急性心肌梗死治疗指南解读.ppt

* * * Options for Transportation of STEMI Patients and Initial Reperfusion Treatment: Goals Reperfusion in patients with STEMI can be accomplished by the pharmacologic (fibrinolysis) or catheter-based (primary PCI) approaches. The overarching goal is to keep total ischemic time within 120 minutes (ideally within 60 minutes) from symptom onset to initiation of reperfusion treatment. The medical system goal is to facilitate rapid recognition and treatment of patients with STEMI such that door-to-needle (or medical-contact-to-needle) for initiation of fibrinolytic therapy can be achieved within 30 minutes or door-to-balloon (or medical-contact-to-balloon) for PCI can be achieved within 90 minutes. These goals should not be understood as “ideal” times, but rather the longest times that should be considered acceptable for a given system. Systems that are able to achieve even more rapid times for treatment of patients with STEMI should be encouraged. Note “medical contact” is defined as the “time of EMS arrival on scene” after the patient calls EMS/9-1-1 or the “time of arrival at the emergency department door” (whether PCI-capable or non-PCI-capable hospital) when the patient self-transports. * 突发冠状动脉梗塞后的心肌坏死与血管梗塞时间关系曲线分为几个阶段：起始阶段平坦，该阶段几乎没有心肌坏死，时间持续大约是冠状动脉梗塞后20分钟；第2阶段斜率明显升高，心肌坏死量明显增加，如果在这段时间内争取抢时间，尽管只缩短一部分时间，但是可以抢救大量的心肌；第3阶段平坦，时间延迟对心肌坏死量的变化不大。溶栓药物治疗的目的就是降低第2阶段曲线的斜率，以保护心肌。 * GISSI试验显示了再灌注时间与降低的死亡率之间的关系，y轴为降低的死亡率，x轴为再灌注时间。1小时内开始溶栓治疗，降低死亡率47％；3小时内治疗，降低死亡率23％，疗效降低一半；3至6小时内治疗，降低死亡率17％；6至9小时治疗，溶栓治疗几乎没有疗效。 The therapies used to target this ‘physiology’ (I.e: atherosclerosis/thrombosis) are listed above. * 根据CURE研究结果，NSTE－ACS的患者需要接受9－12个月的两联抗血小板治疗。 * 有些医生倾向在ACS患者接受冠脉造影检查，明确不需要行CABG术后，在PCI开始前再开始两联抗血小板治疗。 但是，CURE研究的结果显示，患者接受两联抗血小板治疗后，在24小时内既可显示出获益，晚期给药将减少患者的获益程度。 * Looking at the per protocol population of those patients who underwent a PCI, pretreatment with a 300mg loading dose of 波立维 led to an 18.5% relative reduction in the risk of 死亡, MI, and urgent target vessel revas