第五章 AMI再灌注治疗,院前我们能做什么.pptVIP

AMI再灌注治疗，院前我们能做什么 张斌 广东省人民医院 广东省心血管病研究所 DOOR 缩短时间 D2B Times Surpass National Campaign’s Goal  Elizabeth H. Bradley, PhD. Yale School of Public Health. Friday, December 04, 2009 The American College of Cardiology (ACC) Door-to-Balloon (D2B) 联盟目标：STEMI 病人 D2B ≤ 90 minutes 达到 75%. 从2005年4月到 2008年3月，614医院参加NCDR登记研究并加入 D2B 联盟 3年中 82,610 住院患者D2B时间显著缩短 Impressive 3-Year Increase 62.8% of US patients had a D2B time within 90 min in 2006 By 2008, the percentage had increased to 76.4%, slightly better than the initial goal of 75% set at the start of the campaign continued to improve beyond the end of the study period (March 31, 2008). 81.7% of eligible patients had D2B times ≤ 90 minutes from June 30, 2009 The average D2B time from an average of 121 minutes at the end of 2005, to an average of 80 minutes as of June 30, 2009 Still Room for Improvement Direct transportation to catheterization laboratory by emergency teams reduces door-to-balloon time Extend accomplishment out into the community so that patients presenting to smaller hospitals and can have faster times from first contact with the health care system until reperfusion 策略上的争论 易化 PCI 荟萃分析： Keeley等对比较直接 PCI和易化PCI疗效的 17项随机对照临床试验进行了，所纳入STEM I患者数分别为 2 267例和 2 237例 最终冠脉血流达到 TIMI 3级者的比例相似 ( 89% vs 88% )：易化PCI组冠脉血流在术后立即达到 TIMI 3级者多于直接PCI组 (37% vs 15% ) 易化 PCI组死亡率较高(5% vs 3%)： 非致死性M I率较高 (3% vs 2% ) ，靶血管的紧急血运重建率较高 (4% vs 1% ) ，大出血率也较高 (7% vs 5% ) 易化 PCI组不良反应发生率的增高主要原因： 溶栓药易化 PC I亚组出血性脑卒中和总的脑卒中发生率均显著增高 (分别为 0 . 7% vs 0 . 1%和 1 . 1% vs 0 . 3% )。 产生机理 可能是早期激活血小板的副作用，无有效的抗血小板作用 动脉粥样硬化斑块出血 可能原因 It is possible that the time between fibrinolysis and PCI (median, 90 to 104 minutes) was too short in these trials, with the result that persistent fibrinolytic activity led to increased bleeding complications The lack of adequate ant iplatelet therapy in these trials may have also conferred a predisposition to thrombotic complications. Fibrinolysis is followed by increased platelet activation and aggre