ST抬高心肌梗死溶栓與抗栓治療進(jìn)展

1、1會(huì)計(jì)學(xué)ST抬高心肌梗死溶栓與抗栓治療進(jìn)展抬高心肌梗死溶栓與抗栓治療進(jìn)展Symptom RecognitionCall to Medical SystemEDCath LabPreHospitalDelay in Initiation of Reperfusion TherapyIncreasing Loss of Myocytes溶栓 vs 直接 PCI溶栓血流TIMI 3 比例60% 再梗死發(fā)生率 4%卒中總發(fā)生率 2%ICH發(fā)生率 1%任何地點(diǎn)(院前)任何時(shí)間所有醫(yī)生無(wú)時(shí)間延遲大規(guī)模臨床試驗(yàn)證實(shí)直接PCI血流TIMI 3 比例80-90% 再梗死發(fā)生率 1h)Circulation 20

2、07 August 10;114:671-719步驟1：評(píng)估時(shí)間和危險(xiǎn)性Circulation 2007 August 10;114:671-719Circulation 2007 August 10;114:671-7197%7%5%9%1% (%) Events0.05%2%1% 7%3%Circulation 2007 August 10;114:671-719Circulation 2007 August 10;114:671-719急性ST段抬高心肌梗死溶栓治療的中國(guó)專家共識(shí)(2009年更新版).P=0.01P=0.0007P=0.0003NRMI 2: Primary PCI do

3、or-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 180Mortality(%)時(shí)間就是心??！n非特異性非特異性纖溶酶原激活劑纖溶酶原激活劑-n 鏈激酶鏈激酶(SK) (SK) 和尿激酶（和尿激酶（UKUK）n特異性特異性纖溶酶原激活劑纖溶酶原激活劑-n 人重組組織型纖溶酶原激活劑（人重組組織型纖溶酶原激活劑（rt-PArt-PA） n 瑞替普酶瑞替普酶(r-PA)(r-PA)，蘭替普酶

4、，蘭替普酶(n-PA)(n-PA)，替耐普酶，替耐普酶 (TNK-tPA(TNK-tPA溶栓藥物溶栓藥物常規(guī)劑量常規(guī)劑量纖維蛋白纖維蛋白特異性特異性抗原性及抗原性及過(guò)敏反應(yīng)過(guò)敏反應(yīng)纖維蛋白纖維蛋白原消耗原消耗90分鐘分鐘再通率再通率(%)#TIMI 3級(jí)級(jí)血流血流(%)尿激酶60分鐘,150萬(wàn)單位否無(wú)明顯未知未知鏈激酶3060分鐘,150萬(wàn)單位否有明顯5032阿替普酶90分鐘 100mg是無(wú)輕度8054瑞替普酶10MU2,每次2分鐘是無(wú)中度8060替奈普酶3050mg根據(jù)體重*是無(wú)極小7563 2009急性ST段抬高心梗溶栓治療的中國(guó)專家共識(shí)急性ST段抬高心肌梗死溶栓治療的中國(guó)專家共識(shí)(200

5、9年更新版).23.0%15.0%8.0%ESC 2007, Sept 1-4ESC 2007, Sept 1-4隨機(jī)5000 U IV肝素+250-500mg阿司匹林主要終點(diǎn)：5年隨訪中的死亡率Bonnefoy E et al, European Heart Journal 2009.急性ST段抬高心?；颊咧苯有蠵CI(n=421)rt-PA異化PCI (n=419)患者癥狀發(fā)作6小時(shí)內(nèi)，rt-PA溶栓后行PCI的5年全因死亡率為 9.7% vs 12.6%Bonnefoy E et al, European Heart Journal 2009.癥狀發(fā)作6小時(shí)內(nèi)，P=0.18HR 0.75

6、 (95% CI,0.50-1.14)死亡風(fēng)險(xiǎn)25%癥狀發(fā)作2小時(shí)內(nèi)，p=0.04HR 0.50(95% CI,0.25-0.97)癥狀發(fā)作2小時(shí)內(nèi)，rt-PA溶栓后行PCI的5年死亡率僅為單純PCI組的50%Bonnefoy E et al, European Heart Journal 2009.死亡風(fēng)險(xiǎn)50%Halvorsen S: Presented in ESC 2009Bonnefoy E et al, European Heart Journal 2009.Acute STEMI 90 min21%4.5%9.8%10% (%) Events 2.2%2.3%Bonnefoy E

7、 et al, European Heart Journal 2009.ESC 2008: STEMI GuidelineESC 2008: STEMI Guideline2009STEMI溶栓治療的中國(guó)專家共識(shí)依諾肝素顯著降低主要終點(diǎn)事件（死亡或非致命性心梗）相對(duì)風(fēng)險(xiǎn)17(ExTRACT-TIMI 25)相對(duì)風(fēng)險(xiǎn): 0.83 (0.770.90)p0.0001 依諾肝素普通肝素051015202530天03691215主要終點(diǎn)事件 (%)相對(duì)風(fēng)險(xiǎn): 0.90(0.801.01)p=0.08 相對(duì)風(fēng)險(xiǎn): 0.77(0.71 0.85)p0.000148 h 8 days 9.9%12.0%4.

8、7% 5.2% 7.2% 9.3% RRR17%2 8 (2006年3月ACC 上首次公布的對(duì)所有患者的分析結(jié)果)Restore 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

9、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 MyocytesThrombolysis vs Primary PCIThro

10、mbolysisTIMI 3 flow: 60% Re-MI rate: 4%Stroke rate: 2%ICH rate: 1%Anywhere (pre-hospital)anytimeAll doctorNo time delayRCT documentedPrimary PCITIMI 3 flow: 80-90% Re-MI rate: 1h)Circulation 2007 August 10;114:671-719Step 1：Evaluating the time and riskCirculation 2007 August 10;114:671-719Strategies

11、 for STEMI: ACC/AHA 2007 & ESC 2008 STEMI GuidelinesCirculation 2007 August 10;114:671-7197%7%5%9%1% (%) Events0.05%2%1% 7%3%Circulation 2007 August 10;114:671-719Circulation 2007 August 10;114:671-719急性ST段抬高心肌梗死溶栓治療的中國(guó)專家共識(shí)(2009年更新版).P=0.01P=0.0007P=0.0003NRMI 2: Primary PCI door-to- balloon tim

12、e vs mortalityn = 2,2305,734Door-to-balloon time (minutes)6,6164,4612,6275,4120-60 61-90 91-120 121-150 150-180 180Mortality(%)Time is the myocardium！n非特異性非特異性纖溶酶原激活劑纖溶酶原激活劑-n 鏈激酶鏈激酶(SK) (SK) 和尿激酶（和尿激酶（UKUK）n特異性特異性纖溶酶原激活劑纖溶酶原激活劑-n 人重組組織型纖溶酶原激活劑（人重組組織型纖溶酶原激活劑（rt-PArt-PA） n 瑞替普酶瑞替普酶(r-PA)(r-PA)，蘭替普酶，蘭

13、替普酶(n-PA)(n-PA)，替耐普酶，替耐普酶 (TNK-tPA(TNK-tPA溶栓藥物溶栓藥物常規(guī)劑量常規(guī)劑量纖維蛋白纖維蛋白特異性特異性抗原性及抗原性及過(guò)敏反應(yīng)過(guò)敏反應(yīng)纖維蛋白纖維蛋白原消耗原消耗90分鐘分鐘再通率再通率(%)#TIMI 3級(jí)級(jí)血流血流(%)尿激酶60分鐘,150萬(wàn)單位否無(wú)明顯未知未知鏈激酶3060分鐘,150萬(wàn)單位否有明顯5032阿替普酶90分鐘 100mg是無(wú)輕度8054瑞替普酶10MU2,每次2分鐘是無(wú)中度8060替奈普酶3050mg根據(jù)體重*是無(wú)極小7563 2009急性ST段抬高心梗溶栓治療的中國(guó)專家共識(shí)急性ST段抬高心肌梗死溶栓治療的中國(guó)專家共識(shí)(2009年

14、更新版).23.0%15.0%8.0%ESC 2007, Sept 1-4ESC 2007, Sept 1-4STEMIrandomlization 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.Bonnefoy E et al, European Heart Journal 2009.Onset 6 hours，P=0.18HR 0.75 (95% C

15、I,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%Halvorsen S: Presented in ESC 2009Bonnefoy E et al, European Heart Journal 2009.Acute STEMI 90 min21%4.5%9.8%10% (%) Events 2.2%2.3%Bonnefoy E et al, European Heart Journal 2009.ESC 2008:

16、STEMI GuidelineESC 2008: STEMI Guideline2009STEMI溶栓治療的中國(guó)專家共識(shí)ExTRACT-TIMI 25: Enoxaparin on AMIRR: 0.83 (0.770.90)p0.0001 enoxaparinhaprin051015202530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 Symptom RecognitionCall to Medic

17、al SystemEDCath LabPreHospitalDelay in Initiation of Reperfusion TherapyIncreasing Loss of Myocytes7%7%5%9%1% (%) Events0.05%2%1% 7%3%Circulation 2007 August 10;114:671-71921%4.5%9.8%10% (%) Events 2.2%2.3%Bonnefoy E et al, European Heart Journal 2009.Thrombolysis vs Primary PCIThrombolysisTIMI 3 flow: 60% Re-MI rate: 4%Stroke rate: 2%ICH rate: 1%Anywhere (pre-hospital)anytimeAll doctorNo time delayRCT documentedPrimary PCITIMI 3 flow: 80-90% Re-MI rate: 1h)P=0.01P=0.0007P=0.0003NRMI 2: Primary PCI door-to- balloon time vs mortalityn = 2,2305,734Door-to-b