《ST抬高心肌梗死溶栓与抗栓治疗进展》由会员分享，可在线阅读，更多相关《ST抬高心肌梗死溶栓与抗栓治疗进展（74页珍藏版）》请在金锄头文库上搜索。
1、ST抬高心肌梗死溶栓与抗栓治疗抬高心肌梗死溶栓与抗栓治疗-2009进展进展 西安交通大学医学院第一附属医院西安交通大学医学院第一附属医院西安交通大学医学院第一附属医院西安交通大学医学院第一附属医院心内科心内科心内科心内科 袁祖贻袁祖贻袁祖贻袁祖贻 急性急性ST段抬高心梗治疗目标段抬高心梗治疗目标恢复心肌水平再灌注恢复心肌水平再灌注尽早、完全、持续尽早、完全、持续限制梗死面积 保护LV功能避免心力衰竭和心源性休克 解决残余狭窄降低死亡率改善预后降低死亡率改善预后Yusuf S, et al. Circulation. 1990;82(suppl II):II-117-II-134.Schrder
2、 R, et al. J Am Coll Cardiol. 1995;26:1657-1664.时间就是心肌！时间就是心肌！时间就是生命！时间就是生命！Symptom RecognitionCall to Medical SystemEDCath LabPreHospitalDelay in Initiation of Reperfusion TherapyIncreasing Loss of MyocytesTreatment Delayed is Treatment DeniedTreatment Delayed is Treatment Denied溶栓治疗溶栓治疗 ？直接直接 PCI
3、PCI ？STEMI病人，应采取何种再灌注策略：病人，应采取何种再灌注策略：溶栓溶栓 vs 直接直接 PCI溶栓血流血流TIMI 3 比例比例60% 再梗死发生率再梗死发生率 4%卒中总发生率卒中总发生率 2%ICH发生率发生率 1%任何地点任何地点(院前院前)任何时间任何时间所有医生所有医生无时间延迟无时间延迟大规模临床试验证实大规模临床试验证实直接PCI血流血流TIMI 3 比例比例80-90% 再梗死发生率再梗死发生率 1h)评估评估评估评估STEMISTEMI再灌注方式再灌注方式再灌注方式再灌注方式 ACC/AHA 2007 STEMI GuidelinesACC/AHA 2007 S
4、TEMI Guidelinesn n 症状发作后的时间症状发作后的时间症状发作后的时间症状发作后的时间n n STEMISTEMI危险分层危险分层危险分层危险分层n n 溶栓风险溶栓风险溶栓风险溶栓风险n n 转运至熟练转运至熟练转运至熟练转运至熟练PCIPCI导管室所需时间导管室所需时间导管室所需时间导管室所需时间Circulation 2007 August 10;114:671-719步骤步骤1 1：评估时间和危险性评估时间和危险性评估评估评估评估STEMISTEMI再灌注方式再灌注方式再灌注方式再灌注方式 ACC/AHA 2007 STEMI GuidelinesACC/AHA 200
5、7 STEMI Guidelines步骤步骤2：决定应首选溶栓还是决定应首选溶栓还是PCI 如果时间少于如果时间少于如果时间少于如果时间少于3 3 3 3小时，且介入治疗无耽搁，溶栓和小时，且介入治疗无耽搁，溶栓和小时，且介入治疗无耽搁，溶栓和小时，且介入治疗无耽搁，溶栓和PCIPCIPCIPCI首选哪种都可以，二者在减少梗死面积，降低死亡首选哪种都可以，二者在减少梗死面积，降低死亡首选哪种都可以，二者在减少梗死面积，降低死亡首选哪种都可以，二者在减少梗死面积，降低死亡率方面效果相似。但倾向率方面效果相似。但倾向率方面效果相似。但倾向率方面效果相似。但倾向PCIPCIPCIPCI，因可降低出血
6、与卒中。，因可降低出血与卒中。，因可降低出血与卒中。，因可降低出血与卒中。Circulation 2007 August 10;114:671-7193 3 3 312121212小时患者，小时患者，小时患者，小时患者， PCIPCIPCIPCI可挽救更多心肌，还可减少卒中。可挽救更多心肌，还可减少卒中。可挽救更多心肌，还可减少卒中。可挽救更多心肌，还可减少卒中。如无如无如无如无PCIPCIPCIPCI条件，且有溶栓禁忌，应立即转院。条件，且有溶栓禁忌，应立即转院。条件，且有溶栓禁忌，应立即转院。条件，且有溶栓禁忌，应立即转院。23232323个随机研究，直接个随机研究，直接个随机研究，直接个
7、随机研究，直接PCIPCIPCIPCI降低全因死亡，非致死降低全因死亡，非致死降低全因死亡，非致死降低全因死亡，非致死MIMIMIMI，卒，卒，卒，卒中，通畅率，心功能等指标优于静脉溶栓。中，通畅率，心功能等指标优于静脉溶栓。中，通畅率，心功能等指标优于静脉溶栓。中，通畅率，心功能等指标优于静脉溶栓。Circulation 2007 August 10;114:671-719直接直接PCI与溶栓疗法的汇萃分析与溶栓疗法的汇萃分析（23个随机研究）个随机研究）PCIPCILyticsLytics7%7%5%9%总死亡总死亡总死亡总死亡( (包括心源性休克包括心源性休克包括心源性休克包括心源性休克
8、) )1%P=0.0002P=0.0002P=0.0003P=0.0003(n = 7739)(n = 7739) (%) Events死亡死亡死亡死亡( (排除心源性休克排除心源性休克排除心源性休克排除心源性休克) )非致命性非致命性非致命性非致命性再次心梗再次心梗再次心梗再次心梗中风中风中风中风Hemorrhagic Hemorrhagic CVACVA0.05%2%1% 7%3%P0.0001P0.0001P0.0001P0.0001P0.0001P0.0001KeeleyKeeley et al et al， Lancet 2003; 361:13-20Lancet 2003; 361
9、:13-20ACC/AHA 2007 & ESC 2008 指南指南: 直接直接PCI 应用于急性应用于急性ST段抬高心梗段抬高心梗 Class I 一般考虑一般考虑发病发病发病发病 12 12 小时之内小时之内小时之内小时之内患者就诊到球囊开通血管时间患者就诊到球囊开通血管时间患者就诊到球囊开通血管时间患者就诊到球囊开通血管时间 90 min 75 75 例例例例 / / 年年年年导管室手术量导管室手术量导管室手术量导管室手术量 200 200 例例例例 / / 年年年年，直接直接直接直接PCI 36 PCI 36 例例例例 / / 年年年年有胸外科支持有胸外科支持有胸外科支持有胸外科支持C
10、irculation 2007 August 10;114:671-719Class I 症状发作时间症状发作时间症状发作时间症状发作时间 3 3小时，预计：小时，预计：小时，预计：小时，预计： 就诊就诊就诊就诊- - 球囊开通血管时间（球囊开通血管时间（球囊开通血管时间（球囊开通血管时间（D-ND-N）减去就诊）减去就诊）减去就诊）减去就诊- -开始溶开始溶开始溶开始溶栓时间栓时间栓时间栓时间(D-B) (D-B) l l 1 1 1小时小时小时小时, , 溶栓疗法更好溶栓疗法更好溶栓疗法更好溶栓疗法更好 症状发作时间症状发作时间症状发作时间症状发作时间 3 3小时，直接小时，直接小时，直接
11、小时，直接 PCI PCI 更好更好更好更好Circulation 2007 August 10;114:671-719STEMI STEMI ：直接：直接：直接：直接 PCI PCI 治疗治疗治疗治疗n n四个高危亚组直接四个高危亚组直接PCI疗效优于溶栓组疗效优于溶栓组心源性休克心源性休克前壁心梗、再发心梗前壁心梗、再发心梗心力衰竭心力衰竭老年人老年人 70 70 岁岁溶栓治疗是否已经过时溶栓治疗是否已经过时？n n各种原因导致的各种原因导致的时间延迟大大降低了直接时间延迟大大降低了直接时间延迟大大降低了直接时间延迟大大降低了直接PCIPCI的获益的获益的获益的获益。对。对于不能直接于不能
12、直接PCIPCI达到理想再灌注的患者，达到理想再灌注的患者，溶栓治疗溶栓治疗溶栓治疗溶栓治疗仍然是仍然是较好的选择！较好的选择！n n即使在欧美国家，即使在欧美国家，AMIAMI再灌注治疗中再灌注治疗中溶栓与直接溶栓与直接PCIPCI的比的比例相当例相当。国际上多项注册研究显示，虽然。国际上多项注册研究显示，虽然PCIPCI治疗近年来治疗近年来增长迅速，但增长迅速，但仍有接近仍有接近仍有接近仍有接近40%40%的患者接受溶栓治疗的患者接受溶栓治疗的患者接受溶栓治疗的患者接受溶栓治疗。急性ST段抬高心肌梗死溶栓治疗的中国专家共识(2009年更新版).“ “时间就是心肌时间就是心肌” ” - -
13、时间与死亡率关系时间与死亡率关系时间与死亡率关系时间与死亡率关系（NRMI-2 NRMI-2 研究）研究）研究）研究）P=0.01P=0.0007P=0.0003NRMI 2: Primary PCI door-to- balloon time vs mortalityn = 2,2305,734Door-to-balloon time (minutes)6,6164,4612,6275,4120-60 61-90 91-120 121-150 150-180 0-60 61-90 91-120 121-150 150-180 180180Mortality(%)不具备不具备不具备不具备24h
14、24h24h24h急诊急诊急诊急诊PCIPCIPCIPCI治疗条件的医院。治疗条件的医院。治疗条件的医院。治疗条件的医院。不具备不具备不具备不具备24h24h24h24h急诊急诊急诊急诊PCIPCIPCIPCI治疗条件也不具备迅速转运条件的医院。治疗条件也不具备迅速转运条件的医院。治疗条件也不具备迅速转运条件的医院。治疗条件也不具备迅速转运条件的医院。具备具备具备具备24h24h24h24h急诊急诊急诊急诊PCIPCIPCIPCI治疗条件，患者就诊早（症状持续治疗条件，患者就诊早（症状持续治疗条件，患者就诊早（症状持续治疗条件，患者就诊早（症状持续3h3h3h3h）；）；）；）；具备具备具备具
15、备24h24h24h24h急诊急诊急诊急诊PCIPCIPCIPCI治疗条件，患者就诊时症状持续大于治疗条件，患者就诊时症状持续大于治疗条件，患者就诊时症状持续大于治疗条件，患者就诊时症状持续大于3 3 3 3小时，但小时，但小时，但小时，但就诊就诊就诊就诊- - - -球囊扩张球囊扩张球囊扩张球囊扩张与与与与就诊就诊就诊就诊- - - -溶栓溶栓溶栓溶栓时间相差（时间相差（时间相差（时间相差（PCIPCIPCIPCI相关的延误）超过相关的延误）超过相关的延误）超过相关的延误）超过60min60min60min60min或或或或就诊就诊就诊就诊- - - -球囊扩张球囊扩张球囊扩张球囊扩张时间超
16、过时间超过时间超过时间超过90min90min90min90min（新指南的建议为：（新指南的建议为：（新指南的建议为：（新指南的建议为：FMCFMCFMCFMC（首次医疗接触）到（首次医疗接触）到（首次医疗接触）到（首次医疗接触）到球囊扩张的时间）。球囊扩张的时间）。球囊扩张的时间）。球囊扩张的时间）。 时间就是心肌！时间就是心肌！溶栓治疗首选条件溶栓治疗首选条件(2009)20092009急性急性STST段抬高心梗溶栓治疗中国专家共识段抬高心梗溶栓治疗中国专家共识再次溶栓治疗n n如果患者有证据显示血管持续闭塞、开通后在闭塞或下降的ST段再次抬高。患者应该立即进行PCI或转运至可行PCI的
17、医院，此外，可考虑进行再次溶栓治疗，并选择无免疫原性的溶栓药物。溶栓药物的选择n非特异性非特异性纤溶酶原激活剂纤溶酶原激活剂- 链激酶链激酶(SK) (SK) 和尿激酶（和尿激酶（UKUK）n特异性特异性纤溶酶原激活剂纤溶酶原激活剂- 人重组组织型纤溶酶原激活剂（人重组组织型纤溶酶原激活剂（rtrt-PA-PA） 瑞替普酶瑞替普酶(r-PA)(r-PA)，兰替普酶，兰替普酶(n-PA)(n-PA)，替耐普酶，替耐普酶 (TNK-(TNK-tPAtPA) ) ) ) 不同溶栓药物主要特点的比较不同溶栓药物主要特点的比较溶栓药物溶栓药物常规剂量常规剂量纤维蛋白纤维蛋白特异性特异性抗原性及抗原性及过
18、敏反应过敏反应纤维蛋白纤维蛋白原消耗原消耗90分钟分钟再通率再通率(%)#TIMI 3级级血流血流(%)尿激酶60分钟,150万单位否无明显未知未知链激酶3060分钟,150万单位否有明显5032阿替普酶90分钟 100mg是无轻度8054瑞替普酶10MU2,每次2分钟是无中度8060替奈普酶3050mg根据体重*是无极小7563 2009急性急性ST段抬高心梗溶栓治疗的中国专家共识段抬高心梗溶栓治疗的中国专家共识n n我国溶栓治疗的患者中绝大多数（我国溶栓治疗的患者中绝大多数（90%90%）应）应用非选择性溶栓药物用非选择性溶栓药物, , 应用组织型纤溶酶原激应用组织型纤溶酶原激活剂（活剂（
19、t-PAt-PA）者仅占）者仅占2.7%2.7%。n n应该积极推进应该积极推进规范的溶栓治疗规范的溶栓治疗，以提高我国，以提高我国急性急性急性急性STST段抬高心梗的再灌注治疗的段抬高心梗的再灌注治疗的比例比例和和成功率成功率！急性ST段抬高心肌梗死溶栓治疗的中国专家共识(2009年更新版). 首诊到基层医院的首诊到基层医院的AMIAMI病病人，应采取何种再灌注策略：人，应采取何种再灌注策略：就地溶栓治疗就地溶栓治疗 ？转运直接转运直接 PCI PCI ？PRAGUE PRAGUE 研究研究研究研究p = nsp = nsp 0.02p 0.02WidimskyWidimsky et al
20、et al EurEur Heart J 2003; 24: 94 Heart J 2003; 24: 94转运转运转运转运PCI PCI 和就地溶栓治疗对死亡率的影响（发病时间考虑）和就地溶栓治疗对死亡率的影响（发病时间考虑）和就地溶栓治疗对死亡率的影响（发病时间考虑）和就地溶栓治疗对死亡率的影响（发病时间考虑）STEMI：转院距离短，延迟时间不长（：转院距离短，延迟时间不长（PCI90min） PRAGUE-2 StudyPRAGUE-2 Study (N=300)(N=300)(N=300)p0.001p0.00123.0%15.0%8.0%p0.001p90min) n直接PCI？n易
21、化PCI？ASSENT-4研究研究20062006年发表在年发表在LancetLancet；11201120例患者比较：直接例患者比较：直接PCI PCI vsvs 易化易化PCIPCI；易化易化PCIPCI组死亡率显著增高；组死亡率显著增高；只有低出血只有低出血/ /高危高危STEMISTEMI患者获益。患者获益。FINESSE研究研究20072007年年ESCESC会议上公布；会议上公布；24532453例例STEMISTEMI：瑞替普酶瑞替普酶+ +阿昔单抗易化阿昔单抗易化PCIPCI vsvs 阿昔单阿昔单抗易化抗易化PCIPCI vsvs 直接直接PCIPCI虽然易化虽然易化PCIP
22、CI组术前冠脉血流明显优于直接组术前冠脉血流明显优于直接PCIPCI组，但三组，但三组组9090天死亡、心衰、心源性休克等天死亡、心衰、心源性休克等MACEMACE发生率无差异；发生率无差异；易化易化PCIPCI组出血危险明显增高。组出血危险明显增高。ESC 2007, Sept 1-4AHA/ACC 2007 & ESC 2008 Guideline：异化：异化PCIn n低出血风险的低出血风险的高危高危STEMISTEMI患者，在不能立即行患者，在不能立即行PCIPCI时可采用异化时可采用异化PCIPCI策略。（策略。（Class Class b b）2009年：年：CAPTIM最新随访结
23、果最新随访结果随机5000 U IV肝素肝素+250-500mg阿司匹林阿司匹林主要终点：主要终点：5年随访中的死亡率年随访中的死亡率Bonnefoy E et al, European Heart Journal 2009.急性急性ST段抬高心梗患者段抬高心梗患者直接行直接行PCI(n=421)rt-PA异化异化PCI (n=419)CAPTIM:异化异化PCI降低降低5年全因死亡率年全因死亡率患者症状发作6小时内，rt-PA溶栓后行PCI的5年全因死亡率为 9.7% vs 12.6%Bonnefoy E et al, European Heart Journal 2009.症状发作症状发作
24、6小时小时内，内，P=0.18HR 0.75 (95% CI,0.50-1.14)死亡风险死亡风险25%症状发作症状发作2小时小时内，内，p=0.04HR 0.50(95% CI,0.25-0.97)症状发作2小时内，rt-PA溶栓后行PCI的5年死亡率仅为单纯PCI组的50%Bonnefoy E et al, European Heart Journal 2009.死亡风险死亡风险50%CAPTIM:异化异化PCI降低降低5年全因死亡率年全因死亡率2009ESC：NORDISTEMIn nObjective: To compare 2 different strategies after t
25、hrombolysis Objective: To compare 2 different strategies after thrombolysis for STEMI in patients with very long transfer times:for STEMI in patients with very long transfer times:A: Immediate transfer for CAG/PCIA: Immediate transfer for CAG/PCIB: Conservative, ischemia-guided treatmentB: Conservat
26、ive, ischemia-guided treatmentHalvorsen S: Presented in ESC 2009NORDISTEMI：study designBonnefoy E et al, European Heart Journal 2009. 300mg + Tenecteplase (TNK)Enoxaparin + Clopidogrel 300mgA: Immediate transfer A: Immediate transfer for CAG/PCIfor CAG/PCIB: ConservativeB: Conservativeischemia-guide
27、d treatmentischemia-guided treatmentAcute STEMI 90 minClinical Outcome at 30 days:ConservativeConservativeInvasiveInvasive21%4.5%9.8%10%Death,re-MI,strokeDeath,re-MI,strokeNew ischemiaNew ischemiaRR=0.49(0.27-0.89)RR=0.49(0.27-0.89)P=0.003P=0.003 (%) EventsDeath,re-Death,re-MI,strokeMI,stroke) )Deat
28、h Death 2.2%2.3%Bonnefoy E et al, European Heart Journal 2009.RR=0.45(0.16-1.14)RR=0.45(0.16-1.14)P=0.14P=0.14 STEMI药物再灌注治疗药物再灌注治疗组成要素组成要素FibrinolyticFibrinolyticSKSK Fibrin- specificFibrin- specificAntiplateletAntiplateletASAASA GP IIb/IIIaGP IIb/IIIa ClopidegrelClopidegrelAnticoagulantAnticoagulan
29、tUFHUFH Alternative Agents Alternative AgentsSTEMI长期双重抗血小板治疗明显获益长期双重抗血小板治疗明显获益CLARITY TIMI-28CLARITY TIMI-28COMMIT/CCS-2COMMIT/CCS-2ESC 2008: STEMI Guideline糖蛋白b/a抑制剂：n n糖蛋白糖蛋白糖蛋白糖蛋白b/ab/ab/ab/a抑制剂与溶栓药物联合可提高疗效，但出血并发症增加。抑制剂与溶栓药物联合可提高疗效，但出血并发症增加。抑制剂与溶栓药物联合可提高疗效，但出血并发症增加。抑制剂与溶栓药物联合可提高疗效，但出血并发症增加。n n阿昔单
30、抗和半量瑞替普酶或替奈普酶联合使用进行再灌注治疗对前壁阿昔单抗和半量瑞替普酶或替奈普酶联合使用进行再灌注治疗对前壁阿昔单抗和半量瑞替普酶或替奈普酶联合使用进行再灌注治疗对前壁阿昔单抗和半量瑞替普酶或替奈普酶联合使用进行再灌注治疗对前壁心肌梗死、年龄心肌梗死、年龄心肌梗死、年龄心肌梗死、年龄75757575岁，没有出血危险因素的患者可能有益，可预防再岁，没有出血危险因素的患者可能有益，可预防再岁，没有出血危险因素的患者可能有益，可预防再岁，没有出血危险因素的患者可能有益，可预防再梗死以及梗死以及梗死以及梗死以及STEMISTEMISTEMISTEMI的并发症。的并发症。的并发症。的并发症。n n
31、但是临床研究显示，糖蛋白但是临床研究显示，糖蛋白但是临床研究显示，糖蛋白但是临床研究显示，糖蛋白b/ab/ab/ab/a抑制剂与溶栓联合没有降低病死率，抑制剂与溶栓联合没有降低病死率，抑制剂与溶栓联合没有降低病死率，抑制剂与溶栓联合没有降低病死率，尤其对尤其对尤其对尤其对75757575岁以上的患者，因为出血风险明显增加，岁以上的患者，因为出血风险明显增加，岁以上的患者，因为出血风险明显增加，岁以上的患者，因为出血风险明显增加，n n不建议药物溶栓与糖蛋白不建议药物溶栓与糖蛋白不建议药物溶栓与糖蛋白不建议药物溶栓与糖蛋白b/a b/a b/a b/a 抑制剂联合。抑制剂联合。抑制剂联合。抑制剂
32、联合。 ESC 2008: STEMI Guideline2009STEMI溶栓治疗的中国专家共识溶栓治疗的中国专家共识依诺肝素显著降低主要终点事件（死亡或非致依诺肝素显著降低主要终点事件（死亡或非致命性心梗）相对风险命性心梗）相对风险17(ExTRACT-TIMI 25)相相对风险: 0.83 (0.770.90)p0.0001 依依诺肝素肝素普通肝素普通肝素051015202530天天03691215主要主要终点事件点事件 (%)相相对风险: 0.90(0.801.01)p=0.08 相相对风险: 0.77(0.71 0.85)p0.000148 h 8 days 9.9%12.0%4.7
33、% 5.2% 7.2% 9.3% RRR17%2 8 (2006年3月ACC 上首次公布的对所有患者的分析结果)Thrombolysis and antithrombolism for STEMI-Advancement in 2009ZuyiZuyi Yuan YuanDept of Cardiovascular Medicine, First Affiliated Hospital Dept of Cardiovascular Medicine, First Affiliated Hospital of Medical School, of Medical School, XianXian
34、 JiaotongJiaotong University University Goals for AMI TherapyRestore coronary blood flow to ischemic myocardiumRapidly, Completely and sustainReduce area of MI Preserve LV function Preventing HF & ShockResolve the stenosis Reducing the mortalityAMI survivor with an improved outcomeYusuf S, et al. Ci
35、rculation. 1990;82(suppl II):II-117-II-134.Schrder R, et al. J Am Coll Cardiol. 1995;26:1657-1664.Time is the Myocardium！Time is the life！Symptom RecognitionCall to Medical SystemEDCath LabPreHospitalDelay in Initiation of Reperfusion TherapyIncreasing Loss of MyocytesTreatment Delayed is Treatment
36、DeniedTreatment Delayed is Treatment DeniedThrombolysis Thrombolysis Thrombolysis ？Primary PCI Primary PCI Primary PCI ？STEMI: the choice of strategies for reperfusionThrombolysis vs Primary PCIThrombolysisTIMI 3 flow: 60% Re-MI rate: 4%Stroke rate: 2%ICH rate: 1%Anywhere (pre-hospital)anytimeAll do
37、ctorNo time delayRCT documentedPrimary PCITIMI 3 flow: 80-90% Re-MI rate: 1h)Strategies for STEMI:Strategies for STEMI: ACC/AHA 2007 & ESC 2008 STEMI GuidelinesACC/AHA 2007 & ESC 2008 STEMI Guidelinesn n the time of onset presentthe time of onset presentn n STEMI risk score STEMI risk scoren n risk
38、of thrombolysis risk of thrombolysisn n the time for transfer to PCI cathlab the time for transfer to PCI cathlabCirculation 2007 August 10;114:671-719Step 1Step 1：Evaluating the time and riskEvaluating the time and riskStep 2Step 2：The choice of thrombolysis or PCI?The choice of thrombolysis or PCI
39、? If the time of onset is 3 hours, and no invasive delay, no If the time of onset is 3 hours, and no invasive delay, no If the time of onset is 3 hours, and no invasive delay, no If the time of onset is 3 hours, and no invasive delay, no difference in thrombolysis and PCI; the two strategies are dif
40、ference in thrombolysis and PCI; the two strategies are difference in thrombolysis and PCI; the two strategies are difference in thrombolysis and PCI; the two strategies are similar in reducing the area of infarction and reducing similar in reducing the area of infarction and reducing similar in red
41、ucing the area of infarction and reducing similar in reducing the area of infarction and reducing mortality. But prefer to PCI, since to reducing bleeding and mortality. But prefer to PCI, since to reducing bleeding and mortality. But prefer to PCI, since to reducing bleeding and mortality. But pref
42、er to PCI, since to reducing bleeding and stroke.stroke.stroke.stroke.Circulation 2007 August 10;114:671-719Strategies for STEMI:Strategies for STEMI: ACC/AHA 2007 & ESC 2008 STEMI GuidelinesACC/AHA 2007 & ESC 2008 STEMI GuidelinesOnset in 3Onset in 3Onset in 3Onset in 312 hours, PCI is the better,
43、because of salvaging 12 hours, PCI is the better, because of salvaging 12 hours, PCI is the better, because of salvaging 12 hours, PCI is the better, because of salvaging more ischemic myocardium, and reducing the stroke.more ischemic myocardium, and reducing the stroke.more ischemic myocardium, and
44、 reducing the stroke.more ischemic myocardium, and reducing the stroke.If no PCI qualification, and have the If no PCI qualification, and have the If no PCI qualification, and have the If no PCI qualification, and have the counterconditionscounterconditionscounterconditionscounterconditions，the the
45、the the patient should be transfer immediately.patient should be transfer immediately.patient should be transfer immediately.patient should be transfer immediately.23 RCT have documented, primary PCI reduce the mortality, re-23 RCT have documented, primary PCI reduce the mortality, re-23 RCT have do
46、cumented, primary PCI reduce the mortality, re-23 RCT have documented, primary PCI reduce the mortality, re-MI, stroke, and preserved the heart function is better MI, stroke, and preserved the heart function is better MI, stroke, and preserved the heart function is better MI, stroke, and preserved t
47、he heart function is better vsvsvsvs thrombolysis. thrombolysis. thrombolysis. thrombolysis. Circulation 2007 August 10;114:671-719Primary PCI vs Thrombolysis: Meta-analysis（23 RCT）PCIPCILyticsLytics7%7%5%9%Total mortalityTotal mortality1%P=0.0002P=0.0002P=0.0003P=0.0003(n = 7739)(n = 7739) (%) Even
48、tsmortalitymortalityRe-MIRe-MIstrokestrokeHemorrhagic Hemorrhagic CVACVA0.05%2%1% 7%3%P0.0001P0.0001P0.0001P0.0001P0.0001P0.0001Keeley et alKeeley et al， Lancet 2003; 361:13-20Lancet 2003; 361:13-20ACC/AHA 2007 & ESC 2008 Guigeline: Primary PCI in STEMI: Class I In generalOnset 12 hoursOnset 12 hour
49、sFrom door to From door to baloonbaloon 90 min 75 case / year 75 case / yearCathlab PCI case 200 case / year, Primary PCI 36 case / Cathlab PCI case 200 case / year, Primary PCI 36 case / yearyearSurgical standbySurgical standbyCirculation 2007 August 10;114:671-719Class I if onset 3 hours if onset
50、3 hours： Door to Door to baloonbaloon time (D-N) door to thrombolysis time (D-N) door to thrombolysis time (D-B) : time (D-B) : 1 hour, primary PCI is better 1 hour, thrombolysis is better 1 hour, thrombolysis is better if onset 3 hours if onset 3 hours，primary PCI is betterprimary PCI is betterCirc
51、ulation 2007 August 10;114:671-719STEMI STEMI ：Primary PCI Primary PCI n nFour high risk score subgroup the Four high risk score subgroup the PCIPCI is is better better vsvs thrombolysis thrombolysisCardiac shockCardiac shockAnterioreorAnterioreor M, re-MI M, re-MIHeart failureHeart failureage 70 ye
52、arsage 70 yearsThrombolytic therapy is behind the times？n nDifferent causes result in PCI time delay limited the Different causes result in PCI time delay limited the primary PCI benefice. For nor primary PCI usable primary PCI benefice. For nor primary PCI usable patients, thrombolysis is still the
53、 best patients, thrombolysis is still the best chiocechioce！n nAlthough in westernAlthough in western，AMIAMI reperfusion therapy is still reperfusion therapy is still important. International register study showed: 40% important. International register study showed: 40% AMI were performed thrombolys
54、is.AMI were performed thrombolysis.急性ST段抬高心肌梗死溶栓治疗的中国专家共识(2009年更新版).“ “Time is the myocardiumTime is the myocardium” ” the the ralationshipralationship of of Time and MortalityTime and Mortality（NRMI-2 studyNRMI-2 study）P=0.01P=0.0007P=0.0003NRMI 2: Primary PCI door-to- balloon time vs mortalityn =
55、2,2305,734Door-to-balloon time (minutes)6,6164,4612,6275,4120-60 61-90 91-120 121-150 150-180 0-60 61-90 91-120 121-150 150-180 180180Mortality(%)For hospital: No For hospital: No For hospital: No For hospital: No 24h 24h 24h 24h primary PCI cathlab usableprimary PCI cathlab usableprimary PCI cathla
56、b usableprimary PCI cathlab usable。For hospital: No For hospital: No For hospital: No For hospital: No 24h 24h 24h 24h primary PCI cathlab usable, and primary PCI cathlab usable, and primary PCI cathlab usable, and primary PCI cathlab usable, and meantime, meantime, meantime, meantime, thansferthans
57、ferthansferthansfer is delay. is delay. is delay. is delay.For hospital: For hospital: For hospital: For hospital: 24h 24h 24h 24h primary PCI cathlab usableprimary PCI cathlab usableprimary PCI cathlab usableprimary PCI cathlab usable，onset 3 onset 3 onset 3 onset 3 onset 3 onset 3 onset 3 hourshou
58、rshourshours；D-B time D-B time D-B time D-B time D-N time D-N time D-N time D-N time 60min60min60min60min。 Time is the Time is the myocardiummyocardium！First Chioce for Thrombolysis (2009)20092009急性急性STST段抬高心梗溶栓治疗中国专家共识段抬高心梗溶栓治疗中国专家共识Re-thrombolytic therapy:n nIf have evidence showed the failure of
59、reperfusion and re-MI, patient should be transfer to perform PCI immediately, otherwise patient should be perform re-thrombolytic therapy.The Chioce of Thrombolytic Drugsn非特异性非特异性纤溶酶原激活剂纤溶酶原激活剂- 链激酶链激酶(SK) (SK) 和尿激酶（和尿激酶（UKUK）n特异性特异性纤溶酶原激活剂纤溶酶原激活剂- 人重组组织型纤溶酶原激活剂（人重组组织型纤溶酶原激活剂（rtrt-PA-PA） 瑞替普酶瑞替普酶(r-
60、PA)(r-PA)，兰替普酶，兰替普酶(n-PA)(n-PA)，替耐普酶，替耐普酶 (TNK-(TNK-tPAtPA) ) ) ) The characteristic comparion of difference thrombolytic drugs溶栓药物溶栓药物常规剂量常规剂量纤维蛋白纤维蛋白特异性特异性抗原性及抗原性及过敏反应过敏反应纤维蛋白纤维蛋白原消耗原消耗90分钟分钟再通率再通率(%)#TIMI 3级级血流血流(%)尿激酶60分钟,150万单位否无明显未知未知链激酶3060分钟,150万单位否有明显5032阿替普酶90分钟 100mg是无轻度8054瑞替普酶10MU2,每次2分
61、钟是无中度8060替奈普酶3050mg根据体重*是无极小7563 2009急性急性ST段抬高心梗溶栓治疗的中国专家共识段抬高心梗溶栓治疗的中国专家共识n n我国溶栓治疗的患者中绝大多数（我国溶栓治疗的患者中绝大多数（90%90%）应）应用非选择性溶栓药物用非选择性溶栓药物, , 应用组织型纤溶酶原激应用组织型纤溶酶原激活剂（活剂（t-PAt-PA）者仅占）者仅占2.7%2.7%。n n应该积极推进应该积极推进规范的溶栓治疗规范的溶栓治疗，以提高我国，以提高我国急性急性急性急性STST段抬高心梗的再灌注治疗的段抬高心梗的再灌注治疗的比例比例和和成功率成功率！急性ST段抬高心肌梗死溶栓治疗的中国专
62、家共识(2009年更新版). For AMI patient, the first For AMI patient, the first contact in contact in raralraral hospital hospital，which which strategies for reperfusionstrategies for reperfusion：Thrombolysis Thrombolysis ？Transfer to PCI Transfer to PCI ？PRAGUE studyPRAGUE studyp = nsp = nsp 0.02p 0.02Widimsk
63、yWidimsky et al et al EurEur Heart J 2003; 24: 94 Heart J 2003; 24: 94Transfer PCI Transfer PCI vsvs Thrombolysis Thrombolysis （onset time conciseonset time concise）STEMI：short transfer distant，no cathlab delay（PCI90min） PRAGUE-2 StudyPRAGUE-2 Study (N=300)(N=300)(N=300)p0.001p0.00123.0%15.0%8.0%p0.
64、001p90min) n nPrimary PCIPrimary PCI？n nAfter After thrombolyticthrombolytic PCI (TT-PCI)PCI (TT-PCI)？ASSENT-4 study2006 published in Lancet2006 published in Lancet；1120 case1120 case：Primary PCI Primary PCI vsvs TT-PCI TT-PCI；The mortality is significant higher in TT-PCI The mortality is significan
65、t higher in TT-PCI groupgroup；Only the low bleeding/high risk STEMI subgroup Only the low bleeding/high risk STEMI subgroup is beneficialis beneficial。FINESSE studyFirst presented in ESC 2007First presented in ESC 2007；2453 case STEMI2453 case STEMI：rtrt-PA+GPI PCI-PA+GPI PCI vsvs GPI PCIGPI PCI vsv
66、s Primary PCIPrimary PCIAlthough the Although the cronarycronary flow is better in TT-PCI flow is better in TT-PCI compare the compare the preimarypreimary PCI, but the three groups PCI, but the three groups have not difference in death, HF, cardiac shock have not difference in death, HF, cardiac sh
67、ock (MACE) (MACE) ；The risk for bleeding is high in TT-PCI group .The risk for bleeding is high in TT-PCI group .ESC 2007, Sept 1-4AHA/ACC 2007 & ESC 2008 Guideline： for TT-PCIn nLow bleeding risk and high risk score STEMI Low bleeding risk and high risk score STEMI patientpatient，TT-PCI perform in
68、no cathlab usableTT-PCI perform in no cathlab usable。（Class Class b b）2009：CAPTIM new F-U dataSTEMIrandomlization primary PCI(n=421)rt-PA TT-PCI (n=419)5000 U IV haprin+250-500mg ASAFirst endpoint：5-year mortalityBonnefoy E et al, European Heart Journal 2009.CAPTIM:TT-PCI reduce the 5-year mortality
69、Bonnefoy E et al, European Heart Journal 2009.Onset 6 hours，P=0.18HR 0.75 (95% CI,0.50-1.14)RR25%Onset 2hours，p=0.04HR 0.50(95% CI,0.25-0.97)Bonnefoy E et al, European Heart Journal 2009.RR50%CAPTIM:TT-PCI reduce the 5-year mortality2009ESC：NORDISTEMIn nObjective: To compare 2 different strategies a
70、fter thrombolysis Objective: To compare 2 different strategies after thrombolysis for STEMI in patients with very long transfer times:for STEMI in patients with very long transfer times:A: Immediate transfer for CAG/PCIA: Immediate transfer for CAG/PCIB: Conservative, ischemia-guided treatmentB: Con
71、servative, ischemia-guided treatmentHalvorsen S: Presented in ESC 2009NORDISTEMI：study designBonnefoy E et al, European Heart Journal 2009. 300mg + Tenecteplase (TNK)Enoxaparin + Clopidogrel 300mgA: Immediate transfer A: Immediate transfer for CAG/PCIfor CAG/PCIB: ConservativeB: Conservativeischemia
72、-guided treatmentischemia-guided treatmentAcute STEMI 90 minClinical Outcome at 30 days:ConservativeConservativeInvasiveInvasive21%4.5%9.8%10%Death,re-MI,strokeDeath,re-MI,strokeNew ischemiaNew ischemiaRR=0.49(0.27-0.89)RR=0.49(0.27-0.89)P=0.003P=0.003 (%) EventsDeath,re-Death,re-MI,strokeMI,stroke)
73、 )Death Death 2.2%2.3%Bonnefoy E et al, European Heart Journal 2009.RR=0.45(0.16-1.14)RR=0.45(0.16-1.14)P=0.14P=0.14 STEMI: Drug reperfusionFibrinolyticFibrinolyticSKSK Fibrin- specificFibrin- specificAntiplateletAntiplateletASAASA GP IIb/IIIaGP IIb/IIIa ClopidegrelClopidegrelAnticoagulantAnticoagul
74、antUFHUFH Alternative Agents Alternative AgentsSTEMI长期双重抗血小板治疗明显获益长期双重抗血小板治疗明显获益CLARITY TIMI-28CLARITY TIMI-28COMMIT/CCS-2COMMIT/CCS-2ESC 2008: STEMI GuidelineGPb/a inhibitors：n nGPbGPbGPbGPb/a inhibitor /a inhibitor /a inhibitor /a inhibitor conbamconbamconbamconbam thrombolysis, the therapeutics i
75、s thrombolysis, the therapeutics is thrombolysis, the therapeutics is thrombolysis, the therapeutics is increaseincreaseincreaseincrease，but the bleeding is also increasebut the bleeding is also increasebut the bleeding is also increasebut the bleeding is also increase。n nGPI GPI GPI GPI conbamconba
76、mconbamconbam half-dose half-dose half-dose half-dose rtrtrtrt-PA usage in anterior MI, age75 -PA usage in anterior MI, age75 -PA usage in anterior MI, age75 -PA usage in anterior MI, age75 years, no bleed risk group is beneficialyears, no bleed risk group is beneficialyears, no bleed risk group is
77、beneficialyears, no bleed risk group is beneficial，can prevent the can prevent the can prevent the can prevent the corbilitycorbilitycorbilitycorbility of STEMI of STEMI of STEMI of STEMI。n nBut PCT showedBut PCT showedBut PCT showedBut PCT showed，GPbGPbGPbGPb/a inhibitor /a inhibitor /a inhibitor /
78、a inhibitor conbamconbamconbamconbam thrombolysis can thrombolysis can thrombolysis can thrombolysis can not reduce the mortality, because the increasing bleeding.not reduce the mortality, because the increasing bleeding.not reduce the mortality, because the increasing bleeding.not reduce the mortal
79、ity, because the increasing bleeding.ESC 2008: STEMI Guideline2009STEMI溶栓治疗的中国专家共识溶栓治疗的中国专家共识ExTRACT-TIMI 25: Enoxaparin on AMIRR: 0.83 (0.770.90)p0.0001 enoxaparinhaprin051015202530天天03691215MACE (%)RR: 0.90(0.801.01)p=0.08 RR: 0.77(0.71 0.85)p0.000148 h 8 days 9.9%12.0%4.7% 5.2% 7.2% 9.3% RRR17%2 8
