1、 急性冠脉综合症（急性冠脉综合症（ACS）Pathophysiology of Acute Coronary SyndromeUANo ST ElevationST ElevationNSTEMIUnstable AnginaQWMINQMIMyocardial InfarctionWorking DxECGCardiac BiomarkerFinal DxThe Lancet 2001;358:1533-1538 and Heart 2000;83:361-366.PresentationST抬高型急性心肌梗塞（抬高型急性心肌梗塞（STEMI）的诊断）的诊断AMI的特殊表现的特殊表现AMI的
2、鉴别诊断的鉴别诊断Pathophysiology of STEMIModified with permission from Libby Circulation.2001;104:365-372.165432Management Before STEMIOnset of STEMI Prehospital issuesInitial recognition and management in the Emergency DepartmentReperfusionHospital ManagementMedicationsArrhythmiasComplicationsPreparation f
3、or dischargeSecondary Prevention/Long-Term ManagementSTEMI 的病理生理和治疗原则的病理生理和治疗原则斑块破裂斑块破裂血栓形成血栓形成冠脉急性闭塞冠脉急性闭塞心肌坏死心肌坏死AMI的治疗流程的治疗流程新型溶栓剂新型溶栓剂t-PA及其缺失变异体的结构特点及其缺失变异体的结构特点结结构构区区(自自N端端起起)氨氨基基酸酸 序序列列 t-PA r-PA TNK-t-PA n-PA 功功能能 指指区区（F）4-50+缺缺失失+缺缺失失 与与纤纤维维蛋蛋白白的的高高亲亲和和力力结结合合 生生 长长 因因 子子 区区（EGF）51-87+缺缺失失+缺
4、缺失失 受受体体结结合合部部位位 主主区区域域1（K1）87-176+缺缺失失+(多多一一个个 糖糖基基化化位位置置)+（糖糖基基 修修饰饰）受受体体结结合合部部位位或或与与纤纤维维蛋蛋白白低低亲亲和和力力有有关关 主主区区域域2（K2）176-262+(少少一一个个 糖糖基基化化位位置置)+同同上上 丝丝氨氨酸酸蛋蛋白白酶酶催催化化区区（P）276-527+(4个个 氨氨基基酸酸置置换换物物)+溶溶血血栓栓活活性性部部位位 新型溶栓剂的特点新型溶栓剂的特点小剂量溶栓小剂量溶栓PTCA联合疗法联合疗法急诊急诊PCI梗塞恢复期（出院前）治疗梗塞恢复期（出院前）治疗左室冠脉造影左室冠脉造影冠脉血运
5、重建冠脉血运重建(Revascularization)2004年年ACC/AHA STEMI指南指南2005年年 ESC PCI 指南指南Siber S,et al.Eur Heart J 2005;26:804-847原发原发PCI优于溶栓治疗优于溶栓治疗（meta-analysis n=7739）Keeley EC et al.Lancet 2003;361:13-20PTCA vs Fibrinolysis:Short Term Clinical Outcomes(23 RCTs)PTCA Frequency(%)Keeley E.et al.,Lancet 2003;361:13-20
6、.P=0.0002P=0.0003P0.0001P0.0001P0.0001P=0.0004P=0.032P0.0001DeathDeath,no SHOCKdataReMIRec.IschTotal StrokeHem.StrokeMajor BleedDeathMICVAFibrinolysis N=7739Long-term Outcoms(6-18Ms)死亡死亡出血性出血性 中风中风缺血缺血复发复发非致非致死性死性心梗心梗 死亡死亡（除外休克）（除外休克）中风中风死亡，非致死死亡，非致死性再梗或中风性再梗或中风主要出主要出血事件血事件Keeley EC et al.Lancet 200
7、3;361:13-20转院转院PCI优于溶栓治疗优于溶栓治疗Widimsky P,et al.Eur Heart J 2003;24:94-104 Dalby M,et al.Circulation 2003;108:1809-1814Dalby M,et al.Circulation 2003;108:1809-1814Dalby M,et al.Circulation 2003;108:1809-1814发病发病3hrs STEMI：PCI仍优于溶栓仍优于溶栓Schomig A,et al.Circulation 2003;108:1084-1088Zijlstra F,et al.Eur
8、 Heart J 2002;23:550-557Dalby M,et al.Circulation 2003;108:1809-1814支架优于支架优于PTCAGrines CL,et al.N Engl J Med 1999;341:1949-56Grines CL,et al.N Engl J Med 1999;341:1949-56Stone GW,et al.N Engl J Med 2002;346:957-966Stone GW,et al.N Engl J Med 2002;346:957-966Benefit of Primary PCI Stratified by Morta
9、lity Risk with Fibrinolytic TherapyKent et al J Gen Int Med 17:887,20029 RCTs PCI vs LysisControl Rate Meta-RegressionObservedEstimated易化易化PCI：无益甚至有害？：无益甚至有害？Vant Hof AW,et al.Eur Heart J 2004;25:837-846Rescue PCI is BeneficialEllis SG,et al.Am Heart J 2000;139:1046-53Gershlick AH,et al.N Engl J Med
10、 2005;353:2758-2768Gershlick AH,et al.N Engl J Med 2005;353:2758-2768Gershlick AH,et al.N Engl J Med 2005;353:2758-2768Schomig A,et al.J Am Coll Cardiol 2004;44:2073-2079Stents Superior to Balloon AngioplastySchomig A,et al.J Am Coll Cardiol 2004;44:2073-2079Emergency PCI in Cardiogenic shock Benefi
11、cialWebb JG,et al.J Am Coll Cardiol 2003;42:1380-1386Webb JG,et al.J Am Coll Cardiol 2003;42:1380-1386Hochman JS,et al.N Engl J Med 1999;341:625-634Hochman JS,et al.N Engl J Med 1999;341:625-634溶栓者恢复期应常规冠造和溶栓者恢复期应常规冠造和PCIZeymer U,et al.Circulation 2003;108:1324-1328Zeymer U,et al.Circulation 2003;10
12、8:1324-1328Gibson CM,et al.J Am Coll Cardiol 2003;42:7-16Gibson CM,et al.J Am Coll Cardiol 2003;42:7-16Gibson CM,et al.J Am Coll Cardiol 2003;42:7-16Kaul P,et al.Circulation 2004;110:1754-1760Kaul P,et al.Circulation 2004;110:1754-1760Kaul P,et al.Circulation 2004;110:1754-1760ESC guideline-表6Siber
13、S,et al.Eur Heart J 2005;26:804-847因诱发缺血而因诱发缺血而PCI者预后也好者预后也好Madsen JK,et al.Circulation 1997;96:748-755Madsen JK,et al.Circulation 1997;96:748-755Madsen JK,et al.Circulation 1997;96:748-755Madsen JK,et al.Circulation 1997;96:748-755STEMI 晚期（晚期（12hrs）PCI：有益或有害，一样？有益或有害，一样？PCI应争分夺秒，已成共识应争分夺秒，已成共识De Lu
14、ca G,et al.Eur Heart J 2004;25:1009-1013De Luca G,et al.Eur Heart J 2004;25:1009-1013De Luca G,et al.J Am Coll Cardiol 2003;42:991-997De Luca G,et al.J Am Coll Cardiol 2003;42:991-997De Luca G,et al.J Am Coll Cardiol 2003;42:991-997De Luca G,et al.Circulation 2004;109:1223-1225Nallamothu BK,et al.Am J Cardiol 2004;94:772-774
