137.925.6p0.01Improved CTFC 2021/1/1265Improved MBG 2021/1/126659.737.226.719.936.923.437.821.5n=12n=8n=15n=11Optimal time of early PCI(Pilot)2
22、021/1/1267137.557.3110.851.3116.752.5157.044.8n=12n=8n=4n=14Optimal time of early PCI(Pilot)2021/1/1268Clinical outcomes at 30days after symptom onset(n=47)1.5%8.1%Borgia1 et al.1.0%-4.9%1.2%-5.8%2021/1/1269Take Home MessageTake Home Message 溶栓与介入的选择4个条件：发病时间，可能的拖延时间，患者本身风险度，年龄与梗死部位 溶栓后可以PCI，不管是否溶成，及时转运至有条件的中心是必要的 溶栓药物必须是短效与纤溶特异性的 溶栓后PCI的时间3小时以上是必须的，但最好12-24h2021/1/1270Thank you for your attention2021/1/1271
