1、心肌梗死的药物心肌梗死的药物/介入策略介入策略时间就是心肌，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90年代中已证明溶栓治疗的益处与安慰剂对比2003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溶栓与介入的比较NRMI-2:死亡率与时间的关系“拖拖”多久可以接受？多久可以接受？2004ACC/AHAAMI2004ACC/AHAAMI指南的选择的推荐指
2、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，两种方案均可我们已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
3、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？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PCIPCIWho?When?Where?What?Which?Who?When?Where?What?Which?Sx Door Needle Balloon策略的变化策略的变化2003 Greg Stone(Lancet):PPCI regardness of nearest cath suite 3 floors or 3 hrs awayPPCI r
4、egardness of nearest cath suite 3 floors or 3 hrs away2007JACC ACCAHA guidelineLytic if anticipated PPCI is 90min give lytic within 30minLytic if anticipated PPCI is 90min give lytic within 30min选择依据1-起病长短选择依据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
5、 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减少1%Sx-B每延长30min，RR=1.08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？选择依据3-患者本身风险DANAMI-2发现转运PCI有益于高危者选择依据选择依据4 4年龄，梗死部位，就诊时间Circulation 2006；114：2019-25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
6、-0.033Y-0.0003W-1.3Z=PPCI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越是高危，PPCI越经“拖”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=200min溶栓后还可以溶栓后还可以PCIPCI吗
7、？吗？溶栓成功后的溶栓成功后的PCI-PCI-不行到可行的过程不行到可行的过程Immediate PCIImmediate PCIImmediate PCI-no goodImmediate PCI-no goodBe abandoned for many yearsImmediate PCIImmediate PCI？80-90s data suggest harmful80-90s data suggest harmfullytic activated platelet,more lytic activated platelet,more thrombogenicthrombogenicP
8、rone 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 used Stent not availableACC/AHA2004 AMI Guideline AC
9、C/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 IIbACC/AHA2005 PCIGuidelineACC/AHA2005 PCIGuideline described early ang
10、iogram after described early angiogram after successful lyticsuccessful lyticLittle bit improved?Little bit improved?06 ESC AMI guideline:OK06 ESC AMI guideline:OKKey trials for immediate PCI OKKey trials for immediate PCI OKCAPITAL further support routine PCI CAPITAL further support routine PCI aft
11、er lysisafter lysis07 further meta-analysis07 further meta-analysis：new evidence of PCI reasonable after lysisnew evidence of PCI reasonable after lysis溶栓后立即或缺血驱动溶栓后立即或缺血驱动PCIPCI荟萃荟萃Wijeysundera H:Am Heart J 2008;156:564-572Wijeysundera H:Am Heart J 2008;156:564-572为什么又行了？介入的发展：支架、IIb/IIIa 溶栓药的发展：短效
12、溶栓药 介入的时机选对了溶栓失败后的溶栓失败后的Rescue PCI-Rescue PCI-不得不行到可行的过程不得不行到可行的过程 Rescue PCIearlyRescue PCI(GUSTO-1)THANK YOUSUCCESS2022-10-1437可编辑GUSTO-1-不补救更好 Key trial for rescue PCIKey trial for rescue PCIMeta analysis of Rescue PCI2007易化易化PCI-PCI-与溶栓后与溶栓后PCIPCI有区别有区别区别在哪里？区别在哪里？PACTPACTCAPTIM Trial arouse som
13、e 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-hospital tPA vs primary PCIp=0.29p=0.61p=0.13p=0.12p=0.06Bonnefoy,Lancet 2002；Key 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FINES
14、SEFINESSE 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+OnTime2Finesse+OnTime2：PCIPCI前前AbAb无益处无益处Meta analysis for F-PCIprePCI TIMI flow not transfer to good outcomeMeta analysis for F-PCIFacilitate PCI 2007 guideline PharmacoinvasivePharmacoinvasive概概念的提出念的提出转运是安全的易化，立即，转
15、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?180min110minD2B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;360:2705-2718.32.5h2.8h转运与立即转运与立即PCIPCI的结合的结合:Sx2hTNKSx2hTNKBohmer E etal:JACC2010;55:102-
16、1103d2.7h溶栓后PCI Meta2010溶栓后PCI获益溶栓后PCI Meta-201130d 复合终点溶栓后PCI Meta-201130d缺血终点30d出血终点30d死亡率Latest 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 Lytic then PCI safesafe Pt be divided in
17、to sent to capability of PCI institute or not Emphasize PPCI ASAP2010ESC介入指南rt-PArt-PA半量溶栓后早期半量溶栓后早期PCIPCI治疗急性治疗急性STEMISTEMI 疗效及安疗效及安全性评价全性评价Time intervalsTime intervalslysislysis2.0h 1.1h 0.5h 1.5h 2.0h 1.1h 0.5h 1.5h 6.8h6.8hMedian D-to-N time:1.6h Median D-to-B time:Median D-to-N time:1.6h Median
18、 D-to-B time:8.4h8.4hsymptom symptom onsetonsethospitalizationhospitalizationconsent consent signaturesignature balloon balloon infllationinfllation2 with no lesions 50%2 with no lesions 50%diameter stenosis and 1 diameter stenosis and 1 with unsuitable anatomy with unsuitable anatomy did not underg
19、o PCIdid not undergo PCI6 had 6 had TIMI 0-1TIMI 0-134 had 34 had TIMI 2-3TIMI 2-350 enrolled and accepted half-dose rt-50 enrolled and accepted half-dose rt-PA PA 40(81.6%)Achieved 40(81.6%)Achieved clinical criteria of clinical criteria of reperfusionreperfusion1 was unwilling to undergo angiograp
20、hy 1 was unwilling to undergo angiography 9(18.4%)underwent 9(18.4%)underwent rescue PCI rescue PCI 4 had 4 had TIMI 2-3TIMI 2-35 had 5 had TIMI 0-1TIMI 0-1Early PCI 75.5%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 0-1Procedural characteri
21、stics(n=46)Procedural 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%)Coronary stents,-no.(%)45(97.8%)Complications-no.(%)Minor dissection 1(2.2%)No reflow 2(4.3%)(PPCI 5-25%)Impro
22、ved TIMI grade flowImproved TIMI grade flow 48.532.137.925.6p p0.010.01Improved CTFCImproved CTFC Improved MBGImproved MBG 59.737.226.719.936.923.437.821.5n=12n=8n=15n=11Optimal time of early PCI(Pilot)Optimal time of early PCI(Pilot)137.557.3110.851.3116.752.5157.044.8n=12n=8n=4n=14Optimal time of
23、early PCIOptimal time of early PCI(Pilot)(Pilot)Clinical outcomes at 30days after Clinical outcomes at 30days after symptom onset(n=47)symptom onset(n=47)1.5%8.1%1.5%8.1%Borgia1 et al.1.0%-4.9%1.0%-4.9%1.2%-5.8%1.2%-5.8%Take 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
24、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12-24hp 经常不断地学习,你就什么都知道。你知道得越多,你就越有力量p Study Constantly,And You Will Know Everything.The More You Know,The More Powerful You Will Be学习总结结束语当你尽了自己的最大努力时，失败也是伟大的，所以不要放弃，坚持就是正确的。When You Do Your Best,Failure Is Great,So DonT Give Up,Stick To The End演讲人：XXXXXX 时 间：XX年XX月XX日
