会计学1ST抬高心肌梗死抬高心肌梗死(xn j n s)溶栓与抗溶栓与抗栓治疗进展栓治疗进展第一页，共75页。急性急性STST段抬高段抬高(tio)(tio)心梗治疗目标心梗治疗目标恢复心肌水平再灌注(gunzh)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(jingd)死亡率改善预后Yusuf S, et al. Circulation. 1990;82(suppl II):II-117-II-134.Schrder R, et al. J Am Coll Cardiol. 1995;26:1657-1664.时间就是心肌！时间就是生命！第1页/共74页第二页，共75页。Symptom RecognitionCall to Medical SystemEDCath LabPreHospitalDelay in Initiation of Reperfusion TherapyIncreasing Loss of MyocytesTreatment Delayed is Treatment DeniedTreatment Delayed is Treatment Denied第2页/共74页第三页，共75页。溶栓治疗溶栓治疗(zhlio)(zhlio)？直接直接PCIPCI？STEMISTEMI病人，应采取何种再灌注病人，应采取何种再灌注病人，应采取何种再灌注病人，应采取何种再灌注(gunzh)(gunzh)策略：策略：策略：策略：第3页/共74页第四页，共75页。溶栓 vs 直接(zhji) PCI溶栓血流TIMI 3 比例(bl)60% 再梗死发生率 4%卒中总发生率 2%ICH发生率 1%任何地点(院前)任何时间所有医生无时间延迟大规模临床试验证实直接PCI血流TIMI 3 比例80-90% 再梗死发生率 1h)第4页/共74页第五页，共75页。评估评估评估评估STEMISTEMISTEMISTEMI再灌注再灌注再灌注再灌注(gunzh)(gunzh)(gunzh)(gunzh)方式方式方式方式ACC/AHA2007STEMIGuidelinesACC/AHA2007STEMIGuidelinesACC/AHA2007STEMIGuidelinesACC/AHA2007STEMIGuidelinesn 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 STEMI STEMI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(fngxin)(fngxin)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1：评估(pn )时间和危险性第5页/共74页第六页，共75页。评估评估评估评估(pn)STEMI(pn)STEMI(pn)STEMI(pn)STEMI再灌注方式再灌注方式再灌注方式再灌注方式ACC/AHA2007STEMIACC/AHA2007STEMIACC/AHA2007STEMIACC/AHA2007STEMIGuidelinesGuidelinesGuidelinesGuidelines步骤步骤2 2：决定应首选溶栓还是：决定应首选溶栓还是PCIPCI如果时间少于如果时间少于3 3小时，且介入小时，且介入治疗无耽搁，溶栓和治疗无耽搁，溶栓和PCIPCI首选哪首选哪种都可以，二者在减少种都可以，二者在减少(jinsho)(jinsho)梗死面积，降低死梗死面积，降低死亡率方面效果相似。但倾向亡率方面效果相似。但倾向PCIPCI，因可降低出血与卒中。，因可降低出血与卒中。Circulation 2007 August 10;114:671-719第6页/共74页第七页，共75页。3 3 3 312121212小时患者，小时患者，小时患者，小时患者， PCI PCI PCI PCI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，卒中，卒中，卒中，卒中，通畅通畅通畅通畅(tngchng)(tngchng)(tngchng)(tngchng)率，心功能等指标优于静脉溶栓。率，心功能等指标优于静脉溶栓。率，心功能等指标优于静脉溶栓。率，心功能等指标优于静脉溶栓。Circulation 2007 August 10;114:671-719第7页/共74页第八页，共75页。直接直接PCIPCI与溶栓疗法与溶栓疗法(liof)(liof)的汇萃分析的汇萃分析（2323个随机研究）个随机研究）PCIPCILyticsLytics7%7%5%9%总死亡总死亡(swng)(swng)( (包括心源性休克包括心源性休克) )1%P=0.0002P=0.0002P=0.0003P=0.0003(n = 7739)(n = 7739) (%) Events死亡死亡(swng)(swng)( (排除心源性休克排除心源性休克) )非致命性非致命性再次心梗再次心梗中风中风Hemorrhagic Hemorrhagic CVACVA0.05%2%1% 7%3%P0.0001P0.0001P0.0001P0.0001P0.0001P0.0001Keeley et alKeeley et al， Lancet 2003; 361:13-20Lancet 2003; 361:13-20第8页/共74页第九页，共75页。ACC/AHA 2007 & ESC 2008 ACC/AHA 2007 & ESC 2008 指南指南指南指南: : 直接直接直接直接(zhji)PCI (zhji)PCI 应用于急性应用于急性应用于急性应用于急性STST段抬高心梗段抬高心梗段抬高心梗段抬高心梗 Class I Class I 一般考虑一般考虑发病发病 12 12 小时之内小时之内患者就诊到球囊开通血管患者就诊到球囊开通血管(xugun)(xugun)时间时间 90 75 75 例例 / / 年年导管室手术量导管室手术量 200 200 例例 / / 年，直接年，直接PCI 36 PCI 36 例例 / / 年年有胸外科支持有胸外科支持Circulation 2007 August 10;114:671-719第9页/共74页第十页，共75页。Class I 症状发作时间 3小时，预计： 就诊- 球囊开通血管时间（D-N）减去就诊-开始溶栓时间(D-B) 1小时, 溶栓疗法更好 症状发作时间 3小时，直接(zhji) PCI 更好Circulation 2007 August 10;114:671-719第10页/共74页第十一页，共75页。STEMI STEMI ：直接：直接：直接：直接(zhji) PCI (zhji) 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PCIPCI疗效优疗效优于溶栓组于溶栓组n n心源性休克心源性休克(xik)(xik)n n前壁心梗、再发心梗前壁心梗、再发心梗n n心力衰竭心力衰竭n n老年人老年人7070岁岁第11页/共74页第十二页，共75页。溶栓治疗是否已经溶栓治疗是否已经(yjing)(yjing)过时？过时？n n各种原因导致的时间延迟大大降低了直接各种原因导致的时间延迟大大降低了直接PCIPCI的获益。对于不能的获益。对于不能直接直接PCIPCI达到理想再灌注的患者，溶栓治疗仍然是较好的选择！达到理想再灌注的患者，溶栓治疗仍然是较好的选择！n n即使在欧美国家，即使在欧美国家，AMIAMI再灌注治疗中溶栓与直接再灌注治疗中溶栓与直接PCIPCI的比例相当。的比例相当。国际国际(guj)(guj)上多项注册研究显示，虽然上多项注册研究显示，虽然PCIPCI治疗近年来增长迅治疗近年来增长迅速，但仍有接近速，但仍有接近40%40%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(xn j n s)溶栓治疗的中国专家共识(2009年更新版).第12页/共74页第十三页，共75页。“ “时间时间时间时间(shjin)(shjin)就是心肌就是心肌就是心肌就是心肌” - ” - 时间时间时间时间(shjin)(shjin)与与与与死亡率关系（死亡率关系（死亡率关系（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 180Mortality(%)第13页/共74页第十四页，共75页。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，但就诊小时，但就诊小时，但就诊小时，但就诊- - - -球囊扩张与就诊球囊扩张与就诊球囊扩张与就诊球囊扩张与就诊- - - -溶栓时间相差（溶栓时间相差（溶栓时间相差（溶栓时间相差（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或就或就或就或就诊诊诊诊- - - -球囊扩张时间超过球囊扩张时间超过球囊扩张时间超过球囊扩张时间超过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（首次医疗（首次医疗（首次医疗(ylio)(ylio)(ylio)(ylio)接触）到球囊扩张的时间）。接触）到球囊扩张的时间）。接触）到球囊扩张的时间）。接触）到球囊扩张的时间）。 时间就是(jish)心肌！溶栓治疗溶栓治疗(zhlio)(zhlio)首选条件首选条件(2009)(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第14页/共74页第十五页，共75页。再次(zic)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(lj)进行PCI或转运至可行PCI的医院，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。第15页/共74页第十六页，共75页。溶栓药物(yow)的选择n n非特异性纤溶酶原激活剂非特异性纤溶酶原激活剂非特异性纤溶酶原激活剂非特异性纤溶酶原激活剂-n n 链激酶链激酶链激酶链激酶(SK) (SK) (SK) (SK) 和尿激酶（和尿激酶（和尿激酶（和尿激酶（UKUKUKUK）n n特异性纤溶酶原激活剂特异性纤溶酶原激活剂特异性纤溶酶原激活剂特异性纤溶酶原激活剂-n n 人重组人重组人重组人重组(zhn z)(zhn z)(zhn z)(zhn z)组织型纤溶酶原激活剂（组织型纤溶酶原激活剂（组织型纤溶酶原激活剂（组织型纤溶酶原激活剂（rt-rt-rt-rt-PAPAPAPA） n n 瑞替普酶瑞替普酶瑞替普酶瑞替普酶(r-PA)(r-PA)(r-PA)(r-PA)，兰替普酶，兰替普酶，兰替普酶，兰替普酶(n-PA)(n-PA)(n-PA)(n-PA)，替耐普酶，替耐普酶，替耐普酶，替耐普酶 (TNK-tPA) (TNK-tPA) (TNK-tPA) (TNK-tPA) 第16页/共74页第十七页，共75页。不同溶栓药物主要特点不同溶栓药物主要特点(tdin)(tdin)的比较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ST段抬高心梗溶栓治疗的中国专家(zhunji)共识第17页/共74页第十八页，共75页。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%）应用非）应用非选择性溶栓药物选择性溶栓药物,应用组织型纤溶酶原激活剂应用组织型纤溶酶原激活剂（t-PAt-PA）者仅占）者仅占2.7%2.7%。n n应该积极推进规范应该积极推进规范(gufn)(gufn)的溶栓治疗，以提高的溶栓治疗，以提高我国急性急性我国急性急性STST段抬高心梗的再灌注治疗的比例段抬高心梗的再灌注治疗的比例和成功率！和成功率！急性ST段抬高心肌梗死溶栓治疗的中国(zhn u)专家共识(2009年更新版).第18页/共74页第十九页，共75页。 首诊到基层医院的首诊到基层医院的首诊到基层医院的AMIAMIAMI病人病人病人(bngrn)(bngrn)(bngrn)，应采取何种再灌注，应采取何种再灌注，应采取何种再灌注策略：策略：策略：就地溶栓治疗就地溶栓治疗就地溶栓治疗 ？转运直接转运直接转运直接 PCI PCI PCI ？第19页/共74页第二十页，共75页。PRAGUE PRAGUE 研究研究(ynji)(ynji)p = nsp = nsp 0.02p 0.02Widimsky et al Eur Heart J 2003; 24: 94Widimsky et al Eur Heart J 2003; 24: 94转运转运PCI PCI 和就地溶栓治疗和就地溶栓治疗(zhlio)(zhlio)对死亡率的影响（发病时间对死亡率的影响（发病时间考虑）考虑）STEMISTEMI：转院距离：转院距离：转院距离：转院距离(jl)(jl)短，延迟时间不长（短，延迟时间不长（短，延迟时间不长（短，延迟时间不长（PCI90minPCI90min）第20页/共74页第二十一页，共75页。 PRAGUE-2 StudyPRAGUE-2 Study (N=300)(N=300)(N=300)p0.001p0.00123.0%15.0%8.0%p0.001p90min) n n直接(zhji)PCI？n n易化PCI？第22页/共74页第二十三页，共75页。ASSENT-4研究研究(ynji)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 vs PCI vs 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(znggo)(znggo)；只有低出血只有低出血/ /高危高危STEMISTEMI患者获益。患者获益。第23页/共74页第二十四页，共75页。FINESSE研究研究(ynji)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PCI vs PCI vs 阿昔单阿昔单抗易化抗易化PCI vs PCI vs 直接直接PCIPCI虽然易化虽然易化PCIPCI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，但组，但三组三组9090天死亡、心衰、心源性休克等天死亡、心衰、心源性休克等MACEMACE发生率无差发生率无差异；异；易化易化PCIPCI组出血危险组出血危险(wixin)(wixin)明显增高。明显增高。ESC 2007, Sept 1-4第24页/共74页第二十五页，共75页。AHA/ACC 2007 & ESC 2008 GuidelineAHA/ACC 2007 & ESC 2008 Guideline：异化异化异化异化(yhu)PCI(yhu)PCIn n低出血风险的高危低出血风险的高危STEMISTEMI患者，在不能立即患者，在不能立即(lj)(lj)行行PCIPCI时可采用异化时可采用异化PCIPCI策略。（策略。（ClassClassbb）第25页/共74页第二十六页，共75页。2009年：年：CAPTIM最新随访最新随访(su fn)结果结果随机5000 U IV肝素+250-500mg阿司匹林主要终点：5年随访中的死亡率Bonnefoy E et al, European Heart Journal 2009.急性(jxng)ST段抬高心梗患者直接(zhji)行PCI(n=421)rt-PA异化PCI (n=419)第26页/共74页第二十七页，共75页。CAPTIM:CAPTIM:异化异化异化异化(yhu)PCI(yhu)PCI降低降低降低降低5 5年全因死年全因死年全因死年全因死亡率亡率亡率亡率患者症状发作 (fzu)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6小时内，P=0.18HR 0.75 (95% CI,0.50-1.14)死亡风险25%第27页/共74页第二十八页，共75页。症状发作(fzu)2小时内，p=0.04HR 0.50(95% CI,0.25-0.97)症状(zhngzhung) 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(swng)风险50%CAPTIM:异化异化异化异化PCIPCI降低降低降低降低5 5年全因死亡率年全因死亡率年全因死亡率年全因死亡率第28页/共74页第二十九页，共75页。2009ESC：NORDISTEMIn nObjective: To compare 2 different strategies after thrombolysis for Objective: To compare 2 different strategies after thrombolysis for STEMI in patients with very long transfer times:STEMI in patients with very long transfer times:A: Immediate transfer for CAG/PCIA: Immediate transfer for CAG/PCIB: Conservative, ischemia-guided B: Conservative, ischemia-guided treatmenttreatmentHalvorsen S: Presented in ESC 2009第29页/共74页第三十页，共75页。NORDISTEMI：study designBonnefoy E et al, European Heart Journal 2009.Acute STEMI 90 min第30页/共74页第三十一页，共75页。Clinical Outcome at 30 days:Clinical 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-MI,strokeDeath,re-MI,stroke) )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第31页/共74页第三十二页，共75页。 STEMI STEMI药物再灌注治疗组成药物再灌注治疗组成药物再灌注治疗组成药物再灌注治疗组成(z chn)(z chn)要素要素要素要素FibrinolyticFibrinolyticSKSK Fibrin- specificFibrin- specificAntiplateletAntiplateletASAASA GP IIb/IIIaGP IIb/IIIa Clopidegrel ClopidegrelAnticoagulantAnticoagulantUFHUFH Alternative Agents Alternative Agents第32页/共74页第三十三页，共75页。STEMISTEMI长期双重长期双重长期双重长期双重(shungchng)(shungchng)抗血小板治抗血小板治抗血小板治抗血小板治疗明显获益疗明显获益疗明显获益疗明显获益CLARITY TIMI-28CLARITY TIMI-28COMMIT/CCS-2COMMIT/CCS-2ESC 2008: STEMI Guideline第33页/共74页第三十四页，共75页。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、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、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、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、年龄年龄年龄年龄75757575岁，没有出血危险因素的患者可能有益，可预防再梗死以及岁，没有出血危险因素的患者可能有益，可预防再梗死以及岁，没有出血危险因素的患者可能有益，可预防再梗死以及岁，没有出血危险因素的患者可能有益，可预防再梗死以及STEMISTEMISTEMISTEMI的并的并的并的并发症。发症。发症。发症。n n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，尤其抑制剂与溶栓联合没有降低病死率，尤其抑制剂与溶栓联合没有降低病死率，尤其抑制剂与溶栓联合没有降低病死率，尤其对对对对75757575岁以上岁以上岁以上岁以上(yshng)(yshng)(yshng)(yshng)的患者，因为出血风险明显增加，的患者，因为出血风险明显增加，的患者，因为出血风险明显增加，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。抑制剂联合。 ESC 2008: STEMI Guideline2009STEMI溶栓治疗的中国专家(zhunji)共识第34页/共74页第三十五页，共75页。依诺肝素显著降低主要终点(zhngdin)事件（死亡或非致命性心梗）相对风险17(ExTRACT-TIMI 25)相对(xingdu)风险: 0.83 (0.770.90)p0.0001 依诺肝素(n s)普通肝素051015202530天03691215主要终点事件 (%)相对风险: 0.90(0.801.01)p=0.08 相对风险: 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 (2006年3月ACC 上首次公布的对所有患者的分析结果)第35页/共74页第三十六页，共75页。第36页/共74页第三十七页，共75页。Thrombolysis and antith hrombolism for rombolism for STEMI-Advancement in 2009STEMI-Advancement in 2009Zuyi YuanZuyi YuanDept of Cardiovascular Medicine, First Affiliated Hospital of Dept of Cardiovascular Medicine, First Affiliated Hospital of Medical School, Xian Jiaotong University Medical School, Xian Jiaotong University 第37页/共74页第三十八页，共75页。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. Circulation. 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！第38页/共74页第三十九页，共75页。Symptom RecognitionCall to Medical SystemEDCath LabPreHospitalDelay in Initiation of Reperfusion TherapyIncreasing Loss of MyocytesTreatment Delayed is Treatment DeniedTreatment Delayed is Treatment Denied第39页/共74页第四十页，共75页。Thrombolysis Thrombolysis Thrombolysis ？Primary PCI Primary PCI Primary PCI ？STEMI: the choice of strategies for STEMI: the choice of strategies for reperfusionreperfusion第40页/共74页第四十一页，共75页。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)第41页/共74页第四十二页，共75页。Strategies for STEMI:Strategies for STEMI: ACC/AHA 2007 & ESC 2008 STEMI GuidelinesACC/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 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 1：Evaluating the time and risk第42页/共74页第四十三页，共75页。Step 2Step 2：The choice of thrombolysis or PCI?The choice of thrombolysis or PCI? 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 similar in difference in thrombolysis and PCI; the two strategies are similar in difference in thrombolysis and PCI; the two strategies are similar in difference in thrombolysis and PCI; the two strategies are similar in reducing the area of infarction and reducing mortality. But prefer to reducing the area of infarction and reducing mortality. But prefer to reducing the area of infarction and reducing mortality. But prefer to reducing the area of infarction and reducing mortality. But prefer to PCI, since to reducing bleeding and stroke.PCI, since to reducing bleeding and stroke.PCI, since to reducing bleeding and stroke.PCI, since to reducing bleeding and 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 Guidelines第43页/共74页第四十四页，共75页。Onset in 3Onset in 3Onset in 3Onset in 312 hours, PCI is the better, because of salvaging more 12 hours, PCI is the better, because of salvaging more 12 hours, PCI is the better, because of salvaging more 12 hours, PCI is the better, because of salvaging more ischemic myocardium, and reducing the stroke.ischemic myocardium, and reducing the stroke.ischemic myocardium, and reducing the stroke.ischemic myocardium, and reducing the stroke.If no PCI qualification, and have the counterconditionsIf no PCI qualification, and have the counterconditionsIf no PCI qualification, and have the counterconditionsIf no PCI qualification, and have the counterconditions，the patient the patient the patient the patient should be transfer immediately.should be transfer immediately.should be transfer immediately.should be transfer immediately.23 RCT have documented, primary PCI reduce the mortality, re-MI, 23 RCT have documented, primary PCI reduce the mortality, re-MI, 23 RCT have documented, primary PCI reduce the mortality, re-MI, 23 RCT have documented, primary PCI reduce the mortality, re-MI, stroke, and preserved the heart function is better vs stroke, and preserved the heart function is better vs stroke, and preserved the heart function is better vs stroke, and preserved the heart function is better vs thrombolysis. thrombolysis. thrombolysis. thrombolysis. Circulation 2007 August 10;114:671-719第44页/共74页第四十五页，共75页。Primary PCI vs Thrombolysis: Primary PCI vs Thrombolysis: Meta-analysisMeta-analysis（23 RCT23 RCT）PCIPCILyticsLytics7%7%5%9%Total mortalityTotal mortality1%P=0.0002P=0.0002P=0.0003P=0.0003(n = 7739)(n = 7739) (%) EventsmortalitymortalityRe-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; 361:13-20第45页/共74页第四十六页，共75页。ACC/AHA 2007 & ESC 2008 Guigeline:ACC/AHA 2007 & ESC 2008 Guigeline: Primary PCI in STEMI:Primary PCI in STEMI: Class IClass I In generalIn generalOnset 12 hoursOnset 12 hoursFrom door to baloon 90 min From door to baloon 75 case / yearPCI precedure 75 case / yearCathlab PCI case 200 case / year, Primary PCI 36 case / yearCathlab PCI case 200 case / year, Primary PCI 36 case / yearSurgical standbySurgical standbyCirculation 2007 August 10;114:671-719第46页/共74页第四十七页，共75页。Class I if onset 3 hours if onset 3 hours： Door to baloon time (D-N) door to thrombolysis time (D-B) : Door to baloon time (D-N) door to thrombolysis 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 betterCirculation 2007 August 10;114:671-719第47页/共74页第四十八页，共75页。STEMI STEMI ：Primary PCI Primary PCI n nFour high risk score subgroup the Four high risk score subgroup the PCIPCI is is better vs thrombolysisbetter vs thrombolysisCardiac shockCardiac shockAnterioreor M, re-MIAnterioreor M, re-MIHeart failureHeart failureage 70 yearsage 70 years第48页/共74页第四十九页，共75页。Thrombolytic therapy is behind the times？n nDifferent causes result in PCI time delay limited the primary Different causes result in PCI time delay limited the primary PCI benefice. For nor primary PCI usable patients, PCI benefice. For nor primary PCI usable patients, thrombolysis is still the best chiocethrombolysis is still the best chioce！n nAlthough in westernAlthough in western，AMIAMI reperfusion therapy is still important. reperfusion therapy is still important. International register study showed: 40% AMI were performed International register study showed: 40% AMI were performed thrombolysis.thrombolysis.急性ST段抬高(ti o)心肌梗死溶栓治疗的中国专家共识(2009年更新版).第49页/共74页第五十页，共75页。“ “ “Time is the myocardiumTime is the myocardiumTime is the myocardium” ” ” the ralationship of Time the ralationship of Time the ralationship of Time and Mortalityand Mortalityand Mortality（NRMI-2 studyNRMI-2 studyNRMI-2 study）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 180Mortality(%)第50页/共74页第五十一页，共75页。For hospital: No For hospital: No For hospital: No For hospital: No 24h 24h 24h 24h primary PCI cathlab usableprimary PCI cathlab usableprimary PCI cathlab 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, thansfer is delay.meantime, thansfer is delay.meantime, thansfer is delay.meantime, thansfer 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 hoursonset 3 hoursonset 3 hoursonset 3 hoursonset 3 hoursonset 3 hoursonset 3 hours；D-B D-B D-B D-B time time time time D-N time D-N time D-N time D-N time 60min60min60min60min。 Time is the myocardium！First Chioce for Thrombolysis (2009)20092009急性急性(jxng)ST(jxng)ST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第51页/共74页第五十二页，共75页。Re-thrombolytic therapy:n nIf have evidence showed the failure of reperfusion and re-MI, patient should be transfer to perform PCI immediately, otherwise patient should be perform re-thrombolytic therapy.第52页/共74页第五十三页，共75页。The Chioce of Thrombolytic Drugsn n非特异性纤溶酶原激活剂非特异性纤溶酶原激活剂非特异性纤溶酶原激活剂非特异性纤溶酶原激活剂-n n 链激酶链激酶链激酶链激酶(SK) (SK) (SK) (SK) 和尿激酶（和尿激酶（和尿激酶（和尿激酶（UKUKUKUK）n n特异性纤溶酶原激活剂特异性纤溶酶原激活剂特异性纤溶酶原激活剂特异性纤溶酶原激活剂-n n 人重组人重组人重组人重组(zhn z)(zhn z)(zhn z)(zhn z)组织型纤溶酶原激活剂（组织型纤溶酶原激活剂（组织型纤溶酶原激活剂（组织型纤溶酶原激活剂（rt-rt-rt-rt-PAPAPAPA） n n 瑞替普酶瑞替普酶瑞替普酶瑞替普酶(r-PA)(r-PA)(r-PA)(r-PA)，兰替普酶，兰替普酶，兰替普酶，兰替普酶(n-PA)(n-PA)(n-PA)(n-PA)，替耐普酶，替耐普酶，替耐普酶，替耐普酶 (TNK-tPA) (TNK-tPA) (TNK-tPA) (TNK-tPA) 第53页/共74页第五十四页，共75页。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分钟是无中度8060替奈普酶3050mg根据体重*是无极小7563 2009急性ST段抬高心梗溶栓治疗(zhlio)的中国专家共识第54页/共74页第五十五页，共75页。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%）应用非）应用非选择性溶栓药物选择性溶栓药物,应用组织型纤溶酶原激活剂应用组织型纤溶酶原激活剂（t-PAt-PA）者仅占）者仅占2.7%2.7%。n n应该积极推进规范应该积极推进规范(gufn)(gufn)的溶栓治疗，以提高的溶栓治疗，以提高我国急性急性我国急性急性STST段抬高心梗的再灌注治疗的比例段抬高心梗的再灌注治疗的比例和成功率！和成功率！急性ST段抬高心肌梗死溶栓治疗的中国专家(zhunji)共识(2009年更新版).第55页/共74页第五十六页，共75页。 For AMI patient, the For AMI patient, the first contact in raral first contact in raral hospitalhospital，which which strategies for reperfusionstrategies for reperfusion：Thrombolysis Thrombolysis ？Transfer to PCI Transfer to PCI ？第56页/共74页第五十七页，共75页。PRAGUE studyPRAGUE studyp = nsp = nsp 0.02p 0.02Widimsky et al Eur Heart J 2003; 24: 94Widimsky et al Eur Heart J 2003; 24: 94Transfer PCI vs Thrombolysis Transfer PCI vs Thrombolysis （onset time conciseonset time concise）STEMISTEMI：short transfer distantshort transfer distant，no cathlab no cathlab delaydelay（PCI90minPCI90min）第57页/共74页第五十八页，共75页。 PRAGUE-2 StudyPRAGUE-2 Study (N=300)(N=300)(N=300)p0.001p0.00123.0%15.0%8.0%p0.001p90min) (PCI90min) n nPrimary PCIPrimary PCI？n nAfter thrombolytic After thrombolytic PCI (TT-PCI)PCI (TT-PCI)？第59页/共74页第六十页，共75页。ASSENT-4 study2006 published in Lancet2006 published in Lancet；1120 case1120 case：Primary PCI vs TT-PCIPrimary PCI vs TT-PCI；The mortality is significant higher in TT-PCI The mortality is significant higher in TT-PCI groupgroup；Only the low bleeding/high risk STEMI subgroup is Only the low bleeding/high risk STEMI subgroup is beneficialbeneficial。第60页/共74页第六十一页，共75页。FINESSE studyFirst presented in ESC 2007First presented in ESC 2007；2453 case STEMI2453 case STEMI：rt-PA+GPI PCIrt-PA+GPI PCI vs vs GPI PCIGPI PCI vs vs Primary Primary PCIPCIAlthough the cronary flow is better in TT-PCI Although the cronary flow is better in TT-PCI compare the preimary PCI, but the three groups have compare the preimary PCI, but the three groups have not difference in death, HF, cardiac shock (MACE) not difference in death, HF, cardiac shock (MACE) ；The risk for bleeding is high in TT-PCI group .The risk for bleeding is high in TT-PCI group .ESC 2007, Sept 1-4第61页/共74页第六十二页，共75页。AHA/ACC 2007 & ESC 2008 GuidelineAHA/ACC 2007 & ESC 2008 Guideline： for TT-PCIfor TT-PCIn nLow bleeding risk and high risk score STEMI Low bleeding risk and high risk score STEMI patientpatient，TT-PCI perform in no cathlab usableTT-PCI perform in no cathlab usable。（Class Class b b）第62页/共74页第六十三页，共75页。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.第63页/共74页第六十四页，共75页。CAPTIM:TT-PCI reduce the 5-year CAPTIM:TT-PCI reduce the 5-year mortalitymortalityBonnefoy E et al, European Heart Journal 2009.Onset 6 hours，P=0.18HR 0.75 (95% CI,0.50-1.14)RR25%第64页/共74页第六十五页，共75页。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 CAPTIM:TT-PCI reduce the 5-year mortalitymortality第65页/共74页第六十六页，共75页。2009ESC：NORDISTEMIn nObjective: To compare 2 different strategies after thrombolysis for Objective: To compare 2 different strategies after thrombolysis for STEMI in patients with very long transfer times:STEMI in patients with very long transfer times:A: Immediate transfer for CAG/PCIA: Immediate transfer for CAG/PCIB: Conservative, ischemia-guided B: Conservative, ischemia-guided treatmenttreatmentHalvorsen S: Presented in ESC 2009第66页/共74页第六十七页，共75页。NORDISTEMI：study designBonnefoy E et al, European Heart Journal 2009.Acute STEMI 90 min第67页/共74页第六十八页，共75页。Clinical Outcome at 30 days:Clinical 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-MI,strokeDeath,re-MI,stroke) )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第68页/共74页第六十九页，共75页。 STEMI: Drug reperfusion STEMI: Drug reperfusionFibrinolyticFibrinolyticSKSK Fibrin- specificFibrin- specificAntiplateletAntiplateletASAASA GP IIb/IIIaGP IIb/IIIa Clopidegrel ClopidegrelAnticoagulantAnticoagulantUFHUFH Alternative Agents Alternative Agents第69页/共74页第七十页，共75页。STEMISTEMI长期双重抗血小板治疗长期双重抗血小板治疗长期双重抗血小板治疗长期双重抗血小板治疗(zhlio)(zhlio)明显获益明显获益明显获益明显获益CLARITY TIMI-28CLARITY TIMI-28COMMIT/CCS-2COMMIT/CCS-2ESC 2008: STEMI Guideline第70页/共74页第七十一页，共75页。GPb/a inhibitors：n nGPb/a inhibitor conbam thrombolysis, the therapeutics is increaseGPb/a inhibitor conbam thrombolysis, the therapeutics is increaseGPb/a inhibitor conbam thrombolysis, the therapeutics is increaseGPb/a inhibitor conbam thrombolysis, the therapeutics is increase，but the bleeding is also increasebut the bleeding is also increasebut the bleeding is also increasebut the bleeding is also increase。n nGPI conbam half-dose rt-PA usage in anterior MI, age75 years, no bleed GPI conbam half-dose rt-PA usage in anterior MI, age75 years, no bleed GPI conbam half-dose rt-PA usage in anterior MI, age75 years, no bleed GPI conbam half-dose rt-PA usage in anterior MI, age75 years, no bleed risk group is beneficialrisk group is beneficialrisk group is beneficialrisk group is beneficial，can prevent the corbility of STEMIcan prevent the corbility of STEMIcan prevent the corbility of STEMIcan prevent the corbility of STEMI。n nBut PCT showedBut PCT showedBut PCT showedBut PCT showed，GPb/a inhibitor conbam thrombolysis can not GPb/a inhibitor conbam thrombolysis can not GPb/a inhibitor conbam thrombolysis can not GPb/a inhibitor conbam thrombolysis can not reduce the mortality, because the increasing bleeding.reduce the mortality, because the increasing bleeding.reduce the mortality, because the increasing bleeding.reduce the mortality, because the increasing bleeding.ESC 2008: STEMI Guideline2009STEMI溶栓治疗(zhlio)的中国专家共识第71页/共74页第七十二页，共75页。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)p2分钟。STEMI：拟转院PCI，但延迟时间较长(PCI90min)。(2006年3月ACC 上首次公布的对所有患者的分析结果)第七十五页，共75页。