β受體阻滯劑在PCI中的應(yīng)用

1、受體阻滯劑在受體阻滯劑在PCI術(shù)的應(yīng)用術(shù)的應(yīng)用提提 綱綱受體阻滯劑藥理受體阻滯劑藥理心率心率增快增加冠心病患者的臨床事件增快增加冠心病患者的臨床事件受體阻滯劑在受體阻滯劑在PCI圍手術(shù)期的應(yīng)用圍手術(shù)期的應(yīng)用藥理學(xué)及作用機(jī)制藥理學(xué)及作用機(jī)制 主要機(jī)制：對(duì)抗兒茶酚胺類腎上腺素能遞質(zhì)毒性尤其是通過1受體介導(dǎo)的心臟毒性，是此類藥物發(fā)揮心血管保護(hù)作用。 其他機(jī)制： 1.抗高血壓作用 2.抗心肌缺血作用 3.阻斷腎小球旁細(xì)胞1受體，抑制腎素-AngII-醛固酮系統(tǒng)。 4.改善心臟功能增加LVEF: 5.抗心律失常作用 6.其他：抑制腎上腺素能通路介導(dǎo)的心肌細(xì)胞凋亡、抑制血小板聚集、減少對(duì)粥樣硬化斑塊的機(jī)械

2、應(yīng)激、防止斑塊破裂等。心率增快增加冠心病患者的風(fēng)險(xiǎn)！The effect of heart rate on local haemodynamic forces on the endothelium.Mechanisms whereby an elevated heart rate leads to adverse outcomes in patients with coronary artery disease.Impact of Left Ventricular Ejection Fraction on Clinical OutcomesOver Five Years After Infar

3、ct-Related Coronary ArteryRecanalization (from the Occluded Artery Trial OAT)In conclusion, optimal medical therapy remains the overall treatment of choice for stable patients with a persistent total occlusion of the infarct-related artery after acute myocardial infarction, irrespective of the basel

4、ine EF. In patients with normal or moderately impaired left ventricular contractility, PCI reduced the need for subsequent revascularization but did not otherwise improve outcomes. (Am J Cardiol 2010;105:10 16)包括倍他樂克在內(nèi)的最佳藥物治療仍然是冠心病治療的基石！阻滯劑在急性心肌梗死的應(yīng)用阻滯劑在急性心肌梗死的應(yīng)用Setting/indicationClassLeveli.v. admi

5、nistrationFor relief of ischaemic painTo control hypertension, sinus tachycardiaPrimary prevention of sudden cardiac deathSustained ventricular tachycardiaSupraventricular tachyarrhythmiasTo limit infarct sizeAll patients without contraindicationsOral administrationAll patients without contraindicat

6、ionsIIIIIIIaIIbIBBBCCAAA阻滯劑在慢性穩(wěn)定性心絞痛的應(yīng)用阻滯劑在慢性穩(wěn)定性心絞痛的應(yīng)用Expert consensus document on -adrenergic receptor blockers. European Heart Journal .2004, 25: 13411362.Setting/indicationClassLevelPrevious infarctionTo improve survivalTo reduce reinfarctionTo prevent/control ischaemiaNo previous infarctionTo im

7、prove survivalTo reduce reinfarctionTo prevent/control ischaemiaIIIIIIAAACBAHeart Rate as an Independent Prognostic Risk Factor in Patients with Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary InterventionCONCLUSION: In patients with acute myocardial infarction undergoing primar

8、y PCI, elevatedheart rate (80 bpm or greater) identifies those at increased risk of death. It is unknown whether heart rate reduction will result in improved outcome in this setting of patients.急性心肌梗死患者即使行PCI，心率增快的患者發(fā)生院內(nèi)死亡的風(fēng)險(xiǎn)明顯增高！阻滯劑在心肌梗塞后二級(jí)預(yù)防的應(yīng)用阻滯劑在心肌梗塞后二級(jí)預(yù)防的應(yīng)用Setting/indicationClassLevelAll patien

9、ts without contraindications, indefinitelyTo improve survivalTo prevent reinfarctionPrimary prevention of sudden cardiac deathTo prevent/treat late ventricular arrhythmiasIIIIIIaAAAAB阻滯劑在非阻滯劑在非ST段抬高段抬高ACS的應(yīng)用的應(yīng)用Setting/indicationClassLevelEarly benefit, reduction of ischaemiaEarly benefit, prevention

10、 MILong-term secondary preventionIIIBBB實(shí)踐與指南的差距：實(shí)踐與指南的差距：阻滯劑在中國冠心病患者中使阻滯劑在中國冠心病患者中使用現(xiàn)狀用現(xiàn)狀中華醫(yī)學(xué)會(huì)心血管病學(xué)分會(huì)中華心血管病雜志編輯委員會(huì).腎上腺素能受體阻滯劑在心血管疾病應(yīng)用專家共識(shí). 使用率低使用率低使用時(shí)間滯后使用時(shí)間滯后劑量較低劑量較低獲益漸少獲益漸少 受體阻滯劑在受體阻滯劑在PCI圍手術(shù)期的應(yīng)用圍手術(shù)期的應(yīng)用受體阻斷劑在非心臟手術(shù)期間的使用一直受到重視!但是在PCI圍手術(shù)期間的使用？2009 Focused Updates: ACC/AHA Guidelines for the Manageme

11、nt of Patients With ST-Elevation Myocardial Infarction.2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention.Antithrombotic： 1. UH, LMWH 2. GP IIb/IIIa Inhibitors 3. Bivalirudin-block？ statin ？Antiplatelet： 1. Aspirin 2. clopidogrel 受體阻斷劑在受體阻斷劑在PCI圍手術(shù)期間

12、的使用圍手術(shù)期間的使用 術(shù)前術(shù)前 術(shù)中術(shù)中 術(shù)后術(shù)后PCI術(shù)前使用術(shù)前使用阻滯劑漸少術(shù)后阻滯劑漸少術(shù)后CK-MB的上升的上升Samin K. Sharma, Annapoorna Kini, Jonathan D. Marmur,et al. Cardioprotective Effect of Prior -Blocker Therapy in Reducing Creatine Kinase-MB Elevation After Coronary Intervention . Circulation. 2000,102:166 -172PCIPCI術(shù)前使用術(shù)前使用阻滯劑與未使用組術(shù)后阻滯劑

13、與未使用組術(shù)后CK-MBCK-MB增高的發(fā)生率及增高程度比較增高的發(fā)生率及增高程度比較術(shù)前使用術(shù)前使用阻滯劑對(duì)阻滯劑對(duì)AMI PCI術(shù)后臨床預(yù)后的影響術(shù)后臨床預(yù)后的影響Harjai KJ, Stone GW, Boura J, et al. Effects of prior beta-blocker therapy on clinical outcomes after primary coronary angioplasty for acute myocardial infarction. Am J Cardiol 2003;91:65560.AMI PCI術(shù)前使用BB與未使用兩組術(shù)后并發(fā)癥、

14、住院期間及一年隨訪臨床預(yù)后的比較AMI PCI術(shù)前靜注術(shù)前靜注阻滯劑提高術(shù)后生存率阻滯劑提高術(shù)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 undergoing mechanical reperfusion therapy for acute myocardial infarction. J Am Coll Cardiol, 2004; 43:1780-17

15、87 . 術(shù)前靜脈注射BB與未注射組隨訪三個(gè)月及一年生存率的比較RABBIT II 研究研究 PCI術(shù)中冠狀動(dòng)脈內(nèi)注射術(shù)中冠狀動(dòng)脈內(nèi)注射阻滯劑漸少術(shù)后不良事件發(fā)生率阻滯劑漸少術(shù)后不良事件發(fā)生率Barry F Uretsky; Ernst R Schwarz; Abdulfatah Osman ,et al.Intracoronary Beta Blockade (BB) During Percutaneous Coronary Intervention (PCI): 30 Day Results of the Randomized Angioplasty Beta Blocker Intrac

16、oronary Trial II (RABBIT II). Circulation. 2006;114:II_547 急性心肌梗塞急性心肌梗塞PCI術(shù)后使用術(shù)后使用阻滯劑對(duì)臨床預(yù)后的影響阻滯劑對(duì)臨床預(yù)后的影響Steven J. Kernis, Kishore J. Harjai, Gregg W. Stone, et.al. Does beta-blocker therapy improve clinical outcomes of acute myocardial infarction after successful primary angioplasty?JACC,43（10）:1773

17、 - 1779.術(shù)后使用術(shù)后使用BB組較未使用組顯著降低死亡率及主要心臟不良事件率組較未使用組顯著降低死亡率及主要心臟不良事件率急性心肌梗塞急性心肌梗塞PCI術(shù)后使用術(shù)后使用阻滯劑對(duì)臨床預(yù)后的影響阻滯劑對(duì)臨床預(yù)后的影響AMI PCI術(shù)后使用術(shù)后使用阻滯劑顯著漸少六個(gè)月死亡風(fēng)險(xiǎn)阻滯劑顯著漸少六個(gè)月死亡風(fēng)險(xiǎn)PCI術(shù)后使用術(shù)后使用阻滯劑漸少一年死亡率阻滯劑漸少一年死亡率 PCI術(shù)后使用術(shù)后使用BB與未使用組隨訪一年生存率的比較與未使用組隨訪一年生存率的比較.P=0.0014.Albert W. Chan, Martin J. Quinn, Deepak L. Bhatt, et.al, Mortal

18、ity Benefit of Beta-Blockade After Successful Elective Percutaneous Coronary Intervention. Journal of the American College of Cardiology.2002,40(4)670-675.Am Heart J 2003;145:875-81Conclusions -Adrenergic receptor blockers prescribed after PCI reduced the risk of clinical restenosis, target lesion r

19、estenosis, and MACE in this cohort of 4840 patients. The mechanism by which -blockers conferred a protective effectagainst restenosis remains to be determined. (Am Heart J 2003;145:875-81.)PCI術(shù)后長期使用受體阻斷劑可以明顯減少再狹窄及臨床事件！圍圍PCI期間使用期間使用受體阻斷劑基于以下幾個(gè)方面受體阻斷劑基于以下幾個(gè)方面 抗炎與穩(wěn)定斑塊抗炎與穩(wěn)定斑塊 心肌保護(hù)心肌保護(hù) 預(yù)防再狹窄！預(yù)防再狹窄！These

20、findings suggest that metoprolol could inhibit the development 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 reperfusion results in larger myocardial salvage than its oral administration initiated early after reperfusion. If confirmed