STEMI急诊直接介入治疗-如何把握适应证.pptVIP

Time dependency of myocardial salvage expressed as percentage of initial area at risk. The initial parts of the curve up to 2?h were reconstructed based on the experimental studies. For the first 15?min (15?m) after coronary occlusion, myocardial necrosis is not observed. At 40?min (40?m) after coronary occlusion, myocardial cell death develops rapidly and the myocardial necrosis is confluent.10 After this point, progression to necrosis is slowed considerably. The other parts of the curve showing myocardial salvage from 2 to 12?h from the symptom onset are reconstructed according to the data of scintigraphic studies.21,42,63 Efficacy of reperfusion is expressed as follows: ++++, very effective; +++, effective; ++, moderately effective; ±, uncertainly effective; ?, not effective. Time dependence of myocardial salvage according to time-to-treatment interval in patients with ST-segment elevation AMI treated by PCI or thrombolysis. (A) Myocardial salvage expressed as percentage of the left ventricle (LV). (B) Myocardial salvage expressed as proportion of the initial area at risk salvaged by reperfusion therapy.21,63 CPXXXXXXX XXXXX, X XX XX-XX-XXXX * * 1.15 (0.77-1.72) * GRACE研究中STEMI的治疗趋势 Fox et al. JAMA 2007;297:1892 7月-12月 1999 7月-12月 2005 溶栓 直接PCI CABG 非再灌注治疗 % P0.001 P0.001 NS NS 44,372例ACS患者, 113家医院, 14个国家 首选直接PCI策略 ESC / ACC / AHA指南：症状发生在12小时以内的STEMI患者应选择直接 PCI，并将 D2B 控制在90分钟以内 优势：靶血管开通率更高，再闭塞率更低，严重出血并发症减少，死亡率明显降低，有利于改善残余左心功能和临床结果 要求：合格术者 (择期 PCI 年手术量 ≥75例，STEMI直接 PCI 操作 ≥11例)，合格医疗机构 (年PCI量 ≥400例，直接 PCI 操作 ≥36例) 直接PCI适应证 有溶栓禁忌症患者 发病＞3小时以上的患者，更趋首选直接 PCI 不推荐12～24小时内常规行 PCI，除非患者仍存在心肌缺血，出现严重充血性心力衰竭、血动力学不稳定或严重心律失常 2010年ESC / EACTS欧洲心肌血运重建指南：对于症状发生后到入院大于12～24小时 (甚至到60小时) 就诊或有溶栓禁忌证、再灌注成功后仍有残余狭窄或出现血管再闭塞等情况下的患者，即使无胸痛且血动力学状态稳定，仍可能从早期冠脉造影 (或可能行PCI) 获益 直接PCI适应证 合并心源性休克患者：为预防终末器官衰竭甚至死亡，应积极行早期再灌注治疗以及血动力学支持 2010年 ESC / EACTS欧洲心肌血运重建指南：对于心源性休克患者，不应设置症状发生至侵入诊断和血运重建的时间限制，无论事先患者已接受溶栓与否，应尽可能争取血运重建、争取全部血运重建 转运PCI的地位提高 建立区域性 STEMI 救治系统，其职能包括：定期召开协调会，会议成员包括急救医疗系统、未开展急诊PCI医院和可行急诊PCI的医院