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1、受体阻滞剂在PCI术的应用,提 纲, 受体阻滞剂药理 心率增快增加冠心病患者的临床事件 受体阻滞剂在PCI围手术期的应用,药理学及作用机制,主要机制：对抗儿茶酚胺类肾上腺素能递质毒性尤其是通过1受体介导的心脏毒性，是此类药物发挥心血管保护作用。 其他机制： 1.抗高血压作用 2.抗心肌缺血作用 3.阻断肾小球旁细胞1受体，抑制肾素-AngII-醛固酮系统。 4.改善心脏功能增加LVEF: 5.抗心律失常作用 6.其他：抑制肾上腺素能通路介导的心肌细胞凋亡、抑制血小板聚集、减少对粥样硬化斑块的机械应激、防止斑块破裂等。,心率增快增加冠心病患者的风险！,The effect of heart ra
2、te on local haemodynamic forces on the endothelium.,Mechanisms whereby an elevated heart rate leads to adverse outcomes in patients with coronary artery disease.,阻滞剂在急性心肌梗死的应用,阻滞剂在慢性稳定性心绞痛的应用,Expert consensus document on -adrenergic receptor blockers. European Heart Journal .2004, 25: 13411362.,Hear
3、t Rate as an Independent Prognostic Risk Factor in Patients with Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention,CONCLUSION: In patients with acute myocardial infarction undergoing primary PCI, elevated heart rate (80 bpm or greater) identifies those at increased ri
4、sk of death. It is unknown whether heart rate reduction will result in improved outcome in this setting of patients.,急性心肌梗死患者急诊行PCI，心率增快的患者发生院内死亡的风险明显增高！,阻滞剂在心肌梗塞后二级预防的应用,阻滞剂在非ST段抬高ACS的应用,PURE研究：我国社区冠心病患者的受体阻滞剂使用率低于中低收入国家平均水平,Yusuf S, et al. Lancet. 2011;378:1231-1233.,中国属于 中低收入国家,实践与指南的差距：阻滞剂在中国冠心病
5、患者中使用现状,中华医学会心血管病学分会中华心血管病杂志编辑委员会.肾上腺素能受体阻滞剂在心血管疾病应用专家共识.,使用率低,使用时间滞后,剂量较低,获益渐少,受体阻滞剂在PCI围手术期的应用,受体阻断剂在非心脏手术期间的使用一直受到重视!,但是在PCI围手术期间的使用？,2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction. 2007 Focused Update of the ACC/AHA/SCAI 2005 Guide
6、line Update for Percutaneous Coronary Intervention. .,Antithrombotic： 1. UH, LMWH 2. GP IIb/IIIa Inhibitors 3. Bivalirudin,-block？ statin ？,Antiplatelet： 1. Aspirin 2. clopidogrel,受体阻断剂在PCI围手术期间的使用,术前 术中 术后,PCI术前使用阻滞剂减少术后CK-MB的上升,Samin K. Sharma, Annapoorna Kini, Jonathan D. Marmur,et al. Cardioprot
7、ective Effect of Prior -Blocker Therapy in Reducing Creatine Kinase-MB Elevation After Coronary Intervention . Circulation. 2000,102:166 -172,PCI术前使用阻滞剂与未使用组术后CK-MB增高的发生率及增高程度比较,术前使用阻滞剂对AMI PCI术后临床预后的影响,Harjai KJ, Stone GW, Boura J, et al. Effects of prior beta-blocker therapy on clinical outcomes a
8、fter primary coronary angioplasty for acute myocardial infarction. Am J Cardiol 2003;91:65560.,AMI PCI术前使用BB与未使用两组术后并发症、住院期间及一年随访临床预后的比较,AMI PCI术前静注阻滞剂提高术后生存率,Amir Halkin , Cindy L. Grines , David A. Cox ,et.al.Impact of intravenous Beta-Blockade before primary angioplasty on survival in patients un
9、dergoing mechanical reperfusion therapy for acute myocardial infarction. J Am Coll Cardiol, 2004; 43:1780-1787 .,术前静脉注射BB与未注射组随访30天及一年生存率的比较,RABBIT II 研究,PCI术中冠状动脉内注射阻滞剂渐少术后不良事件发生率,Barry F Uretsky; Ernst R Schwarz; Abdulfatah Osman ,et al.Intracoronary Beta Blockade (BB) During Percutaneous Coronary
10、 Intervention (PCI): 30 Day Results of the Randomized Angioplasty Beta Blocker Intracoronary Trial II (RABBIT II). Circulation. 2006;114:II_547,急性心肌梗塞PCI术后使用阻滞剂对临床预后的影响,Steven J. Kernis, Kishore J. Harjai, Gregg W. Stone, et.al. Does beta-blocker therapy improve clinical outcomes of acute myocardial
11、 infarction after successful primary angioplasty?JACC,43（10）:1773 - 1779.,术后使用BB组较未使用组显著降低死亡率及主要心脏不良事件率,急性心肌梗塞PCI术后使用阻滞剂对临床预后的影响,AMI PCI术后使用阻滞剂显著渐少六个月死亡风险,PCI术后使用阻滞剂减少一年死亡率,PCI术后使用BB与未使用组随访一年生存率的比较.P=0.0014.,Albert W. Chan, Martin J. Quinn, Deepak L. Bhatt, et.al, Mortality Benefit of Beta-Blockade
12、After Successful Elective Percutaneous Coronary Intervention. Journal of the American College of Cardiology.2002,40(4)670-675.,Am Heart J 2003;145:875-81,Conclusions -Adrenergic receptor blockers prescribed after PCI reduced the risk of clinical restenosis, target lesion restenosis, and MACE in this
13、 cohort of 4840 patients. The mechanism by which -blockers conferred a protective effect against restenosis remains to be determined. (Am Heart J 2003;145:875-81.),PCI术后长期使用受体阻断剂可以明显减少再狭窄导致的临床事件！,围PCI期间使用受体阻断剂基于以下几个方面,抗炎与稳定斑块 心肌保护 预防再狭窄！,These findings suggest that metoprolol could inhibit the devel
14、opment of atherosclerosis and stabilize vulnerable plaque by regulation of lipid and reduction of inflammation, in which the change from low shear stress to physiological shear stress around plaque may play an important role.,Conclusions: The intravenous administration of metoprolol before coronary
15、reperfusion results in larger myocardial salvage than its oral administration initiated early after reperfusion. If confirmed in the clinical setting, the timing and route of -blocker initiation could be revisited.,结论： 术前尽早静脉使用美托洛尔可以挽救更多的心肌！,问题是： 受体阻断剂的使用远远不足！,Use of -blockers and effects on heart r
16、ate and blood pressure post-acute coronary syndromes: Are we on target?,Results Only 5.3% achieved an average HR of 50 to 60 beat/min throughout the hospital stay. Conclusions Although effective levels of BP were maintained during hospitalization for an ACS, target HRs were generally not achieved. (Am Heart J 2009;158:378-85.),小 结,受体阻滞剂是冠心病药物治疗的基石，不仅改善症状且能改善预后 PCI术围手术期使用受体阻滞剂可减少并发症、改善患者预后；减轻围手术期的心肌微损伤，减少再狭窄。 临床上受体阻滞剂的使用相当不足！,