急診PCI治療要點(diǎn)課件

1、12急性心肌梗塞治療的目標(biāo)急性心肌梗塞治療的目標(biāo): 縮小梗塞面積縮小梗塞面積 保護(hù)心功能保護(hù)心功能 防治并發(fā)癥防治并發(fā)癥 降低死亡率降低死亡率3 無論何種血運(yùn)重建無論何種血運(yùn)重建方式，都應(yīng)強(qiáng)調(diào)：方式，都應(yīng)強(qiáng)調(diào)：時間就是心肌，時間就是心肌，時間就是生命時間就是生命4癥狀識別癥狀識別呼叫急救系統(tǒng)呼叫急救系統(tǒng)急診科急診科心導(dǎo)管室心導(dǎo)管室院前處理院前處理再灌注治療時間延遲再灌注治療時間延遲心肌細(xì)胞丟失增加延遲治療就是否定治療延遲治療就是否定治療5時間就是心肌時間就是心肌0h 1h 2h 3h 4h 5h 6h心心肌肌壞壞死死程程度度 血管閉塞時間血管閉塞時間60 0.5 hrs 預(yù)防梗死0.5 2 h

2、rs 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7891011時間段（分）時間段（分）平均平均onset-door183150door-lab7459door-consult3.52.1consult-consent3744consent-lab3111onset-balloon278159door-balloon9858lab-balloon2510onset-lab2571641213冠脈堵塞冠脈堵塞再灌注再灌注遠(yuǎn)端栓塞遠(yuǎn)端栓塞炎癥細(xì)胞聚集炎癥細(xì)胞聚集內(nèi)皮損傷內(nèi)皮損傷組織水腫組織水腫血小板血小板/

3、/纖維素聚集纖維素聚集氧自由基氧自由基微血管收縮微血管收縮血栓、粥樣斑塊遠(yuǎn)端微循環(huán)栓塞血栓、粥樣斑塊遠(yuǎn)端微循環(huán)栓塞 no-reflow141516occlusionocclusionpenetrationpenetrationslow flowslow flownormal flownormal flowtimi 0timi 0timi 1timi 1timi 2timi 2timi 3timi 3% mortality% mortality9.3%9.3%6.1%6.1%3.7%3.7%p0.0001 vs timi 0/1p0.0001 vs timi 0/1p0.0001 vs timi

4、 2p0.0001 vs timi 2p=0.003 vs timi 0/1p=0.003 vs timi 0/1team 2team 2team 2team 2team 2team 2germangermangermangermangermangermangusto 1gusto 1gusto 1gusto 1gusto 1gusto 1tam i 1-7tam i 1-7tam i 1-7tam i 1-7tam i 1-7tam i 1-7tim i 1,4tim i 1,45,10b5,10btim i 1,4tim i 1,45,10b5,10btim i 1,4tim i 1,45

5、,10b5,10bcm gibson 1998 in acute coronary syndromessample size of pooled analysis: sample size of pooled analysis: 5,4985,4981010161633333434444427278 84 4131319199 91515181829293434restoration of “normal” epicardial flow yields better outcomesrestoration of “normal” epicardial flow yields better ou

6、tcomesunfortunately rate unfortunately rate of agreement only of agreement only 71%71%1718fz 2008-10myocardial blush gradep = 0.001tapas研究研究19fz 2008-12myocardial blush gradep = 0.001tapas研究研究20emeraldemerald研究：遠(yuǎn)端保護(hù)裝置作用被否定研究：遠(yuǎn)端保護(hù)裝置作用被否定212223241071 stemi patients randomized535 were assigned tothromb

7、us aspiration33 did not undergo pci502 underwent primary pci295 underwent ta followed bydirect stenting153 underwent ta with additionalballoon dilation 54 had crossover to conventionalpci536 were assigned toconventional pci33 did not undergo pci503 underwent primary pci485 underwent balloon dilation

8、followed by stenting 12 underwent conventional pciwith additional ta 6 had crossover to ta530 complete follow-up at 1 year530 complete follow-up at 1 yeartapas研究：研究： 血栓抽吸導(dǎo)管作用血栓抽吸導(dǎo)管作用得到肯定得到肯定25svilaas t et al. nejm 2008;358:557 - fz 2008-8p 0.001 patients (%)thrombus aspirationconventional pci26svila

9、as t et al. nejm 2008;358-557 - fz 2008-9patients (%)thrombus aspirationconventional pcip 0.00127282930new recommendationnew recommendationaspiration thrombectomy isreasonable for patientsundergoing primary pcii i i i i i iiaiiaiiaiiaiiaiiaiibiibiibiibiibiibiiiiiiiiiiiiiiiiiii i i i i i iiaiiaiiaiia

10、iiaiiaiibiibiibiibiibiibiiiiiiiiiiiiiiiiiii i i i i i iiaiiaiiaiiaiiaiiaiibiibiibiibiibiibiiiiiiiiiiiiiiiiiiiiaiiaiiaiiaiiaiiaiibiibiibiibiibiibiiiiiiiiiiiiiiiiiib31% %iib/iiiaiib/iiia受體拮抗受體拮抗劑劑32debater研究33阿昔單抗組及對照組阿昔單抗組及對照組30天靶血管重建失?。ㄌ彀醒苤亟ㄊ。╰vf）發(fā)生率）發(fā)生率 34阿昔單抗組及對照組阿昔單抗組及對照組1年年mace發(fā)生率發(fā)生率 35轉(zhuǎn)運(yùn)轉(zhuǎn)運(yùn)pci

11、 centern=984n=9846/2006-11/20076/2006-11/2007pci*bolus: 25 g/kg & 0.15 g/kg/min infusion36ongoing tirofiban in myocardial infarction evaluation14.39.112.19.45.98.14.86.314.59.110.99.24.45.33.34.30.0020.0020.0220.0220.0280.028p=0.84p=0.84mm隨機(jī)時隨機(jī)時造影前造影前術(shù)后術(shù)后60分鐘分鐘術(shù)后術(shù)后90分鐘分鐘37time (days)302520151050

12、event free survival90%80%70%60%50%40%tirofibanplacebop value 0,012ongoing tirofiban in myocardial infarction evaluationp = 0.013 74.0%66.7%38p = 0.007open label & double-blind, n = 1.1553939it is reasonable to start treatment with glycoprotein iib/iiia receptor antagonists at the time of primary

13、 pci (with or without stenting) in selected patients with stemi:abciximabtirofiban and eptifibatideuse of glycoprotein iib/iiia receptor antagonists in stemii i i i i i iiaiiaiiaiiaiiaiia iibiibiibiibiibiib iiiiiiiiiiiiiiiiiii i i i i i iiaiiaiiaiiaiiaiia iibiibiibiibiibiib iiiiiiiiiiiiiiiiiii i i i i i iiaiiaiiaiiaiiaiia iibiibiibiibiibiib iiiiiiiiiiiiiiiiiiiiaiiaiiaiiaiiaiia iibiibiibiibiibiib iiiiiiiiiiiiiiiiiibi i i i i i iiaiiaiiaiiaiiaiia iibiibiibiibiibiib iiiiiiiiiiiiiiiiiii i i i i i iiaiiaiiaiiaiiaiia iibiibiibiibiibiib iiiiiiiiiiiiiiiiiii i i i i i iiaiiaiiaiiai