急性心梗再灌注實(shí)踐(何奔)課件

1、急性心肌梗死的再灌注治療證據(jù)指南到實(shí)踐上海交通大學(xué)仁濟(jì)醫(yī)院 何奔再灌注治療的效果取決于治療的時(shí)間-時(shí)間就是心肌血流的盡早與充分恢復(fù)血流恢復(fù)的持續(xù)性盡早，充分，持續(xù)的心肌血流灌注時(shí)間對(duì)再灌注搶救的意義0 - 0.5 hrs預(yù)防梗死0.5 2 hrs 大量挽救心肌 + IRA開通的益處2 6 hrs心肌挽救降低, IRA開通的益處 6 hrs基本不挽救心肌, 但有IRA開通的益處Giugliano & Braunwald Circ 2003 溶栓治療的益處與安慰劑對(duì)比心梗治療-溶栓與介入對(duì)比 Keeley EC, et al. Lancet. 2003;361:13-20.PCIThromboly

2、tic therapy0510251520Frequency (%)Short-term OutcomesDeathP=.0002Death, Excluding SHOCK DataP=.0003NonfatalMIP.0001RecurrentIschemiaP.0001Total StrokeP=.0004Hemor-rhagicStrokeP.0001MajorBleedP=.032Death, Nonfatal Reinfarction,or StrokeP1hMedical contact-balloon time1.5h下列情形下介入更好熟練的隊(duì)伍且有外科保障(Door-ball

3、oon)-(Door-needle)1hMedical contact-balloon time3h診斷STEMI有疑問如果3小時(shí)之內(nèi)到院，沒有特別情況，兩種方案均可轉(zhuǎn)運(yùn)還是比就地溶栓好NRMI 3/4:轉(zhuǎn)運(yùn)的現(xiàn)實(shí)延遲% of Patients進(jìn)門至球囊擴(kuò)張時(shí)間(hours)Nallamothu et al. Circulation 2005; 111: 761-767中位轉(zhuǎn)運(yùn)時(shí)間3h 僅4.2% 的病人符合 ACC/AHA指南推薦的D-B時(shí)間 90 minutes急性心梗PCI的新舊名詞分類直接PCI( Direct/Primary PCI)立即PCI( Immediate PCI): 溶栓

4、后IRA開補(bǔ)救性PCI( Rescue PCI):溶栓后IRA未開延遲性PCI(Delayed PCI/Deferred)6-24h選擇性PCI(Elective PCI)易化PCI(Facilitated PCI)ESC補(bǔ)救性PCI早年補(bǔ)救性PCI(GUSTO-1)提示了啥？REACT 試驗(yàn)再次肯定了補(bǔ)救PCIDec2005 發(fā)表于NEJM溶栓后常規(guī)PCI對(duì)生存率的影響: TIMI experience（20，000例）P0.0001P=0.0001P0.0001P0.0001P=0.0001P0.0001N=20,101Gibson et al JACC 2003; 42: 7-16支架時(shí)

5、代的延遲( ASA + Heparin 5000U; pre-hospital tPA vs primary PCIp=0.29p=0.61p=0.13p=0.12p=0.0630天事件率Bonnefoy, Lancet 2002 ；360:825-29ASSENT-4-易化PCI的終結(jié)者？ON-TIME: Post PCIp=0.022p=nsp=nsp=nsConclusion: No difference with early pretreatments with Tirofiban for PCI in AMI這一時(shí)段我們無所作為嗎？如果病人癥狀12h，怎么辦？問題？-答案PCI與溶栓如何選擇？轉(zhuǎn)運(yùn)的時(shí)間延擱，多久可以接受？安全嗎？如果溶栓失敗，下一步咋辦？如果溶栓成功，還要常規(guī)造影+/-PCI？如果是，什么時(shí)間合適？立即/補(bǔ)救/延