1、S.Chiu Wong MD,FACCAssociate Professor of MedicineWeill Medical College of Cornell UniversityDirector,Cardiac Catheterization LaboratoriesThe New York Presbyterian Hospital-Cornell CampusThe ACC Symposium at the Great Wall Meeting,Beijing ChinaOctober 17,2004Thrombolysis or Primary PCI in the Treatm
2、ent of Acute MI2021/01/211 Patho-anatomy of AMI Fibrinolysis for AMI Fibrinolysis Vs.Primary PCI Adjunct Pharmacology and Strategies Current Recommendations in Treatment of AMIThrombolysis or PCI in AMI Summary2021/01/212 Patho-anatomy of AMI Fibrinolysis for AMI Fibrinolysis Vs.Primary PCI Adjunct
3、Pharmacology and Strategies Current Recommendations in Treatment of AMIThrombolysis or PCI in AMI 2021/01/213Circulation,Volume XLV,January 1972.Page 215-230Coronary Arteries in Fatal AcuteMyocardial InfarctionBy WILLIAM C.ROBERTS,M.D.SUMMARY The coronary arteries are diffusely involved by atheroscl
4、erotic plaques in fatal acute myocardial infarction(AMI).The degree of luminal narrowing may vary but plaques are present in practically every millimeter of extramural coronary artery.Usually the lumens of at least two of the three major coronary arteries are narrowed 75%by old plaques in patients w
5、ho die suddenly(75 yrs and treated 12 hrs from sx onset were.The earlier treatment initiation,the greater the benefit and thus re-affirm the concept of “time is muscle.”2021/01/2110 Not every patient is eligible for thrombolytic treatment Cerebral/vascular bleed Percent AMI pts with TIMI 3 flow foll
6、owing thrombolysis is less than ideal Thrombolysis or PCI in AMI Limitations of Thrombolysis in AMI Patients2021/01/2111Thrombolysis or PCI in AMI Contraindications for fibrinolytics in AMIContraindicationsPrevious hemorrhagic stroke at any time;other strokes or cerebrovascular events within 1 yrKno
7、wn intracranial neoplasmActive internal bleeding(does not include menses)Suspected aortic dissectionAdapted from Ryan TJ,et al.ACC/AHA guidelines for the management of patients with AMI.J Am Coll Cardiol 1996;28:132814282021/01/2112Relative contraindicationsSevere uncontrolled hypertension on presen
8、tation(blood pressure 180/110 mm Hg)or chronic history of severe hypertensionHistory of prior cerebrovascular accident or known intracerebral pathology not covered in contraindicationsCurrent use of anticoagulants in therapeutic doses(international normalized ratio 23);known bleeding diathesisRecent
9、 trauma(within 24 wk),including head trauma or traumatic or prolonged(10 min)cardiopulmonary resuscitation or major surgery Noncompressible vascular puncturesRecent(within 24 wk)internal bleedingFor streptokinase/anistreplase:prior exposure(especially within 5 d2 yr)or prior allergic reactionPregnan
10、cy and Active peptic ulcerAdapted from Ryan TJ,et al.ACC/AHA guidelines for the management of patients with AMI.J Am Coll Cardiol 1996;28:13281428Thrombolysis or PCI in AMI Contraindications for fibrinolytics in AMI2021/01/2113 Previous large-scale randomized thrombolytic studies would suggest that
11、only 15-20%of Acute MI(AMI)patients are considered eligible for reperfusion therapy by conventional criteria More recent observational studies*with broader inclusion criteria would estimate that approximately 45 to 50%of AMI pts were eligible(ie.12 hrs symptom onset,chest pain with 2mm ST in any 2 c
12、ontiguous ECG leads or new LBBB)and 32-45%of pts actually received thrombolytic agents.Thrombolysis or PCI in AMI Eligibility for Thrombolysis in AMI PatientsKarlson BW et al Circ 1990;82:1140-6,*French JK et al BMJ 1996;312:1637-41*Reikvm et al Int J Cardiol 1997;61:79-832021/01/2114 Not every pati
13、ent is eligible for thrombolytic treatment Cerebral/vascular bleed and re-infarction Percent AMI pts with TIMI 3 flow following thrombolysis is less than ideal Thrombolysis or PCI in AMI Limitations of Thrombolysis in AMI Patients2021/01/2115ReteplaseN=8260Reteplase+Reopro N=8326OR(95%CI)P value30-d
14、ay mortality5.9%5.6%0.95(0.84-1.08)0.43Re-MI up to 7 days3.52.30.66(0.72-0.93)75yrs1.12.11.91(0.95-3.84)0.069Sever/Mod.Bleed2.34.62.03(1.7-2.42)0.0001Thrombolysis or PCI in AMI GUSTO V:Primary and Secondary Endpoints16,588 pts within 6hrs of STEMI randomized to standard dose of reteplase(n=8260)or-d
15、ose reteplase and full-dose Reopro(n=8328).The GUSTOV Investigators.Lancet 2001;357:1905-142021/01/2116 Not every patient is eligible for thrombolytic treatment Cerebral/vascular bleed Percent AMI pts with TIMI 3 flow following thrombolysis is less than ideal Thrombolysis or PCI in AMI Limitations o
16、f Thrombolysis in AMI Patients2021/01/2117The 90 Minute Wall:60%Rates of TIMI Grade 3 Flow%TIMI 3 Flow2021/01/2118 Incidence and Patho-anatomy of AMI Fibrinolysis for AMI Fibrinolysis Vs.Primary PCI Adjunct Pharmacology and Strategies Current Recommendations in Treatment of AMIThrombolysis or PCI in
17、 AMI 2021/01/2119Grines,C.L.et al.N Engl J Med 1993;328:673-679Thrombolysis or PCI in AMI PAMI:In-Hospital Reinfarction and Death395 Pts were enrolled in 12 sites with AMI within 12 hrs of symptom onset and randomized to immediate PTCA(n=195)vs.tPA(n=200)By 6 months,reMI or death had occurred in 15.
18、8%of pts treated with tPA and 8.5%treated with PTCA(p=0.02).2021/01/2120Thrombolysis or PCI in AMI Short(4-6wks)-term clinical Outcomes Post 1 PTCA Vs.ThrombolysisKeeley et al,Lancet 2003;361:13-20Summary of 23 trials totaling 7,739 pts(PTCA=3,872 and Thrombolysis=3,867 pts)27%65%54%47%2021/01/2121T
19、hrombolysis or PCI in AMI Advantages and Disadvantages of 1 PTCA Vs.ThrombolysisAdvantagesDisadvantagesSuperior vessel patency and TIMI 3 flowLack of generalized availabilityEarly definition of coronary anatomy allows risk stratificationDelay in mobilizing cath labReduced rates of recurrent ischemia
20、,re-MI,death,and strokeSkilled interventional cardiologys requiredImproved survival in high risk patientsNo large single mortality trial data availableReduced intracranial bleedShorter length of hospital stayAllows reperfusion when thrombolytics are contra-indicated2021/01/2122 Incidence and Patho-a
21、natomy of AMI Fibrinolysis for AMI Fibrinolysis Vs.Primary PCI Adjunct Pharmacology and Strategies Current Recommendations in Treatment of AMIThrombolysis or PCI in AMI 2021/01/2123Thrombolysis or PCI in AMI The ADMIRAL Trial Multi-center 300 pts randomized,double-blind placebo controlled study to d
22、emonstrate the superiority of abciximab over placebo in primary PTCA with stenting in acute myocardial infarctionMontalescot G et al NEJM 2001;344:1895-19032021/01/2124Thrombolysis or PCI in AMI ADMIRAL:Frequency of TIMI III FLOWP=0.01P=0.04P=0.33P=0.04Montalescot G et al NEJM 2001;344:1895-19032021
23、/01/2125Thrombolysis or PCI in AMI ADMIRAL:Composite Endpoint 6 monthP=0.13Montalescot G et al NEJM 2001;344:1895-1903P=0.32P=0.049P=0.02Reopro improves coronary patency before stenting,and clinical outcome at 30 days and 6 monthsN=149N=1512021/01/2126Thrombolysis or PCI in AMI CAPTIM:Study DesignPr
24、imary Composite Endpoint-30-day Death,Reinfarction,Disabling StrokeBonnefoy E,et al.Lancet 2002;360:825-9AMI within 6 hours1200 planned840 enrolledPrehospitalThrombolysisn=419PrimaryAngioplastyn=421Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction2021/01/2127Throm
25、bolysis or PCI in AMI CAPTIM:Study DesignP=0.61P=0.13P=0.12P=0.29Bonnefoy E,et al.Lancet 2002;360:825-9Primary PTCA was not better than pre-hospital thrombolysis with transfer for possible rescue PTCA in pts with 4 mm elevation),Sx 12 hrs5 PCI centers(n=443)and 22 referring hospitals(n=1,129),transf
26、er in 3 hrsLytic therapyFront-loaded tPA 100 mg(n=782)Death/Re-MI/Stroke at 30 DaysThrombolysis or PCI in AMI DANAMI-2:Study DesignPrimary PCIwith transfer(n=567)Primary PCIwithout transfer(n=223)Stopped early by safety and efficacy committeeAnderson HR et al NEJM 2003;349:733-422021/01/2129Death/MI
27、/Stroke(%)LyticPrimary PCIP=0.0003P=0.002CombinedTransfer SitesP=0.048Non-Transfer SitesThrombolysis or PCI in AMI DANAMI-2:Primary ResultsRRR 45%LyticPrimary PCILyticPrimary PCIRRR 40%RRR 45%Anderson HR et al NEJM 2003;349:733-422021/01/2130LyticPrimary PCIP=0.35DeathThrombolysis or PCI in AMI DANA
28、MI-2:ResultsLyticPrimary PCIP=0.15StrokeLyticPrimary PCIP0.0001Recurrent MIAnderson HR et al NEJM 2003;349:733-4296%OF PTS WERE TRANSFERRED FROM REFERRAL HOSP.TO INVASIVE CETNER WITHIN 2 HRS2021/01/2131Thrombolysis or PCI in AMI Prague 2:Long distant transfer vs.Thrombolysis in AMI Multicenter Czech
29、 study involving 850 pts with ST elevation MI within 12 hrs of symptom onset.Primary end point was 30-day moratlity,and composite secondary end points were:death,re-MI,stroke at 30 days.Widimsky P et al Eur Heart J 2003;24:94-1042021/01/2132Thrombolysis or PCI in AMI Prague 2:Long distant transfer v
30、s.Thrombolysis in AMIP=0.12P=NSP0.02P 3 hrs of symptom onset,PCI results in better clinical outcome despite long distance transfer.Widimsky P et al Eur Heart J 2003;24:94-1042021/01/2133Thrombolysis or PCI in AMI C-port:Key FindingsP=0.72P=0.04P=0.28P=0.03Aversano T et al JAMA 2002;287:1943-512021/0
31、1/2134 Time to Perfusion Volume of Hospital and experience of OperatorThrombolysis or PCI in AMIWhat Else is Important in AMI Treatment Strategy?Additional important parameters to maximize quality of care in the treatment of AMI patients2021/01/2135N=27,080,P 0.00001Thrombolysis or PCI in AMINRMI-2:
32、Primary PCI Door-to-Balloon time vs.MortalityDoor-to-Balloon Time(minutes)2021/01/2136Thrombolysis or PCI in AMI Mortality rates with primary PCI as a function of PCI-related time delayP=0.006020406080100PCI-Related Time Delay(door-to-balloon-door to needle)-5051015Circle sizes=sample size of the in
33、dividual studySolid line=weighted meta-regression Nallamothu BK,Bates ER.Am J Cardiol.2003;92:824-662 minBenefitFavors PCIHarmFavors LysisFor Every 10 min delay to PCI:1%reduction in mortality difference towards lyticsMeta-analysis of 23 studies with 7419 pts2021/01/2137 Time to Perfusion Volume of
34、Hospital and experience of OperatorThrombolysis or PCI in AMIWhat Else is Important in AMI Treatment Strategy?Additional important parameters to maximize quality of care in the treatment of AMI patients2021/01/2138Thrombolysis or PCI in AMINRMI-2:Hospital Volume of Primary PCI vs.Mortality N=4,740 1
35、4,078 8,262P=0.033P=0.00010.860.672021/01/2139 Incidence and Patho-anatomy of AMI Fibrinolysis for AMI Fibrinolysis Vs.Primary PCI Adjunct Pharmacology and Strategies Current Recommendations in Treatment of AMIThrombolysis or PCI in AMI 2021/01/2140Thrombolysis or PCI in AMI Importance of Early Repe
36、rfusion Therapy in STEMIOutcomes Dependent Upon:Time to treatment-TIME IS STILL MUSCLE Early and full restoration in coronary blood flow Sustained restoration of flow 2021/01/2141Thrombolysis or PCI in AMI Pharmacological ReperfusionAvailable ResourcesClass I1.STEMI patients presenting to a facility
37、 without the capability for expert,prompt intervention with primary PCI within 90 minutes of first medical contact should undergo fibrinolysis unless contraindicated.(Level of Evidence:A)Antman et al.JACC 2004;44:682.2021/01/2142Thrombolysis or PCI in AMI Fibrinolytic TherapyClass I In the absence o
38、f contraindication,fibrinolytic therapyshould be administered to STEMI patients with symptom onset within the prior 12 hours&ST elevation2.In the absence of contraindications,fibrinolytic therapyshould be administered to STEMI patients with symptom onset within the prior 12 hours and new or presumab
39、ly new LBBB.(Level of Evidence:A)Antman et al.JACC 2004;44:682-3.2021/01/2143Thrombolysis or PCI in AMI Primary Percutaneous Coronary InterventionClass I 1.General considerations:The procedure should be supported by experienced personnel in an appropriate laboratory environment(performs more than 20
40、0 PCI procedures per year,of which at least 36 are primary PCI for STEMI,and has cardiac surgery capability).(Level of Evidence:A)Antman et al.JACC 2004;44:682.2021/01/2144Thrombolysis or PCI in AMI Primary Percutaneous Coronary InterventionClass I 2.Specific Considerations:a.Primary PCI should be p
41、erformed as quickly as possible,with a goal of a medical contactto-balloon or door-to-balloon time of within 90 minutes.(Level of Evidence:B)b.If the symptom duration is within 3 hours and the expected door-to-balloon time minus the expected door-to-needle time is:i)within 1 hour,primary PCI is gene
42、rally preferred.(Level of Evidence:B)ii)greater than 1 hour,fibrinolytic therapy(fibrin-specific agents)is generally preferred.(Level of Evidence:B)c.If symptom duration is greater than 3 hours,primary PCI is generally preferred and should be performed with a medical contactto-balloon or door-to-bal
43、loon time as brief as possible,with a goal of within 90 minutes.(Level of Evidence:B)Antman et al.JACC 2004;44:6842021/01/2145Primary Percutaneous Coronary Intervention Facilitated PCIClass IIb1.Facilitated PCI might be performed as a reperfusion strategy in higher-risk patients when PCI is not imme
44、diately available and bleeding risk is low.2.(Level of Evidence:B)Antman et al.JACC 2004;44:686.2021/01/2146Fibrinolytic Therapy Combination Therapy with GP IIb/IIIaClass III1.Combination pharmacological reperfusion with abciximab and half-dose reteplase or tenecteplase should not be given to patien
45、ts aged greater than 75 years because of an increased risk of ICH.(Level of Evidence:B)Antman et al.JACC 2004;44:683.2021/01/2147Adapted from Figure 3;Antman et al.JACC 2004;44:682If presentation is 75 PPCI cases per year/Team experience 36 PPCI cases per year Delay to invasive strategyProlonged transport(Door-to Balloon)(Door-to-needle)time is 1 HRMedical contact-to-balloon time is than 90 minThrombolysis or PCI in AMIWhich Strategy to Choose?2021/01/2148THANKS FOR WATCHING谢谢大家观看为了方便教学与学习使用，本文档内容可以在下载后随意修改，调整。欢迎下载！时间：20XX.XX.XX汇报人：XXX2021/01/2149
