β受體阻滯劑在PCI中的應(yīng)用課件

1、受體阻滯劑在PCI術(shù)的應(yīng)用提 綱受體阻滯劑藥理心率增快增加冠心病患者的臨床事件受體阻滯劑在PCI圍手術(shù)期的應(yīng)用藥理學(xué)及作用機(jī)制主要機(jī)制：對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、減少對粥樣硬化斑塊的機(jī)械應(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 haem

2、odynamic forces on the endothelium.Mechanisms whereby an elevated heart rate leads to adverse outcomes in patients with coronary artery disease.阻滯劑在急性心肌梗死的應(yīng)用Setting/indicationClassLeveli.v. administrationFor relief of ischaemic painTo control hypertension, sinus tachycardiaPrimary prevention of sudd

3、en cardiac deathSustained ventricular tachycardiaSupraventricular tachyarrhythmiasTo limit infarct sizeAll patients without contraindicationsOral administrationAll patients without contraindicationsIIIIIIIaIIbIBBBCCAAA阻滯劑在慢性穩(wěn)定性心絞痛的應(yīng)用Expert consensus document on -adrenergic receptor blockers. Europea

4、n Heart Journal .2004, 25: 13411362.Setting/indicationClassLevelPrevious infarctionTo improve survivalTo reduce reinfarctionTo prevent/control ischaemiaNo previous infarctionTo improve survivalTo reduce reinfarctionTo prevent/control ischaemiaIIIIIIAAACBA阻滯劑在心肌梗塞后二級預(yù)防的應(yīng)用Setting/indicationClassLevelA

5、ll patients without contraindications, indenitelyTo improve survivalTo prevent reinfarctionPrimary prevention of sudden cardiac deathTo prevent/treat late ventricular arrhythmiasIIIIIIaAAAAB阻滯劑在非ST段抬高ACS的應(yīng)用Setting/indicationClassLevelEarly benet, reduction of ischaemiaEarly benet, prevention MILong-

6、term secondary preventionIIIBBB實(shí)踐與指南的差距：阻滯劑在中國冠心病患者中使用現(xiàn)狀中華醫(yī)學(xué)會心血管病學(xué)分會中華心血管病雜志編輯委員會.腎上腺素能受體阻滯劑在心血管疾病應(yīng)用專家共識. 使用率低使用時(shí)間滯后劑量較低獲益漸少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 Management of Patients With ST-Elevation Myocardial Infarction.2007 Focused Update of the

7、 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 PCI術(shù)前使用阻滯劑漸少術(shù)后CK-MB的上升Samin K. Sharma, Annapoorna Kini, Jonathan D. Marmur,et al. Cardioprotective Ef

8、fect of Prior -Blocker Therapy in Reducing Creatine Kinase-MB Elevation After Coronary Intervention . Circulation. 2000,102:166 -172PCI術(shù)前使用阻滯劑與未使用組術(shù)后CK-MB增高的發(fā)生率及增高程度比較術(shù)前使用阻滯劑對AMI PCI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

9、 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、住院期間及一年隨訪臨床預(yù)后的比較AMI PCI術(shù)前靜注阻滯劑提高術(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 mechan

10、ical reperfusion therapy for acute myocardial infarction. J Am Coll Cardiol, 2004; 43:1780-1787 . 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 PCI術(shù)中冠狀動脈內(nèi)注射阻滯劑漸少術(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 (PC

11、I): 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術(shù)后使用阻滯劑對臨床預(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

12、successful primary angioplasty?JACC,43（10）:1773 - 1779.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急性心肌梗塞PCI術(shù)后使用阻滯劑對臨床預(yù)后的影響AMI PCI術(shù)后使用阻滯劑顯著漸少六個(gè)月死亡風(fēng)險(xiǎn)Am Heart J 2003;145:875-81Conclusions -Adrenergic receptor blockers prescribed after PCI reduced the risk of clinical restenosis, target lesion restenosis, and MACE in

13、 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！These findings suggest that metoprolol could inhibit the development of atherosclerosis and stabilize vu

14、lnerable 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 sa

15、lvage than its oral administration initiated early after reperfusion. If confirmed in the clinicalsetting, the timing and route of -blocker initiation could be revisited.結(jié)論：術(shù)前盡早靜脈使用倍他樂克可以挽救更多的心肌！問題是：受體阻斷劑的使用遠(yuǎn)遠(yuǎn)不足！Use of -blockers and effects on heart rate 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 Altho