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1、心肌梗死的药物/介入策略,时间就是心肌，就是生命,时间对再灌注抢救的意义,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,Door-to-Balloon Time (minutes),校
2、正了的死亡率,P=0.01,P=0.0007,P=0.0003,n = 2,230,5,734,6,616,4,461,2,627,5,412,“拖” 多久可以接受？,2004ACC/AHAAMI指南的选择的推荐,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)1h Medical contact-balloon time1.5h,下列情形下介入更好 熟练的队伍且有外科保障 (Door-balloon)-(Door-needle)3h 诊断STEMI有疑问,如果3小时之内
3、到院，没有特别情况，两种方案均可,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？ 溶栓后还可以介入？,溶栓与PCI选择之考虑,至少有部分病人，溶栓可能优于PCI Who? When? Where? What? Which?,Sx Door Needle Balloon,策略的变化,2003 Greg Stone(Lancet): PPCI regardness of nearest cath suite 3 floors or 3 hrs away 2007JACC ACCAHA g
4、uideline Lytic 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 起病早3h到院者PCI/溶栓的衡量,圆的尺寸 = 单独研究的样本大小. 实 线= 加权meta回归.,62 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；114：2019-25,114min是个坎 但：所有病人一样吗？,选
5、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4 年龄，梗死部位，就诊时间,Circulation 2006；114：2019-25,直接PCI的可接受延搁时间取决于患者病情,Z=0.59X-0.033Y-0.0003W-1.3,Z=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PCI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-y
6、M Pt,3hAnt STEMI hemodynamically unstable TRS=5;Mortality=12.4% D2B-D2N=200min,溶栓后还可以PCI吗？,溶栓成功后的PCI- 不行到可行的过程,Immediate PCI,Immediate PCI-no good,Be abandoned for many years,Immediate PCI？ 80-90s data suggest harmful,lytic activated platelet,more thrombogenic Prone to hemorragic in intracoronary le
7、sion More vascular complications Aspirin not given with thrombolysis Low dose heparine,noACT monitor GP IIb/IIIa antagonist & Thienopydine not used Stent not available,ACC/AHA2004 AMI Guideline described early angiogram after successful lytic,Routine ,Immediately after lytic Tx ClassIII Following su
8、ccessful lytic Tx in Asx Pts without ischemia Class IIb,ACC/AHA2005 PCIGuideline described early angiogram after successful lytic,Little bit improved?,06 ESC AMI guideline :OK,Key trials for immediate PCI OK,CAPITAL further support routine PCI after lysis,07 further meta-analysis： new evidence of PC
9、I reasonable after lysis,溶栓后立即或缺血驱动PCI荟萃,Wijeysundera 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：短效溶栓药 介入的时机选对了,溶栓失败后的Rescue PCI- 不得不行到可行的过程,Rescue PCIearly,Rescue PCI(GUSTO-1),GUSTO-1-不补救更好,Key trial for rescue PCI,Meta analysis of Rescue PCI2007,易化PCI-与溶栓后PCI有区别 区别在哪里？,PACT,PA
10、CT,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 PCI,p=0.29,p=0.61,p=0.13,p=0.12,p=0.06,30d events rate,Bonnefoy, Lancet 2002 ；360:825-29,Key trials for facilitate PCI,如果已经准备PCI,不要乱给药了，不
11、给更好,FINESSE,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Ab无益处,Meta analysis for F-PCI prePCI TIMI flow not transfer to good outcome,Meta analysis for F-PCI,Facilitate PCI 2007 guideline,Pharmacoinvasive概念的提出,转运是安全的,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
12、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?,180min,110min,D2B,转运与立即PCI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.,32.5h,2.8h,转运与立即PCI的结合: Sx2hTNK,Bohmer E etal:JACC2010;55:102-110,3d,2.7h,溶栓后PCI Meta2010,溶栓后PCI获益,溶栓后PCI Meta-2011,30d 复合终点,
13、溶栓后PCI Meta-2011,30d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 safe Pt be divided into sent to capability of PCI institute or not Emphasize PPCI ASAP,
14、2010ESC介入指南,rt-PA半量溶栓后早期PCI治疗急性STEMI 疗效及安全性评价,Time intervals,lysis,2.0h 1.1h 0.5h 1.5h 6.8h,Median D-to-N time: 1.6h Median D-to-B time: 8.4h,symptom onset,hospitalization,consent signature,balloon infllation,2 with no lesions 50% diameter stenosis and 1 with unsuitable anatomy did not undergo PCI,6
15、 had TIMI 0-1,34 had TIMI 2-3,50 enrolled and accepted half-dose rt-PA,40(81.6%) Achieved clinical criteria of reperfusion,1 was unwilling to undergo angiography,9(18.4%) underwent rescue PCI,4 had TIMI 2-3,5 had TIMI 0-1,Early PCI 75.5%,Final flow of IRA,Final flow of IRA,8 had TIMI 2-3,1 had TIMI
16、0-1,36 had TIMI 2-3,1 had TIMI 0-1,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 % ) Complication
17、s - no.(%) Minor dissection 1 ( 2.2 % ) No reflow 2 ( 4.3 % ),(PPCI 5-25%),Improved TIMI grade flow,48.532.1,37.925.6,p0.01,Improved CTFC,Improved MBG,Optimal time of early PCI (Pilot),137.557.3,110.851.3,116.752.5,157.044.8,n=12,n=8,n=4,n=14,Optimal time of early PCI (Pilot),Clinical outcomes at 30days after symptom onset (n=47),1.5% 8.1%,Borgia1 et al.,1.0% - 4.9%,1.2% - 5.8%,Take 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12-24h,Thank you for your attention,