急性心肌梗塞战略

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1、AMIStrategyHowtoAchieveDoor-to-BalloonTimesof90MinutesandWhattoDoNext?AaronKugelmass,MDDirector,CardiacCathLabAssociateDivisionChiefHenryFordHospitalDetroit,Michigan,USAOverviewIntroductionTheArgumentforPrimaryPCIOverviewoftheHenryFordProgramProgramSpecificsProcessDictatesOutcom

2、esAlternativeOpportunitiesAcuteMI:Introduction1.1millionpeopleyearlyintheUS*About500,000haveSTEMI220,000diefromtheirAMI50%ofdeathsinthefirsthourOutlookofhospitalizedpatientsbetter*AHA:2001HeartandstrokestatisticsAcuteMI:EarlyManagementReperfusionPharmacological(Thrombolysis)Fib

3、rinolyticsAntithrombinsPlateletInhibitorsMechanical(Direct/PrimaryPCI)AngioplastyStentThrombectomyCombined?FacilitatedPCIAcuteMI:DirectPCIAdvantagesRapidassessmentofanatomyandhemodynamicsTIMI-3flowrates75-95%ininfarctarteryLowincidenceofhemorrhagicstrokeCanbedoneinpatientswithc

4、ontraindicationsforthrombolysisResultssuperiortothrombolyticsinrandomizedtrialsDirectPTCAvs.ThrombolysisPAMI-1NEnglJMed1993;328:673-679PrimaryAngioplastyvs.Thrombolysis:Meta-analysisDeathp=0.02Death+MIp<0.01WeaverDW,JAMA1997;278:2093-2098PrimaryAngioplastyvs.Thrombolysis:Meta-a

5、nalysisWeaverDW,JAMA1997;278:2093-2098PCIvsLysisMetaAnalysisKeeleyE,Lancet2003;361:13–20LyticsvsTransferforPCI:DANAMIAcuteMI:DirectPCILimitationsOnly20%ofUShospitalshavecathlabsandfewerhavePTCAfacilitiesToachieveresultssimilartorandomizedtrialsthefollowinghastobemet:PTCAwithin9

6、0minutesofpresentationSkilledoperator(>75cases/year)Skilledlab(>200cases/year)SurgicalbackupnecessaryIsTimeasCriticalinPrimaryPCI?30-daymortalityTimefromonsetofCPtorandomizationZijlstra,EurHeartJ2002;23:550ACC/AHARecommendationsforDirectPCIinAMI2004ClassIGeneral:Patientspresent

7、ingwithin12hours;ifperformedinatimelyfashionbyindividualsskilledintheprocedureandsupportedbyexperiencedpersonnelinhighvolumecentersSpecific:DoorToBalloonTime<90min<3hourssymptom,PCIiftreatment<1hour,lyticsif>1hourSymptom>3hours,PCIpreferred<90minWithin36hoursofMIwhenpatientdevel

8、opscardiogenicshock,is<75yearsandrevascularizat